Inspection on 15/11/05 for Five Oaks

This inspection was carried out on 15th November 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Five Oaks 21/05/07

Five Oaks 27/06/06

Five Oaks 30/06/05

Five Oaks 20/10/04

Five Oaks 03/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Five Oaks 377 Cockfosters Road Hadley Wood Hertfordshire EN4 0JT Lead Inspector Mr Teferi Degeneh Unannounced Inspection 15th November 2005 10:30 X10015.doc Version 1.40 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 Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 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 Older People. 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. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Five Oaks Address 377 Cockfosters Road Hadley Wood Hertfordshire EN4 0JT 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) 020 8449 7000 020 8449 7311 Scimitar Care Hotels Plc Ms Lynnsey Mitchell Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Five Oaks is a private residential home owned by Scimitar Care Hotels PLC. The home is registered to provide personal care for 44 elderly people. The home is purpose built; facilities include 42 single rooms and two double rooms on three floors; service users are never asked to share a room so the double rooms are used as single rooms. There is a large lounge with interconnecting doors to a dining room, a smaller lounge, the garden room, and a sitting area in the lobby, furnished with comfortable armchairs. The three floors are accessible via two shaft lifts. There is a well-maintained garden with patio, accessible, through French windows.The home is located in a quiet residential area. At front of the building there is a parking space for staff and visitors’ cars. The home is also accessible by public transport. The Cockfosters underground station, Piccadilly line, is a few minutes’ car drive from the home. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is based on information obtained mainly through discussions with people who live at the home. Observations of the people, the staff and the premises are also used as evidence gathering tools for this inspection. The files of the people who live at the home and those of the staff were analysed. Other documents such as the rotas, policies, procedures, medication administration sheets and the menus were seen. Some people who were visiting the home were spoken to. The responsible person, Mrs Sylvia Sanderson, H&S Officer of the Company, was present throughout the inspection. The staff were observed while supporting people with activities such as moving, assisting with meals and administering medication. What the service does well: What has improved since the last inspection? What they could do better: While the facilities available at this home are satisfactory, there are a number of issues that the registered person must undertake to improve the standard of Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 6 services and to ensure the safety of service users. To begin with, service users with a diagnosis of dementia are accommodated at the home. It is important for the registered person to ensure that appropriate facilities that meet the needs of these service users are in place and these do not impact on the welfare of the other service users. The certificate of registration needs to be changed to reflect the realities in the home. Care plans need to be reviewed regularly for all service users. The registered person must ensure that service users and their representatives are involved the review of care plans. The registered person must strictly follow the home’s recruitment procedure when employing staff. Clear CRB’s and two written references must be obtained for the two new members of staff. The registered person must visit the home once every month and monitor the premises and services by checking documents, talking to service users, the manager and the staff and looking around the premises. A report of the visit must be prepared and a copy sent to the CSCI Inspector. A system of quality assurance must be implemented. The registered person must ensure the health and safety of service users by reviewing the facilities at the home, for example, by arranging for a qualified occupational therapist (OT) to assess the premises and services users who are prone to frequent falls and by acting on the recommendations that follow the OT assessment. The outstanding recommendations of the fire and the environmental health officers must be complied with. Finally, the registered person must consult services users and provide them with their preferences of meals. 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. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 7 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 Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, and 5 The admission procedures and the process for pre-admission assessments are satisfactory enabling service to know that the home meets their needs. Despite the previous requirements, the registered person has made no progress regarding the conditions of registration and the certificate of the home. Service users are not clear about the category of registration of the home. EVIDENCE: It was evident from the seven service users’ files assessed that assessments are completed before admission. In a discussion with the responsible person it was confirmed that social workers completed assessments for people placed by local authorities. The assessments of people not funded by local authorities are completed by the home. The assessments seen were detailed. Two relatives who were spoken to said that service users had an opportunity to see and stay at the home before admission. They said that they had seen some other homes before making their decision to move into the home. This home is registered to accommodate up to 44 people within the Category of old age, not falling within any other Category. The pre-inspection questionnaire completed by the Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 9 registered person and sent to CSCI states that six people with dementia are currently accommodated at the home. A requirement had been made twice for the registered person to apply to the CSCI for a variation of conditions of registration in respect of service users with dementia. The application must be supported by evidence that appropriate facilities and services are available to meet the needs of service users. The registered person is yet to comply with this. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 The processes of care plan reviews are not consistent with the evidence that not all care plans are reviewed regularly. This potentially puts service users at risk since possible changes in their needs are not identified appropriate care plans are not put in place. The progress made in respect of risk assessment and medication handling and administration is encouraging are reassured that their health and safety is protected. Service users can be confident that their health needs, privacy and dignity are ensured by the facilities, systems and the staff of the home. EVIDENCE: Seven service users’ files were examined. Only two of these files had evidence of up-to-date care plans. The care plans in the remaining five files have not been reviewed for at least a year. There was no evidence that relatives or representatives have been involved in the care plans. A representative of a service user who contacted the inspector said they were not aware that they could contribute to the care plans of service users. Risk assessments have been completed for some service users. The files, the home’s diary and the visitor’s book contained evidence that service users received appropriate health care. The responsible person said that health professionals such as a dentist, chiropodist, an optician, a district nurse and general practitioners Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 11 regularly come to the home. A visitor confirmed that a service user is able to access medical care regularly at a hospital. Medication is administered by a trained care staff and is witnessed by another member of staff. The medicines and the medication administration record sheets were in order on the day of the inspection. There are procedures for recording, receipt and disposal of medicines. The temperature of the area where medication is kept is monitored and kept at below 25oC. Appropriate medication risk assessments are carried out for service users who wish to selfadminister their medication. The responsible person confirmed that some people who are more able have been given keys for their bedrooms. The others who are not able to use or look after their keys have not been given bedroom keys and these have been recorded in their files. Discussions with the responsible person indicated that telephone lines have been provided for service users who requested and agreed to pay the bills. A number of service users and visitors spoken to are satisfied with the staff. The staff were observed supporting and talking to people appropriately. “Privacy, respect and dignity” are some of the values included in the home’s “work book”, a copy of which is given to all staff as part of their induction programme. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14, and 15 Food must be improved The home has a wide range of activities to stimulate, engage and entertain service users. The arrangements for service users’ financial management are satisfactory enabling service users to buy items they need and later on after receiving invoices. There are conducive and welcoming atmosphere in the home for service users to have visitors in private. The process for setting up the menus has not improved. Service users are not consulted about the food items provided. EVIDENCE: An activities co-ordinator comes to the home at least two times a week to organize board games, bingos and quizzes. Records showed that the staff are involved in providing similar activities in the afternoon. Discussions with the responsible person and an examination of service users’ files indicated that service users are supported to go out to coffee shops and the theatres. A programme of activities is displayed in the lounge. It was evident from the programme that various entertainers visit the home on different days. Many service users were reading newspapers, books or watching television programmes in the lounge or in their rooms during most part of the inspection. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 13 A number of visitors were observed coming in and going out during the inspection. Two visitors who were spoken to confirmed that they were satisfied with the home. They said that they are able to visit the home without restriction and that the staff always welcome them with a smile. A number of service users said their families and friends visit them at the home. From the files and discussions with service users it was evident that service users are seen at a place of their choice including in their bedroom. All people at the home have either their relatives or representatives to look after their finances. The home does not manage people’s money. People are able to buy personal items such as toiletries and newspapers on credit from the home. The people then receive invoices at the end of the month for the costs they incur. This arrangement is part of an agreement between service users and the home and it has worked well for a number of years. People who live at the home are able to bring with them personal possessions such as pictures and family photos. It was evident in the files that records are kept of service users’ possessions. A number of people spoken to have mixed opinions about the meals. They said the meals are good but can be improved. Some said soup and sandwiches are offered regularly. An examination of the menus confirmed that “soup” is a frequent option for evenings. This was discussed with the responsible person who agreed that there is a room for improvement of the menus. It was discussed that the people who live at the home need to be consulted about their preferences of meals. At the last inspection this issue was raised and the registered person agreed to consult service users and review the menus. People were observed eating their lunch at around 12:00. The presentation of the meals and the atmosphere in the dining room were satisfactory. A number of staff were present to support people with feeding as appropriate. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, and 18 The home’s policies and procedures on complaints and the protection of vulnerable adults from abuse are satisfactory. Service users and relatives are reassured and feel protected by their knowledge of the home’s policies and procedures. EVIDENCE: The visitors and the people who live at the home and who were spoken to said that they did not have to make a complaint but they knew that they can talk to the manager if they had a concern. No new complaints have been recorded since the last inspection. The home’s complaints procedure contains details of how complaints are dealt with and the local office address of the CSCI. Four members of staff have attended training on the protection of vulnerable people from abuse. The responsible person said she is hoping to attend “Training the Trainers Course” to enable her to provide in-house adult protection training for all the staff. The staff spoken demonstrated good understanding of how to protect vulnerable people and deal with abuse. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, and 26 The premises, facilities and cleanliness of this home are of high standard giving comfort to service users. However, service users’ safety is endangered by the lack adaptations or strategies to prevent falls in the corridors. EVIDENCE: The home was clean, tidy and there was no offensive odour in all parts of the premises inspected. Three domestic staff are employed to clean the bedrooms and communal areas. There is also a laundry assistant responsible for washing, ironing and folding service users’ clothes. Staff were observed using hand gloves when transporting clothes to the laundry room. There is a satisfactory infection control policy. The laundry is equipped with a modern washing machine, in which foul laundry can be washed at an appropriate temperature. An environmental health officer visited the home and stated that the standards were “generally satisfactory” but there were no pest control records available for inspection. The home has a generator, which automatically turns on if and when there is an electric supply failure. A full time handyperson repairs, maintains and decorates the buildings and the equipment as appropriate. The people at the home and the visitors spoken to were satisfied with the facilities Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 16 and the rooms. The home is accessible to wheelchair users and there are two passenger lifts for accessing the entire floors from the basement to the third floor. The lifts are tested every month. Handrails are provided in the stairs. There are also adaptations and hoists in the toilets, bathrooms and bedrooms. However, there are no handrails in the corridors. The responsible person said it is the policy of the organisation not to have handrails in the corridors. Each service user has a single bedroom. Except one, all the bedrooms have a wash hand basin and a toilet. Additionally, all bedrooms on basement, ground, first and second floors have a shower. The bedrooms are decorated to service users’ tests. Service users have television sets, books, pictures and family photos in their rooms. All service users spoken to said they liked their rooms. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30 The home has experienced and committed staff in sufficient number to meet service users’ needs. The recruitment practices of the home are poor with the evidence that some staff are employed without CRB checks and written references being obtained by the home. These reduce service users’ confidence in the knowledge, experience and integrity of the staff. EVIDENCE: There are eight care staff on shift in the morning and six in the afternoon. Three domestic staff, a cook, two kitchen assistants, entertainers and a handyperson also work at the home during the days. Night shifts are covered by three waking night carers and an on-call senior member of staff. Five care staff have achieved NVQ (Care) Level 2 qualification and five others have completed the same course but are currently waiting for their certificates. The responsible person said three more care workers have embarked on NVQ (Care) Level 2 training. The registered person has complied with the last requirement that stated that the two existing staff without CRB must undergo a CRB check. However, two new members of staff, who were employed since the last inspection, have been working without the required written references and CRB checks. The CRB certificate for one of these new members of staff was delivered through the post while the inspection was in progress. There was no evidence to confirm that an application to the CRB was made for the other member of staff. One of the two new members of the staff has only one written reference; the other member of staff was employed without a reference Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 18 being obtained for them. Both new members of staff have signed contracts in their files and have been working at the home for over a month. The home has a person responsible for co-ordinating training for the staff. The files assessed contained evidence that the staff have undergone an induction programme. There is also a “work book” with various topics for study and questions for completion by all staff. The responsible person said staff are required to complete the “work book” within six weeks. The training records showed that a number of the staff have attended training programmes including basic food hygiene, fire prevention, care practice, first aid, safe handling of medicines, infection control, and dementia. The service users and the families spoken to said the staff are good. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, and 38 The systems for monitoring the facilities and the quality of services are poor with the evidence that the provider does not undertake monthly visits to the home and that feedback has not been sought from service users and visitors. The transparency in the home is less than service users’ expectation and visitors do not know the outcome of the CSCI inspection report, as the reports are not kept at the home. The maintenance person and the registered person do a good job in keeping the premises and facilities maintained, redecorated and serviced. However, service users remain at risk due to lack of strategies to reduce falls and due to lack of evidence to reassure service users that the registered person has complied with the requirements of relevant fire and health and safety officers. EVIDENCE: The visitors, the people who live at the home, and the staff spoken to said they can talk to the manager and her office is always open to them. The manager is Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 20 supported by senior staff and staff from the Head Office, who visit the home regularly. She was on annual leave on the day of the inspection and it was not possible on this occasion to assess the training she has attended recently. The last requirement that the registered person must carry out unannounced visits to the home on a monthly basis in line with Regulation 26 of the Care Homes Regulations is still outstanding. This requirement is being restated for the third time. Also, during this inspection the responsible person was not able to access a copy of the last CSCI inspection report. A member of staff confirmed that the CSCI inspection report was kept at the home’s Head Office. At the last inspection the registered person was required to implement a quality assurance system for the home. It was noted at the last inspection that questionnaires have been developed as a tool for gathering the views of stakeholders. The appliances and equipment in the home are regularly serviced. Records showed that the fire alarms and emergency lights are tested weekly and the temperature of hot water is monitored and recorded regularly. There are certificates and records to confirm that the lifts, fire extinguishers, and the hoists have been serviced. The local fire officers and the environmental health officer (EHO) visited the home and made recommendations with regard to fire precautions and pest control records respectively. The registered person said the recommendations have been complied with. However, there was no written evidence from the officers to confirm that the recommendations have been satisfactorily met. Twenty-five incidents and accidents have been recorded since the last inspection. A bedroom has been changed for a service user prone to frequent falls. It was mentioned above that there are no handrails in the corridors. Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 21 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 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 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 2 2 X X X X 2 Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation Requirement Timescale for action 31/12/05 2 OP7 3 OP15 4 OP19 9(1)(2)(3) The registered person must apply to the CSCI for a variation of conditions of registration in respect of the two service users with dementia. Assessmensts and care plans of the service users must be submitted with the application form. Timescales of 31/12/, and 31/8/05 not met 15(2)(c) Unless it is impracticable to carry 15/12/05 out such consultation, the registered person must, after consultation with the service users, or their representative, revise the service users plan once every month. 16(2) The registered person must 15/12/05 consult service users and provide them with adequate, suitable, wholesome and nutritious food, which is varied and properly prepared and available at such times as may reasonably be required by service users. (Timescale of 31/7/05 not met). 23(2) The registered person must seek 30/01/06 advice from a qualified occupational therapist in respect of those service users who DS0000010660.V259523.R01.S.doc Version 5.0 Five Oaks Page 23 5 OP26 23 6 OP32 26 7 OP32 17; 24 8 OP33 24(1)(a) (b)(3) 9 OP38 12(1); 13(1); 17; 26 experience frequent falls and provide them with appropriate adaptations throughout the premises. The registered person must assess the corridors and provide adaptations that would enhance the health and safety and independence of the people who live at the home. The matters raised in the Environmental Health Officer’s which remain outstanding must be completed. The registered person must carry out unannounced visits to the home on a monthly basis in line with Regulation 26 of the Care Homes Regulations. A copy of the written report must be sent to the CSCI and a copy must be held in the home. Timescales of 20/11/04 and 31/8/05 not met. The registered person must make available to the staff, service users and interested individuals copies of the CSCI inspection reports. A copy of the report must be kept at the home. The registered person must put in place effective quality assurance and quality monitoring systems, which seek the views of service users, visitors and professionals. The outcome of the surveys must be published and made available to all parties including the CSCI. (Timescales of 1/3/05, and 31/10/05 not met). The registered person must ensure that appropriate arrangements are in place for the prevention of falls and care of service users who are prone to frequent falls. The registered person must update the CSCI Inspector regarding the number DS0000010660.V259523.R01.S.doc 15/12/05 15/12/05 15/12/05 25/02/06 15/12/05 Five Oaks Version 5.0 Page 24 10 OP38 17(2)(b); 23(4); 43 of falls on a monthly basis. The registered person must comply with the requirements made on 26/4/4/05 by a fire safety officer. A copy of the action plan regarding the requirements by the fire officer must be forwarded to the CSCI. 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Five Oaks DS0000010660.V259523.R01.S.doc Version 5.0 Page 26 - 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. 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