Inspection on 12/01/06 for Freeland House Nursing Home

This inspection was carried out on 12th January 2006.

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

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

Other inspections for this house

Freeland House Nursing Home 20/03/08

Freeland House Nursing Home 25/05/06

Freeland House Nursing Home 18/08/05

Freeland House Nursing Home 21/03/05

Freeland House Nursing Home 30/06/04

Freeland House Nursing Home 11/03/04

Freeland House Nursing Home 10/09/03

Freeland House Nursing Home 19/09/02

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

CARE HOMES FOR OLDER PEOPLE Freeland House Nursing Home Wroslyn Road Freeland, Witney Oxfordshire OX29 8AH Lead Inspector Annette Miller Unannounced Inspection 12th January 2006 10:45 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 Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 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. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Freeland House Nursing Home Address Wroslyn Road Freeland, Witney Oxfordshire OX29 8AH 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) 01993 881258 01993 883963 Dove Care Homes Limited Frances Payne Care Home 76 Category(ies) of Old age, not falling within any other category registration, with number (76), Physical disability (2) of places Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. On admission persons should be aged 60 years and over. Admittance of two named under age service users The maximum number of servvice users must not exceed 76. Date of last inspection 18th August 2005 Brief Description of the Service: Freeland House is set in six acres of woodland and landscaped gardens at the southern edge of Freeland village, eight miles west of the City of Oxford and approximately 3 miles from the market town of Witney. The original house was built in 1807 and owned by a former Town Clerk of Oxford. From 1984 the house has been run as a care home for older people requiring nursing care. The home was extended in 1998 to provide further bedroom accommodation on two floors. The accommodation comprises 56 single rooms and 10 shared (double) rooms, most with en-suite facilities. There are three lounges and two dining rooms on the ground floor, with an additional sitting area in the link corridor to the new building, all with extensive views over the gardens and fields to the rear of the home. The original house is a three-storey building, with the kitchen, laundry room, administrative offices and a hairdressing room located on the basement floor. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from 10.45 am to 5.30 pm. During this time a tour of the building took place and documents were examined. A number of residents were spoken to but most were unable to express clear opinions due to their general frailty and also some mental confusion. Five members of staff were spoken to and Mrs. Frances Payne (registered manager) was present in the home throughout the inspection. The inspector was made to feel welcome by all the staff and appreciated their cooperation. The last inspection of the home took place on 18th August 2005 and some of the standards assessed during that inspection were not reassessed during this inspection. Therefore, to gain a full report on the home this report should be read in conjunction with the report dated 18th August 2005. What the service does well: What has improved since the last inspection? Four staff completed a Fire Marshall’s course in November 2005 and this enables these staff to give fire training to other staff at the home, ensuring fire safety training is kept up to date. Five carers are undertaking level 2 NVQ in care and two are considering starting this training. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 6 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. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 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 Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 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): 1 and 3 The written information provided to prospective residents is not in the required format and does not contain the full amount of information that is needed for Standard 1 to be assessed as fully met. As a result, prospective residents cannot be assured they have all the necessary information to make an informed decision as to whether or not the home will be right for them. Written information about how the company refunds NHS money to residents for their nursing care is not provided and, therefore, some residents may not be fully aware of their rights in this matter. All prospective residents are assessed before moving into the home to ensure their care needs can be met. EVIDENCE: The home provides information about its services in a document called ‘Welcome to Freeland House’, which was last updated in February 2005. Additional information about the home’s complaints procedure, quality policy statement and the name of the registered manager is attached as appendices, Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 9 but some of the information contained in these documents was out of date. The home is required to have a Statement of Purpose and also a Service User Guide that includes the information shown under Regulations 4 and 5, and Schedule 1, of The Care Homes Regulations 2001. NHS nurses assess residents after admission to determine the level of nursing care needed. The amount of money paid by the NHS for this care is paid directly to the company (Dove Care Homes Ltd), who then deducts it from the month’s fees, as shown on monthly invoices sent to residents. The company is, however, required to inform residents in writing shortly after admission of the arrangements for refunding NHS money for their nursing care. The manager confirmed she assessed prospective residents before admission, usually in hospital or their home. Written evidence of pre-admission assessments was seen for a husband and wife admitted recently. A good range of information about their health care needs was recorded, but there was minimal information about their social history and hobbies. This information is helpful to staff to understand how people like to spend their time and what their interests are, and is also useful information for the activity organiser when planning activities. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 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): 8 The home has good links with healthcare professionals ensuring residents’ healthcare needs are met. EVIDENCE: Doctors from the local surgery regularly visit to provide medical care and registered nurses are on duty at the home 24 hours a day. The nurse in charge said the doctors were very helpful and very willing to give telephone advice between visits. Private physiotherapy can be arranged if residents choose to fund this themselves. A private physiotherapist was in the home during the inspection to treat one resident and advice was given to a nurse about the planned exercise programme that involved nursing staff assisting the resident. NHS physiotherapy is available following a GP referral, but there is a waiting list for this service. A chiropodist visits the home to give foot care, paid for by residents. Residents are assessed on admission for any skin damage to identify if there is a risk of pressure sores developing; evidence of assessments was seen in the care plans. Pressure relieving mattresses and cushions are supplied when needed and a number of residents had been provided with this equipment. No pressure sores existed at the time of inspection. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 11 Residents are also assessed for nutritional needs using the home’s nutritional assessment form. The manager confirmed that consideration was being given to using the nationally validated assessment tool used by community dieticians in Oxfordshire - the Malnutrition Universal Screening Tool (MUST). This was a recommendation made at the last inspection. Standard 9 was not assessed during this inspection but a discussion was held with the nurse in charge about the recommendations made at the last inspection. The nurse said that the GPs and community pharmacist had provided helpful advice about storage of a liquid medication used by many residents and also GPs signing medication record sheets. The nurse was confident that these matters would be satisfactorily resolved in the near future. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 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): 13, 14 and 15 The home operates open visiting to enable residents to maintain contact with relatives and friends. Dietary needs of residents are well catered for with a balanced and varied selection of food that meets their tastes and choices, but the deployment of staff at the start of lunch in the Eynsham dining room was insufficient to provide the level of assistance needed by some of the residents. EVIDENCE: The reception area is spacious and provides a pleasant entrance to the home. The administrator is situated in this area, which is helpful to visitors when they need assistance. The ‘Welcome to Freeland House’ documents states: ‘Visitors are welcome at anytime’. The staff spoken to had a good level of knowledge and understanding about promoting residents’ independence and choices, and helping them to stay independent for as long as possible. Residents can bring personal possessions into the home and the bedrooms visited contained many of these items; all looked comfortable and homely. Residents do not have routine access to their care records, but staff respect the right of residents to see their records if this is their wish. The manager has Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 13 information about advocacy services to give to residents when this service is needed. Residents gathered together in the Knott room at 12 o’clock to enjoy a glass of sherry before lunch. The activities organiser is on long-term sick leave and a carer has been allocated to cover her duties. This carer was originally scheduled to organise activities on the day of inspection, but was needed as a carer to cover sickness. She managed to fit in some activities late morning, including a sing-a-long to music when sherry was served. Two further members of recreational staff are employed to work part-time hours on specific days (including 6 hours on Saturdays), as well as a volunteer who visits twice a week. The two dining rooms are most attractive and the layout allows for ease of access and social interaction to take place. During lunch a hotel service is provided in the Bladon dining room for the more independent residents. Residents who require help are taken to the Eynsham dining room, but on the day of inspection there were too few staff at the start of lunch (two carers) to provide the level of help needed. Meals were served to all residents and five residents made no attempt to eat. Meals should be kept hot in the heated trolley until such time as assistance is available. A third carer was preparing a pureed meal in the kitchen and a fourth carer arrived to help when meals in the Bladon dining room were finished. Two members of staff were each seen assisting more than one resident to eat and this does not provide the one-to-one help that adds to a resident’s enjoyment of his/her meal. Also, these staff were standing and this is not conducive to staff or residents’ comfort or to a relaxed and unhurried mealtime for residents. Other staff were noted to be assisting residents more appropriately, sitting next to them and talking with them whilst the residents were given their meal. Two choices of main course and dessert are routinely provided, with alternatives individually cooked to meet residents’ likes and dislikes. Menus were not inspected on this occasion, but at the last inspection were assessed as ‘fully met’. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 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 complaints policy needs to be updated to ensure complainants know where to send a complaint. The home has systems to protect residents from abuse but needs to obtain local adult protection and prevention of abuse guidance and procedures, as well as ensuring that all staff attend training that is regularly updated. EVIDENCE: The complaints procedure was not amended when the ownership of the home changed in August 2005 and an employee of the previous company is still shown as the person to whom complaints should be sent. Also, the policy shows the regulatory authority as the ‘National Care Standards Commission’, whereas the Commission for Social Care Inspection (CSCI) has been the regulatory authority since April 2004. The procedure does not say that a complaint can be made to CSCI at any time and this must be stated. The manager has received three complaints since the last inspection; two were partially substantiated and have been resolved. The third complaint has been investigated and was not substantiated, although some of the concerns raised have not been fully resolved to the complainant’s satisfaction and a representative of the company is endeavouring to meet with the complainant. There has been no recent adult protection training and this must be arranged for all staff working at the home to ensure they have the knowledge and skills to detect possible abuse. The home does not have a copy of the Oxfordshire Interagency Guidelines for the Protection of Vulnerable Adults and a copy Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 15 should be obtained and brought to the attention of all staff working at the home, both during induction and subsequent training. Also, senior staff need to be aware of the local guidance in relation to how any concerns or allegations are investigated in Oxfordshire. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 16 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 The standard of environment within this home is generally good providing a pleasant place to live. One area for improvement is the corridor carpet on the ground floor, between the old and the new wings, that is stained and has a rip that is potentially a trip hazard. EVIDENCE: The home employs maintenance staff to keep the home in a good state of repair and standards were found to be generally good. Redecoration is ongoing and evidence of this was seen in a recently redecorated bedroom and en-suite facility. Décor and furnishings in the communal rooms are particularly good. Bathroom number 33 did not have a privacy lock and this should be fitted to ensure the privacy of residents who use this facility. A section of carpet on the ground floor (near to the Club Room) was badly stained and there was also a rip that is potentially a trip hazard. The manager said that the carpet is regularly cleaned but due to the heavy wear and the age Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 17 of the carpet, cleaning is ineffective. Therefore, consideration should be given to replacing this carpet. The grounds are extremely pleasant and provide good opportunities for the more physically able residents to enjoy the outdoor facilities. There are paths suitable for wheelchairs, although these are not provided throughout the grounds and wheelchair access in many areas is restricted. Following the last inspection the manager confirmed that this work was planned. Routine visits are made by Oxfordshire Fire Service and Environmental Health to check the standards required by these organisations are in place. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 18 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 and 30 On the day of inspection the number of staff on duty met the minimum requirements of the home’s staffing notice, below which staffing levels must not fall, but the deployment of staff to the Eynsham dining room at the start of lunch was insufficient to provide the assistance required. The number of carers with a National Vocational Qualification in care has not yet reached the required minimum ratio of 50 , but good progress is being made towards achieving this. Induction training is provided but could be improved by implementing the Skills for Care Council (formerly TOPSS) certified induction training. EVIDENCE: There has been staff sickness recently and a number of staff are working extra hours, as it is the home’s policy not to employ agency staff unless this is absolutely necessary. The manager said that one member of staff had left abruptly over the Christmas period without giving notice, and on the day of inspection two carers were off sick. The activity organiser is also on long-term sick leave and although a carer has been moved to cover this area of work, she has recently had to work as a carer on several occasions to cover staff sickness. At the time of inspection a new activity organiser had been appointed to work two hours a day, three days a week. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 19 There were 59 residents in the home, including one resident who was due to be discharged later in the day. There were four registered nurses and seven carers on duty from 8 am – 3 pm; four registered nurses and 7 carers from 3 pm – 8 pm; 2 nurses and 4 carers from 8 pm to 8 am. This level of staffing is at the lowest permitted level when there are 58 – 63 residents in the home. It was the view of the manager that the present staffing levels were adequate, and staff spoken to confirmed this, although a member of staff reported that residents’ care on the first floor during the morning was ‘running behind’. The reason for this was unclear. A carer said that a number of residents got up before the day staff came on duty and were helped to wash and dress by the night staff. The carer said this helped the day staff. The inspector was assured that residents did not get up unless they wanted to. The residents spoken to during the inspection were physically frail and some had mental confusion and could not give clear opinions of their care, or say whether staffing levels were satisfactory. The inspector noted, however, that residents looked clean and well dressed, indicating their personal care needs had been well met. Six carers have nursing qualifications obtained abroad that are equivalent to level 3 NVQ in care, or above; five carers are currently on NVQ training. Whilst the home has not yet reached a minimum ratio of 50 trained members of care staff and cannot therefore be given a ‘fully-met’ score for Standard 28, the manager is nevertheless commended for her encouragement and commitment in supporting staff through this training. All new staff are provided with a period of induction and work with a senior member of staff until they are assessed as competent to work alone, but the present induction does not fully meet national workforce training targets. It is recommended that the Skills for Care Council (formerly TOPSS) certified induction training is implemented to ensure nationally set training targets are achieved. This induction programme links into NVQs and would be helpful to staff when undertaking this training. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 20 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): 33, 35 and 38. The present system whereby the manager obtains residents’ views informally during day-to-day conversations is good, but there are no formal quality assurance and quality monitoring systems in place for residents to be assured their views are sought and acted upon. The management of health and safety issues is generally good but the manager must take action to stop bedroom doors being wedged open as this potentially puts residents at risk if a fire were to occur. The manager arranges regular handling and moving training, but two members of staff were seen to use a lift that is not recommended and the manager must take action to ensure that staff are reminded of the correct procedures. EVIDENCE: The last time that formal questionnaires were sent out was in April 2005 by the home’s previous owner, but the manager did not receive feedback about the Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 21 findings. The new owners have not yet obtained any formal feedback from residents or their relatives and this should be done to find out what people living in the home think about the services provided. The manager said she obtains informal feedback during day-to-day conversations with residents, relatives and staff when she walks round the home. She also has an ‘open door’ approach enabling people to see her without appointments. Staff spoken to confirmed this. Residents and relatives meetings have not been held recently and none are currently planned. Residents control their own money until they are no longer capable of doing so, when the responsibility for this passes to a relative or a representative. The company pays incidental expenses on behalf of residents at the time they are incurred, e.g. chiropody and hairdressing costs, and invoices are sent to residents (or a representative) monthly. The inspector saw a bedroom door on the first floor wedged open placing the resident at potential risk if a fire were to occur. A similar situation regarding another bedroom door was found at the last inspection. The manager must ensure that bedroom doors that need to be kept open to meet residents’ wishes are fitted with appropriate ‘hold-open’ devices that are linked to the home’s fire alarm system. This would ensure doors closed automatically if the fire alarm rang. Any device fitted to a fire door must have the approval of Oxfordshire Fire Service. Staff spoken to confirmed they had received fire training and were able to say what they would do in the event of a fire. The staff also confirmed they had had moving and handling training. However, the inspector observed one resident to be assisted out of her wheelchair by staff using the ‘under-arm’ lift, which is not recommended as this has the potential to cause nerve and/or soft tissue damage under the armpit. The manager said staff were informed of the correct moving and handling techniques during regular training and would ensure that senior staff monitored the practices in this area of care. It is recommended that all staff receive a moving and handling update to remind staff of good practice. Fire training records and general maintenance records were inspected at the last inspection and were found to be in good order. Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 22 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 2 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 23 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 OP1 Regulation 4, 5 and Schedule 1 Requirement The home must have a Statement of Purpose and a Service User Guide. A copy of each document must be submitted to CSCI. The manager must arrange for written information to be produced that explains to residents how they receive NHS money for nursing care. The manager must ensure the complaints procedure includes the required information. All staff must receive training in protecting vulnerable adults from abuse. The manager must review the staffing arrangements during mealtimes to ensure sufficient staff are deployed to provide the help that residents need. The manager must ensure that bedroom doors are not propped open as this places residents at risk if a fire were to occur. Timescale for action 31/03/06 2 OP1 5a 31/03/06 3 4 5 OP16 OP18 OP27 22 13(6) 18(1)(a) 31/03/06 31/03/06 17/02/06 6 OP38 23(4)(e) 31/01/06 Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 24 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 OP3 OP15 Good Practice Recommendations Pre-admission assessment should include details of residents’ social interests and hobbies in order that the activity programme can be structured accordingly. ●Staff should give one-to-one help when helping residents to eat. ●To ensure a relaxed and unhurried mealtime staff should sit down next to residents when giving assistance. The Oxfordshire interagency guidance on the protection of vulnerable adults should be obtained and staff instructed on its contents. Fit a privacy lock to bathroom number 33. Replace the ground floor corridor carpet that is heavily stained, to include the section that is ripped. Implement the Skills for Care Council (formerly TOPSS) certified induction training to ensure nationally set training targets are achieved. Quality assurance and quality monitoring systems should be in place in order to obtain the opinions of residents and relatives about the services the home provides. Arrange for staff involved in providing care to residents to attend a refresher course in handling and moving to ensure that correct moving and handling procedures are followed at all times. 3 4 5 6 7 8 OP18 OP19 OP19 OP30 OP33 OP38 Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Freeland House Nursing Home DS0000027150.V276796.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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