Inspection on 30/10/06 for Oak House

This inspection was carried out on 30th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Oak House 11/09/07

Oak House 17/04/07

Oak House 02/11/05

Oak House 06/06/05

Oak House 20/12/04

Oak House 08/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Oak House Oak House 19 Queens Road Weybridge Surrey KT13 9UE Lead Inspector Suzanne Magnier Unannounced Inspection 30th October 2006 10:00 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 Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oak House Address Oak House 19 Queens Road Weybridge Surrey KT13 9UE 01932 851925 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) Dr Ajit Prasad Mrs Nishi Prasad To be confirmed Care Home 16 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (3), Old age, not falling within any other of places category (16) Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age range of the persons to be accommodated will be over 65 years of age with the exception of one resident aged 60 - 65 years. Of the 16 service users accommodated 3 may be within the category DE(E). Of the 16 service users accommodated 1 may be within the category DE. 2nd November 2005 Date of last inspection Brief Description of the Service: Oak House is a large detached property situated within walking distance of Weybridge town centre. The home provides accommodation and care for up to 16 older people, 3 of whom may also have dementia. There are currently 14 service users living in the home. The home has a large TV lounge, a smaller quiet lounge and a separate spacious dining room. All bedrooms are single occupancy and are arranged over two floors, all except one have en-suite facilities. Bathrooms are situated on the ground and first floor and both have a chair hoist fitted. There is also a further toilet on the ground floor. The first floor may be reached by a passenger lift or stairs. The home has a good sized, enclosed and well- maintained rear garden that is accessible to the service users. The home has its own mini-bus, used to facilitate service users activities, and ample parking to the front of the building. The current fees range from 359.00-555.00 Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit of the key inspection process took place over eight hours commencing at 10.00 and ending at 18.00. Ms S Magnier regulation inspector carried out the inspection. The service manager represented the home. A tour of the premises took place and the inspector saw the majority of the residents and spoke to some of them in more detail. Residents, relatives, friends and other health care professionals comments, which were gained prior to the inspection have been included in the report. Records were also sampled as part of the inspection process including care plans, health and safety records, menus, accident records, policies, procedures and staff files. The inspector would like to thank the residents, staff and managers for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 6 The home must ensure that all resident’s needs have been appropriately assessed by a suitably qualified or trained person in order to ensure that the home can provide appropriate care to meet resident’s needs. The service manager was aware of the shortfalls regarding the care plan documentation and advised the inspector that new care plans had been developed. These need to be documented and implemented. The home must document robust risk assessments for all residents in order to ensure the safety and well being of residents. Staff availability at mealtimes must be reconsidered in order to ensure that appropriate support is available to residents at mealtimes if they require assistance. The registered person must ensure that suitable storage facilities are provided for the purpose of storing walking frames and garden cushions to ensure that the resident’s lounge is safe and comfortable. The bathrooms and toilets in the home could be improved by offering a more homely touch for example coloured blinds, pictures, bathroom ornaments in order that residents may find the bathing environment more stimulating. The registered manager must ensure that the malodour present in several resident’s bedrooms is eliminated to promote resident’s dignity and respect. Gaps in the homes recruitment practices included one staff file with only one reference, no evidence that a new member of staff had received a formal induction to the home and gaps in the staff training records. It is required that the home improve the recruitment policy and procedures in order to fully protect residents. A previous requirement that the home ensure that accurate and accountable records of training are maintained for all staff members was not evidenced during the inspection and a further requirement has been made that the updated record is sent to CSCI local office. The method of storing resident’s money requires review in order to ensure improved security of the resident’s monies. It has been required that the home review the current laundering system and storage of clean laundry to ensure that arrangements are in place to prevent infection, toxic conditions and the spread of infection at the home. During the tour of the premises the inspector and the service manager tested the water outlets in all the service users bedrooms. A significant number of water temperatures exceeded the safe limits and posed a potential hazard of scalding service users and staff. An immediate requirement was made that Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 7 the registered person must ensure that a suitably qualified technician tests all water outlets in the home and water temperatures are reduced to the required safe limits to ensure the safety of service users and staff. The temperature of the water must be close to 43 degrees centigrade. . 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. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 8 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 Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 9 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): 1,2,3,6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is currently updating the Statement of Purpose and the Service User Guide. Improvements have been required regarding the homes admission and assessment procedures to ensure that resident’s needs are appropriately identified and met. EVIDENCE: The inspector sampled that the Statement of Purpose and the Service Users Guide. The Service Manager advised that he was aware of the Care Homes Regulations had been recently amended with regard to the Service Users Guide and these amendments were being included in the document. The homes Statement of Purpose had been recently updated and during the tour of the premises the inspector noted that a copy was available in each residents rooms. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 10 Whilst sampling the resident’s files the inspector noted that documentation was available for residents regarding their contracts and terms and conditions of residency in the home. Several care plans sampled evidenced that resident’s needs had been assessed prior to them moving into the home. Local authority assessments were evidenced yet the documented assessment undertaken by the home lacked sufficient information regarding the support and care needs of the resident. It is required that the home improve the standard of the assessment in order to ensure that the care home is suitable and can provide the support and care for the individual. Intermediate care is not offered by the home. The home was displaying only the front page of the Certificate of Registration and following the inspection a new certificate has been sent and both pages must be displayed within the home. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 11 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): 7,8,10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The resident’s individual plans of care were inadequate to demonstrate that their health and personal care needs and hazards in their daily lives had been assessed and met. There was clear demonstration that residents were responded to in a respectful manner and their privacy respected. EVIDENCE: Comments received by visitors and relatives of residents in the home at the time of the inspection were favourable. The inspector observed that residents and staff interacted well and residents told the inspector that they felt well cared for and that staff treated them with respect and dignity. The inspector sampled three resident’s care plans. The documentation of the assessments and care plans was insufficient to evidence that the resident’s personal care needs, medical needs, daily routines, lifestyles and hazards in their daily lives had been appropriately assessed, recorded and were being met for example: Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 12 Two care plans lacked the resident’s diagnosis. There was insufficient detail with regard to resident’s personal care needs, preferred ways they liked to receive personal care and records to evidence what personal care the person had received. There was insufficient detail regarding the residents mealtime support. For example the care plan for one person stated that food must be cut up. The inspector observed the person being supported by staff at their midday meal as opposed to their food being cut up and the individual eating independently. This occasional support was not documented in the persons care plan. Two care plans documented that the residents were confused however there was no documented risk assessments regarding staff support methods to assist the resident during episodes of confusion or distress. Two care plans documented that the residents were prone to falls and had poor mobility. There was no evidence of completed falls risk assessments regarding the prevention and safeguarding the person from harm. The three care plans did not include moving and handling risk assessments in order to ensure that safety of the resident and staff supporting them. The home has reported a significant number of un-witnessed falls to the Commission for Social Care Inspection (CSCI), which occur during the nighttime in residents rooms. There was no evidence to support that preventative measures had been taken to prevent falls in peoples bedrooms. For example environmental room risk assessments, bed leaving alarms and assessed use of bed rails. There were no associated risk assessments regarding the care of resident’s with diabetes for example staff response in emergencies, the twice daily visits by the district nurse and chiropody needs. One service user had been recently bereaved and there was no records within their care plan regarding arrangements made for the person to attend their relative’s funeral or for the potential need of additional emotional support at this time. One resident told the inspector that whilst she was aware that the staff had to help her stay as independent as possible she found it difficult to dress herself in the mornings as she suffered from dizziness and she would prefer if staff helped her more. Some records were available to evidence that resident in house care reviews had taken place. Some records were not signed and dated by the homes staff. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 13 The service manager was aware of the shortfalls regarding the care plan documentation and advised the inspector that new care plans had been developed and would be documented and implemented as soon as possible. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A variety of activities take place both inside and outside of the home. Visitors are welcomed to the home to maintain contact with their family members. The food at the home was of a good standard. The dining arrangements in the home had been improved although further improvement must be considered regarding the allocation of staff at meal times in order that they are available to support residents with their meals if required. EVIDENCE: The inspector sampled the meeting minutes of a resident meeting recently held at the home. Several residents had commented that they enjoyed the trip to Windsor and other suggestions of future outings included a pantomime, pub lunches and a boat trip. Residents also stated that they did not want to do much in the afternoons after their lunch. The homes atmosphere was observed to be calm and homely throughout the whole of the inspection. Several residents were having their hair dressed by the hairdresser who has been visiting the home for several years. The residents said they liked to have their hair done as it made them feel ‘special’ and commented that the hairdresser ‘did a good job’. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 15 The home has two lounges and it was noted that most of the residents chose to sit in the larger lounge rather than the smaller one. One gentleman sitting in the smaller lounge said it was nicer as it was more quiet, the inspector noted that later in the day he chose to sit in there with his relatives. All visitors spoke highly of the staff and the care received, and felt happy to approach the staff. The service manager explained that resident’s cultural and religious needs could be met by the home and pastoral care could be arranged. Several residents enjoyed reading the daily paper, which is delivered to the home each day. The inspector noticed that residents were free to move around the home freely and one resident had a little walk around the enclosed garden. The home has made improvements in the dining area, which include a new menu, which is available on all the dining tables, floral centrepieces, tablecloths, individual nameplates and napkins available for residents. The meal served was well presented and nutritious. One resident was observed to need assistance and staff were not available to help or assist. The service manager intervened and advised the staff that the resident’s meal should have been kept back and served later in order to ensure that the resident’s meal was hot and that a member of staff could support them with the meal. It has been required that the mealtime staff deployment be reconsidered in order to ensure that appropriate support is available to residents at mealtimes if they require assistance. It is recommended that the home ensures all resident’s have a nutritional risk assessment in order to ensure that their nutritional needs are maintained, as these were not available. One resident told the inspector that they were not sure what their liquidised diet consisted of and that it would be helpful to know. During the inspection the service manager advised the inspector that the liquidised meal was the same as the menu and a member of staff was asked to confirm this information to the resident. The service manager explained that the home had recently been considering the use of specialised food shapes for residents as this could assist in helping residents who have liquidised meals. The menus sampled by the inspector have been updated and residents were observed to read the menus during their meal. The menus were noted not to include choices yet several residents told the inspector that they could ask the staff if they wanted a choice. During the inspection the service manager amended the menus to include a statement to let the residents know there was a choice available and to ask a staff member if they wanted something other than what was on the menu. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 16 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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are protected by the homes complaints and safeguarding adults procedures. Actions taken by the home when investigating complaints has been more fully developed. EVIDENCE: The home has recently updated the complaints procedure and the manager stated that the simplified complaints procedure will be placed within each resident’s bedroom. The home has developed a statement for Care and Protection, which assists residents to reflect upon the practices of the home and to report any concerns to the manager. The home has a complaints logbook available within the service. Visitors spoken with during the inspection told the inspector that they would approach the staff or the manager if they needed to complain. The home had been subject to a vulnerable adults investigation, which has been concluded by the Surrey multi Agency Safeguarding Vulnerable Adults policies and procedures. The home has a whistle blowing policy. The staff files evidenced by the inspector demonstrated that the staff had undertaken safeguarding adults training. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained. Residents have access to comfortable communal facilities and private accommodation. Several requirements have been made regarding more appropriate storage of items, eliminating some malodours in the home and improving the décor in the resident’s bathrooms to promote a more pleasant surrounding. EVIDENCE: The environment of the home was generally well decorated and maintained. The inspector noted that there were small areas for example the peeling wallpaper on the ceiling in an upstairs corridor that needed attention. The home has grab rails on walls throughout the home and window restrictors on all upper floor windows to ensure the safety and welfare of residents. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 18 The home has an enclosed well-maintained garden, which the inspector noted was well equipped for residents to use and included substantial garden furniture. The number of bathrooms and toilets in the home were sufficient for the needs of the residents and could be improved by offering a more homely touch for example coloured blinds, pictures, bathroom ornaments in order that residents may find the bathing environment more stimulating. The inspector noted that throughout the home several portable hoists which had been serviced. Grab rails are sited on the majority of the homes walls to assist resident’s independent mobility and safety whilst moving around the home. The inspector sampled all the resident’s bedrooms. All rooms were well furnished, homely and well decorated. The residents had some of their own furnishings; personal items, photos and the rooms were comfortable. Several residents told the inspector that their rooms were nice, cosy and they felt very comfortable. The communal areas of the home were viewed as comfortable however the inspector noted that in the small lounge a variety of walking frames, garden chair cushions and other items had been stored behind the door causing a potential risk to residents. It is required that this area is cleared and the items stored in a more appropriate place. Four bedrooms within the home had a malodour and the Service Manager advised that the home would be purchasing a specialised cleaning material as soon as reasonably practicable in order to eliminate the odour. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing levels of the home were evidenced as adequate to meet the current needs of residents. The residents were not fully protected by the homes recruitment policy and procedures and records of staff training evidenced gaps. EVIDENCE: Improvements have been made regarding the management of staff records. The inspector sampled several staff files and overall the home has undertaken good recruitment and training practices although several gaps were identified. The inspector sampled that criminal records checks (CRB) had been obtained for all current staff. The gaps included one staff file with only one reference, no evidence that a new member of staff had received a formal induction to the home and gaps in the staff training record. It is required that the home improve the recruitment policy and procedures in order to fully protect residents. A previous requirement that the home ensure that accurate and accountable records of training are maintained for all staff members was not evidenced during the inspection. A training chart was noted on the office wall but had not been completed. The service manager advised that the training records would be sent to CSCI following the previous inspection but at the time of writing the Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 20 report these had not been received. A further requirement has been made that all staff training records are updated and are accessible in order to ascertain the staff training requirements to ensure competent and trained staff support residents. The staff files evidenced that some staff supervision had taken place and five staff are currently registered and are waiting to start their National Vocational Qualification (NVQ) Level 2 in care. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home was under review and arrangements had been made to advertise for a new manager. Requirements have been made that the home review the current policies and procedures with regard to the safekeeping of residents money, arrangement in the homes laundry regarding the prevention of spread of infection in the home and immediate attention to the water temperatures in all water outlets in the home to ensure that the health, safety and welfare of residents and staff. EVIDENCE: The inspector was advised that the registered manager had recently left the service and an acting manager had been appointed. The acting manager was not present at the inspection as it was her day off. The service manager told the inspector that the management post was currently being advertised. Two Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 22 residents told the inspector that they were going to be involved in the recruitment of the new manager and join in the interview. Throughout the inspection the inspector observed that the residents were spoken to respectfully and that staff listened. The routines of the home promoted residents rights of inclusion in their home. Quality Assurance arrangements in 2006 included feedback from the residents meetings regarding the home. The inspector sampled the homes financial procedures and storage of resident’s funds. All transactions and receipts were recorded and sampled as correct by the inspector. The resident’s money was stored in a filing cabinet in marked plastic containers. It has been required that this system is reviewed in order to ensure the security of the residents monies. The inspector sampled the laundry area of the home and noted that the laundry was small, clean and tidy and every effort had been made to keep the area safe. The inspector noted that soiled laundry in the room was stored with clean laundry, which posed an infection control hazard. It has been required that the home review the current laundering system and storage of clean laundry within the home to ensure that arrangements are in place to prevent infection, toxic conditions and the spread of infection at the home. During the tour of the premises the inspector and the service manager tested the water outlets in all the service users bedrooms. A significant number of water temperatures exceeded the safe limits and posed a potential hazard of scalding service users and staff. An immediate requirement was made that the registered person must ensure that a suitably qualified technician tests all water outlets in the home and water temperatures are reduced to the required safe limits to ensure the safety of service users and staff. The temperature of the water must be close to 43 degrees centigrade. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 23 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 3 1 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 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 3 3 3 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 1 Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 24 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 OP3 OP7 OP8 Regulation 12 (1)(a) (b) (2) 14.(1)(ad) (2)(b) 15.(1) (2)(a-d) 13 (4) (a-c). Requirement Timescale for action 30/10/06 2. OP7 OP8 3. OP15 12.(1)(b) The registered person must ensure that residents needs have been assessed by a suitably qualified or trained person and the residents assessment and plan of care are kept under review to ensure proper provision for the health and welfare of residents. The registered person must 30/10/06 ensure that robust risk assessments are documented for all residents and ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety, any activities and in which the resident participates are so far as reasonably practicable free from avoidable risks and any unnecessary risks to their health or safety are identified within the risk assessment and as far as possible eliminated. The registered person must 13/11/06 ensure that the mealtime staff deployment be reconsidered in order to ensure that appropriate support is available to residents DS0000049203.V302596.R01.S.doc Version 5.2 Oak House Page 25 4 OP19 23.(2)(m) 5 OP26 12.(4)(a) 6 OP29 7,9,19 Schedule 2 17 (2) Schedule 4 (6) (g) 7 OP30 8 OP35 13.(6) 9 OP38 13.(3) 23.(2)(l) 10 OP38 13.(4)(ac). at mealtimes if they require assistance. The registered person must ensure that suitable storage facilities are provided for the purpose of storing walking frames and garden cushions to ensure that the resident’s lounge is safe and comfortable for residents. The registered manager must ensure that the malodour present in several resident’s bedrooms is eliminated to promote resident’s dignity and respect. The registered person must ensure that robust recruitment and selection procedures are implemented in order to fully protect residents. The registered person must ensure that accurate and accountable records of training are maintained for all staff members and a copy of the record sent to CSCI local Eashing office. Not met 06/07/05 The registered person must ensure that an improved system of storing resident’s money is implemented in order to ensure the security of the resident’s monies. The registered person must ensure that the home reviews the current laundering system and storage of clean laundry within the home to ensure that arrangements are in place to prevent infection, toxic conditions and the spread of infection at the home. The registered person must ensure that a suitably qualified technician tests all water outlets in the home and water temperatures are reduced to the DS0000049203.V302596.R01.S.doc 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/12/06 30/10/06 Oak House Version 5.2 Page 26 required safe limits to ensure the safety of service users and staff. The temperature of the water must be close to 43 degrees centigrade. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations Further development is recommended that the home ensures all resident’s have a nutritional risk assessment in order to ensure that their nutritional needs are maintained. Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Oak House DS0000049203.V302596.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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