Inspection on 16/08/07 for Oak Mount Rest Home

This inspection was carried out on 16th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official 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 Mount Rest Home 11/07/06

Oak Mount Rest Home 15/09/05

Oak Mount Rest Home 12/04/05

Oak Mount Rest Home 15/12/04

Oak Mount Rest Home 10/08/04

Oak Mount Rest Home 13/02/04

Oak Mount Rest Home 27/03/03

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Oak Mount Rest Home 2 Narrow Lane Poulner Ringwood Hampshire BH24 3EN Lead Inspector Anita Tengnah Unannounced Inspection 10:00 16 August 2007 th 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 Mount Rest Home DS0000011855.V343034.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 Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oak Mount Rest Home Address 2 Narrow Lane Poulner Ringwood Hampshire BH24 3EN 01425 479492 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) Mr M J Foot Mrs H A Foot Linda Bath Care Home 21 Category(ies) of Dementia (21), Dementia - over 65 years of age registration, with number (21), Mental disorder, excluding learning of places disability or dementia (21), Mental Disorder, excluding learning disability or dementia - over 65 years of age (21), Old age, not falling within any other category (21) Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in categories MD and DE must be at least 60 years of age. 11th July 2006 Date of last inspection Brief Description of the Service: Oakmount Rest Home provides accommodation and care for 21 residents in the categories Old Age, Old Age with dementia and Old Age with mental disorder. People in the categories Dementia and Mental Disorder may not be admitted under the age of 60 years. The service has a registered manager who is in day-to-day control of the home. Mr. M. and Mrs. H. Foot own the service with a second home in Southampton. The property is a large family home that has been extended to provide accommodation on two floors. All bedrooms are single and 7 have en suite facilities. There is one bedroom that is currently shared by a couple and the other bedroom is allocated as a sitting area and contains the couple’s furniture. Shared areas comprise a dining room, large lounge and conservatory. Upstairs rooms are reached by a stair lift. The ground floor does not have level access to all areas, as there are a number of single steps to communal areas and some bedrooms. Because of this the home is unable to offer accommodation to residents who need to use a wheelchair. The home is situated at the end of a quiet residential road, close to local shops, amenities and public transport. The current fees range between £410- £445 per week. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the service was undertaken as part of the inspection on the 16th of August 2007. The process included looking at a number of the bedrooms, communal areas, kitchen, and bathrooms. As part of case tracking 3 staff and 7 service users views were sought and care records were looked at. Information gained from the Annual Quality Assurance Assessment (AQAA) was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. Positive comments were received from the people using the service regarding the care that they were receiving at the home. The commission received 7 comment cards from the service users and some contained input from their relatives. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and care was provided in a respectful manner. What the service does well: What has improved since the last inspection? What they could do better: Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 6 The pre admission process must include an assessment of needs prior to admission to the service. This would ensure that the home could meet the needs of the people using the service. Care plans must be in place following assessments on admission so that the home can demonstrate how the people using the service assessed needs would be met. The procedures for handling, ordering and disposal of medication need further developing and staff must adhere to these for the safety of the people using the service. There must be an audit system in place to seek the views of people using the service. This has remained outstanding from the previous visit. All the checks must be undertaken as required as part of staff recruitment in order to ensure that the people using the service are protected. All staff must complete mandatory training in health and safety to ensure that the people using the service are not put at risk. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 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 Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 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. 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 assessments of the people using the service must be part of the pre admission process in order to ensure that the home can meet their needs. EVIDENCE: The manager reported that the people using the service are assessed prior to admission. They are also offered the opportunity to come in and spend some time at the home. One of the comment cards received indicated that the person did visit prior to admission. A sample of three recently admitted people care records was seen as part of this visit. All of these people using the service were admitted in March 07. The manager reported that two of them came in for respite care with a view of remaining at the service long term. There were no pre admission assessments available for both of these people. The manager said that she was sure there were further documents relating to these people but these could not be found. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 9 The two people were referred to the service through social services and a care manager’s assessment should have been sought in order to gain some information about the people using the service needs. The other person was admitted from out of county and the manager reported that an assessment of her needs was carried out on admission. The manager must ensure that a pre admission assessment is carried out prior to people being admitted to the service. This would help in decision- making process in gaining the right information to ensure that the home can meet their needs. The home undertook a long- term assessment needs of the people using the service on admission. The two people admitted for respite care have now been offered permanent residency and social services had completed a review in July 07. Both of thee new people spoken with said that they had settled in well and they thought their daughter might have been given information about the service. The service does not provide intermediate care. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 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. 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. 7,8,9,10 The care plans seen contained appropriate information, however care plans must be in place following admission. This would provide details of how the assessed needs would be met. The health care needs of the service users are met. The medication management relating to ordering, storage and returned medication require further development. The service users are treated with respect and their dignity maintained. EVIDENCE: Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 11 The records of 3 people using the service were looked at as part of this visit. The care plans contained general risk assessments and specific assessments like assistance needed for a service user who was prone to falls. The plans also contained diabetic care plan for one of the service users who was on a diabetic diet. The documents included the plans of care that had been developed following a long- term need assessment that had been carried out on admission to the home It was noted that the care plans were not formulated until June 07 whilst the people using the service had been admitted in March 07. This was discussed with the manager and care plans must be in place and set out in details the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs of people living at the home are met. This would help in promoting consistency in care and give clear details oh how the assessed needs would be met. The record showed that care plans were being reviewed at three monthly intervals. This was discussed with the manager as Standard 7.4 indicates that the service user’s plan is reviewed at least once a month and updated to reflect changing needs of the service users. Further development in assessments to include the psychological needs assessments must be in place. These had not been completed in the three care plans seen. This was discussed with the manager as this related to two of the service users who demonstrated aggressive behaviours and were verbally abusive to staff. There were no assessments or care plans to demonstrate how these were being managed. Care plans must be in place to give detail of action that the staff needed to take and to inform practice. The manager said that she was aware of this shortfall and action would be taken to rectify this. It was evident that the service users received appropriate support from the community health team in order to meet their needs. The manager reported that the GP was available on request but did not undertake routine visit to the service. However the nurses were very supportive and provided assistance in particular with terminal care as required. The manager ensures that the service users have access to optician, dental care. One of the service users was referred to a local dentist and had been visited at the home and started treatment. The chiropodist visits on a six weekly basis. The manager reported that she made referrals to the incontinence team to assess the people using the service as require. A system for ordering incontinence pads was in place and the manager said that this worked well with extra support from the district nurses if they run short. A record of the continence assessment should be maintained of the people using the service and used as part of care planning. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 12 A sample of the Medication Administration Record (MAR) was looked at. A requirement was made at the last visit to ensure that medication administration records are maintained in accordance with the homes policy and this related to gaps on the MAR sheets. Appropriate recording was in place for medication administered and included records of ointments applied. This requirement has been met. The manager said that she carried out random checks of the MAR sheets and staff had been instructed to ensure that MAR records are up to date. There were some medications that were not maintained securely such as inhalers for two people using the service at the time of the visit. This was brought to the attention of the manager. A record of medication received at the home was available. The manager confirmed that only staff who had completed the medication training were responsible for the medication management. The records of medication returned as kept by the home were not up to date. The last record of medication returned was dated February 2006. The manager reported that there is another book and the chemist has sent them the wrong book. The record of medication returned must also contain the name of the person for whom the medication was prescribed, as this was not available. This would help in providing an audit trail of medicines through the care home. The manager is required to ensure that there is an up to date record of medication as disposed by the home. It is recommended that the MAR sheets are reviewed to ensure that these only contained medication that are currently in use. A system for staff for identifying the people they are administering medication to should be in place as discussed such as a photo of the resident. The medications that were no longer required including those belonging to people no longer at the service had not been returned. There was evidence that the stock control was poor and resulted in large stocks of ointments for some of the people. The manager discussed that the home did not keep a copy of the medication ordered. The manager/delegated person at the home did not have sight of the prescriptions as these were sent to the chemist by the surgery. It is also the responsibility of the manager/ designated person at the home to sign the exemption declaration form on behalf of the service users, if they are unable to do so themselves. These issues were brought to the attention of the manager and further guidance can be found in the Royal Pharmaceutical Guidance publication .The manager said that she was not aware of the guidance, advised on how to access it, a copy was later found at the home. The home has a homely remedy list agreed by the GP dated 2005. It is recommended that the list is reviewed and updated. All other medication maintained by the home that is not on the homely remedy list must be disposed of safely. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 13 The service users spoken with and comments received indicated that the service users are treated with respect. It was evident from the interaction observed that the staff and people using the service had developed good relationships. Comments included “they are all made to feel it is their home and they are shown constant affection by the staff”. Another comment was “I can get up when I am ready and this is all right”. Others said that the “staff are kind” and “nothing to grumble about”. Oak Mount Rest Home DS0000011855.V343034.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 The social and recreational needs of the service users are well managed. Contacts with family are encouraged and supported. Meals are satisfactory and the people are offered a choice. EVIDENCE: The people spoken with and comments received indicated that they enjoyed the activities provided at the service. Activities included games, chair aerobics and quizzes. The local college also attended the home and provided art classes though suspended during the holidays. The care staff provided most of the activities and the manager reported that external entertainers attended the service monthly. One of the service users spoken with said that she was aware and heard the activities from her bedroom but preferred not to take part. Other comments were that one enjoyed her knitting and another one liked to spend her time doing puzzles. An activity session observed was interactive and the people appeared to enjoy. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 15 The home has an open visiting policy and the people spoken with said that they usually entertained their visitors in their rooms or the quiet area in the conservatory. A record of visitors to the home was maintained and it was evident that people visited at different times. The home has a menu that was displayed in the entrance hall. The service users said that they usually asked the staff about what was for lunch. The provider, the manager or carers cook the meals at the home. Comments received and the service users spoken with said that the meals were good and there was a choice. Comments were “ staff will always change it to something I like”. Another person said that the food “was all right and plenty to eat”. One of the service users said that she did not like the lunchtime meal on the day of the visit and the manager offered her an alternative. A record of food temperature and meals provided was maintained in the daily diary including alternative puddings for the two diabetics at the service. Lunchtime meal was observed in the dining room and the conservatory area. Staff were available to offer support with meals as required. One of the service users said that she enjoyed joining the others for meals, although chose to spend her time in her bedroom at other times. Oak Mount Rest Home DS0000011855.V343034.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16,18 The service users were confident in raising any concerns with the staff. Staff have understanding of adult protection and ongoing training ensures that the service users are protected. EVIDENCE: The home has a complaint procedure and five comment cards from service users indicated that they were aware of the procedure. Some said that they would speak to the manager if they had any concerns. One of the comment card indicated that no information about raising complaints was provided. The complaint procedure was displayed in the entrance hall. Comments included “I have nothing to complain about” and “everything at the moment is good”. There was a complaint log in place and there was no recorded complaint since the last visit. There were also some compliments cards from people who had used the service. An anonymous complaint was sent to the home following the last visit for the home to investigate. There was no record of this in the log seen. The manager discussed that one of the service users had recently raised concerns about the use of her toilet by other service users. This related to Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 17 occasions when other people were using her bedroom for GP visits. The manager reported that this had been resolved. Discussed that this should have been recorded in the complaint log with details of action taken. The home had a copy of Hampshire’s protection of vulnerable adults procedure. The manager reported that training in adult protection was available for staff. Record seen indicated that 7 staff members had completed a 2- hour course on abuse awareness. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 19,26 The service provides the people living there with a homely environment. The infection control facility at the home needs further development to ensure the safety of the people using the service at all times. EVIDENCE: Accommodation is provided in a comfortable and homely environment with a good complement of communal areas for the people living at the service. Furnishing n the communal lounges was clean and appropriate to the people using the service needs. The bedrooms seen were highly personalised and the service users spoken with said that they were supported to bring in items of personal belongings on admission. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 19 The home has well maintained gardens and some of the people’s bedrooms overlooked the gardens. The people spoken with were complimentary about the views from the lounge and bedrooms. Comments were “it is a lovely garden”. Another service user said that she enjoyed sitting in the garden but this had not been possible due to the poor weather so far. Seating was provided in the garden. There was some building work at the time of the visit; the manager reported that the first floor landing was being extended to allow for easier access for wheelchairs if required. One of the bedrooms would be fitted with an en suite toilet and work was ongoing to replace the sluice room and office space. The carpet in the first floor landing had been lifted and the underlay was exposed that was loose and posed a trip hazard. This was brought to the attention of the manager and must be made safe. It was noted that one of the bedrooms had an unpleasant odour that the manager said was from the carpet. The manager said that this bedroom was due for refurbishment and the carpet would be replaced. There was a bedroom that had been allocated as a sitting room and contained the people’s wardrobes. However this area was not accessible to the people and found in a poor state. This was used as storage while the building work was taking place. The manager must ensure that all accommodation provided for the service users use is available and accessible to them at all times. Another bedroom’s call bell was not accessible to the resident as the call bell was behind the wardrobe. This was brought to the attention of the manager and must be rectified. The home has assisted bathrooms and a newly refurbished shower facility that was suitable for people with limited mobility. The manager said that the people living there enjoyed the shower facility. The home has a laundry and all the people using the service had their laundry undertaken internally. The laundry room was fitted with a washing machine and dryer. The washing machine was fitted with sluicing facility. The provider confirmed that a procedure was in place and staff did not use the kitchen to access the laundry as part of infection control. There was no soap dispensers or disposable towels in the communal areas such as bathrooms and toilets. This was discussed with the manager as the current system pose an infection control risk to the staff and people using the service. The provider later reported that he has been looking into this. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 20 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. 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. 27,28,29,30. The home has adequate staff to meet the present needs of people living there. The recruitment procedure does not fully protect the people using the service. The programme for NVQ training is good. However training in health and safety is lacking. EVIDENCE: The home has rota for carers and a separate rota for the domestic hours. The duty roster indicated that there are 3 care staffs in the morning, 2 in the afternoon and two waking night staff. The manager reported that the 2 domestic staff were responsible for the cleaning and the laundry. The last report indicated that there need to be on ongoing review of the cook’s hours as the manager and carers undertook the cooking at the service. This situation remains unchanged. Comments from people using the service included “ the service is homely and friendly and the girls are always helpful.” They say “usually there are enough staff when they require assistance”. Other comment was ” there is inadequate staff to the resident’s ratio” and “frequently there are only two staff on duty.” The provider said that he was recruiting more staff and a night carer was due Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 21 to start next week. He was very aware of the extra hours that the staff put in to provide cover and was trying to manage this. There is a programme of National Vocational Qualification (NVQ) training available for the carers. The manager reported that six carers had completed NVQ 3 and two were undertaking NVQ 2 in care. Induction records were seen for three of the staff and the manager reported that they were using the Hampshire care induction. The manager is aware that the induction should meet the Skills for Care programme for carers. A sample of three staff records was seen as part of the visit. The applicants completed an application form and references were sought. However not all the checks such as CRB and POVA first were in place prior to employment. One had full clearance; another was employed with no POVA first check and a CRB application was made after she had been employed. The registered person must ensure that staff are registered to work with the appropriate authority as required. Thee were some records of training such as dementia and food hygiene. However it was not possible to assess whether all the staff had completed mandatory training in health and safety. The record was seen for a recently recruited carer who had been instructed in moving and handling. There were no records available for four other staff to indicate that they had completed moving and handling and fire training. This was discussed with the manager and the development of a training matrix would be beneficial and would help identify shortfalls in mandatory training. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 31,33,35,38 The home’s manager is accountable for the management of the service. There are good records in place for safeguarding residents’ financial interests. However their moneys must be maintained individually. The auditing of the service users views need to be developed fully. EVIDENCE: The home has a registered manager who is in day-to-day control of the service. Staff and the service users spoken with said that she was approachable and available if they needed anything. The manager has completed her NVQ 4 in care and the registered manager’s award. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 23 The manager discussed that a supervision programme was in place for the day carers and would be and would be introducing this on night duty shortly. The manager reported that she had started a meeting with the people living at the service as part of seeking their views. She discussed that minutes of the meeting were taken; however these were not available, as the manager reported that this had been sent out for typing. At the last visit the seeking and auditing of views from residents, relatives and other professionals was discussed with the registered owner who stated that this did not currently take place and would be introduced. A requirement was made for the provider to consult with the people using the service and produce a report. This requirement has not been met. The manager reported that she was planning to send out questionnaires to the residents next month. Records of people using the service personal allowance as kept by the home were seen. The records were detailed and receipts of expenditures and money deposited from family were available. The provider said that all the service users monies are in one float. As discussed at the time of the visit all monies kept on behalf of people using the service must not be pooled and must be kept individually. A sample of servicing records checked and information received from AQAA indicated that there is an ongoing programme the servicing of equipment. The fire equipment, gas appliance, and chair lift had all been serviced in the last three months. The provider was not sure about the electrical circuit certificate and would be looking into this. Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1) Requirement All the service users must have a plan of care on admission that sets out in details how their assessed needs would be met. Evidence that the people using the service have been consulted on their plan of care must also be kept. The registered person must ensure that staff adhere to the policy on the safekeeping, handling, and disposal of medication. All appropriate checks including POVA first and CRB must be in place for all staff prior to employment. This is a repeated requirement of 20/08/06. 4 OP30 13(4) The registered person must ensure that staff have mandatory training in moving and handling, fire safety and records of these are kept. The registered provider must DS0000011855.V343034.R01.S.doc Timescale for action 30/09/07 2 OP9 13(2) 30/09/07 3 OP29 19 Schedule 2 30/09/07 30/09/07 5. OP33 24 (1)(2) 30/09/07 Page 26 Oak Mount Rest Home Version 5.2 (3) conduct a review of the home through consultation with the service users and their representatives and produce a quality assurance report. A copy of the report must be available to the people using the service This is a repeated requirement of 20/09/06 that has not been met. 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 Oak Mount Rest Home DS0000011855.V343034.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oak Mount Rest Home DS0000011855.V343034.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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