Inspection on 27/04/06 for Oak Tree House

This inspection was carried out on 27th April 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 Tree House 24/09/08

Oak Tree House 09/10/07

Oak Tree House 27/04/07

Oak Tree House 24/11/05

Oak Tree House 13/06/05

Oak Tree House 04/01/05

Oak Tree House 14/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Oak Tree House Lark Rise Brimsham Park Yate South Glos BS37 7PJ Lead Inspector Grace Agu Unannounced Inspection 27th April 2006 09:00 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 Tree House DS0000020252.V290672.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. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oak Tree House Address Lark Rise Brimsham Park Yate South Glos BS37 7PJ 01454 324141 01454 324151 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) www.fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Janet Elizabeth Miller Care Home 80 Category(ies) of Old age, not falling within any other category registration, with number (80) of places Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 80 persons aged 50 years and over who are receiving nursing care Of the total 80 persons, up to 10 persons (who must be 65 years or over) may be accommodated and provided with personal care. Manager must be a RN on parts 1 or 12 of the NMC register. The staffing notice dated 19/8/1999 applies. Date of last inspection 24th November 2005 Brief Description of the Service: Oak Tree House is a purpose built home, operated by Four Seasons Health Care. Mrs Janet Miller was recently registered as the new Home manager. The home is situated in a residential location, within a quiet cul-de-sac and is accessible to local shops, amenities and bus routes. The property provides bedroom and communal accommodation over two floors for 80 residents. Bedroom accommodation is provided in good-sized single rooms with en-suite facilities. There is level access throughout the home and all areas of the home are accessible via the passenger lift. There are nine communal areas throughout the home, including an activities room. There are a suitable number of bathrooms and toilets with adaptations to meet the care needs of residents in the home. Appropriate equipment is provided for individual use based on assessed identified needs. All rooms have a call alarm system. The home is set in its own grounds with a garden and patio area to the back of the house. Car parking is available for several cars. Visitors are welcome to the home at any time. The home employs two activities organisers who make efforts to provide activities during the week. The fees range from £380 - £540 per week depending on individual needs. Oak Tree House DS0000020252.V290672.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 which took place over twelve hours and was undertaken to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the Home. It was also undertaken to review the requirements made at the last inspection to ensure that they have been met. In addition, the Inspection was undertaken to follow up of issues raised in a comment card by a relative and subsequent phone call from another relative who was not satisfied with the care provided for the individual at the home. The inspection also followed up a phone call from an individual who was concerned about staff shortages at the home. Full details in relation to the above concerns can be found in the body of this report. At the last inspection five requirements were made, it was disappointing to note that two of the requirements have not been met. As a part of this inspection two immediate requirements were made in relation to preparing care plans for identified residents’ needs and ensuring that the medication administration procedure offers protection to the residents. A satisfactory response on how the home addressed the immediate requirements and action plan on how the remaining issues are to be addressed was received before the report was completed. A tour of the building was undertaken and a number of records were viewed. Eleven residents, four staff members and four residents’ representatives were spoken with on the day. What the service does well: Generally, the home was found fairly clean warm and well lit. Staff were noted interacting with the residents in a dignified manner both in their bedrooms and in the lounges. Residents spoken with confirmed that they are happy at the Home and that staff treated them well. Residents are enabled and supported to maintain contact with their families, representatives and the community. Relatives spoken with stated that they were satisfied with the care provided for their loved ones, staff are kind and they are able to visit the home at any time without restrictions. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 6 At a discussion with the Manager she stated that the home promotes and fosters good relationships between the staff and the residents through informal and personalised interactions. Residents are assessed before admission to the home and care plans are developed to ensure that the needs are being met. Generally the home was found fairly clean, warm and well lit. What has improved since the last inspection? What they could do better: Staff must answered call bell promptly following an issue noted whilst touring the building in other to minimise distress to residents and ensure that their dignity is respected. Before this inspection was undertaken, the Commission received two concerns, one was through a comment card and another was by telephone. These concerns were in relation to the care provided for a particular resident. The individuals were concerned that the home had not consulted with the doctor regarding a specific need. Review of the individual’s care file confirmed that the doctor was only consulted after a phone call from the relatives. However, there was no care plan in relation to how the need was to be met to prevent further occurrence. Furthermore another resident recently discharged from hospital with a specific need had no care plan in relation to how the need was to be met. Care plans must be developed to ensure that resident individual needs are met. To ensure that residents are adequately protected, any alteration made on the residents’ Medication Records Sheets must be signed and dated. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 7 At the last inspection a requirement was made in relation to an unpleasant odour, which was noted in a residents bedroom. This requirement had not been met. The manager stated at a discussion that the flooring together with two other bedrooms would be changed to a more appropriate one. The home is waiting for the contractors to provide a date for work to commence. The requirement remains in place. Furthermore, in other to maintain a good standard of hygiene the bedroom windows must be cleaned regularly. Records of staff supervision evidenced that some staff have recieved regular supervision, however two staff members spoken with stated that they have not received any supervision and one staff member had only one supervion in over a year. The manager is reminded that staff must have regular supervision to enable them to review their care practices andbe given support where there are shortfalls. Sufficient numbers of lavatory and bathing facilities must be provided to meet the residents needs. In addition adequate storage facilities must be provided at the home in line with the legislation Adequate numbers of staff mix must be working at all times in line with the Staffing Notice to ensure that residents’ needs are adequately met. 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 Tree House DS0000020252.V290672.R01.S.doc Version 5.1 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 Tree House DS0000020252.V290672.R01.S.doc Version 5.1 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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information about the home and are assessed before admission to ensure their needs will be met. EVIDENCE: The information noted in the Statement of Purpose and the service users Guide is detailed to enable a prospective resident and their relatives to make an informed choice about moving to the home. There was also information about one month trial period to enable the resident to decide whether to stay permanently. Seven residents care files were viewed and all contained pre admission assessment to determine if the home is able to meet their needs, each care file had terms and conditions of stay detailing fees to be paid and facilities available at the home. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 10 Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 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): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are assessed before admission, and their right to privacy is respected. However, it fails to protect the residents through lack of care plans and inappropriate drug administration practices. EVIDENCE: Seven care files were reviewed in detail including four specific residents with various concerns about their care at the home. The care files viewed had pre admission assessment and had care plans developed on how the assessed needs were to be met. However, one care file of a resident whose relatives had raised concerns about how the home was managing a particular health need had no care plans in relation to those needs. Another resident who was admitted to hospital following a health problem had no care plan in place on how staff were to manage this problem should it reoccur. These observations were raised with the manager and an immediate requirement was made for detailed care plans Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 12 to be written with clear information for staff to follow in order to meet those identified needs. Care files viewed had evidence of various risk assessments to include, manual handling, nutritional, pressure area and falls. There was evidence of daily progress records in each file showing how the health and wellbeing of the residents were being monitored. Staff were noted going in frequently to monitor and interact with a resident with challenging behaviour to ensure that the resident was not socially excluded. The residents relative who was met on the day stated that the staff are doing their best, however would like to see more supervision of the resident at meal times. This was discussed with the manager and will be reviewed at the next inspection. Each care file also had evidence of the General Practioner (GP) and other health professional visits regularly and when necessary. All residents interviewed confirmed that staff treat them with respect and provide privacy when attending to them. One resident stated,” staff are good, they come when I ring the bell. Staff were noted knocking at the doors and waiting for an answer before going in to attend to the residents. One comment card received before the inspection raised concern about response time by the care staff when the residents ring the bell and in order to confirm this residents call bell was activated whilst having a discussion with the resident in the room. The response time was twelve minutes. A visitor was met in the corridor whilst touring the building, looking for staff to assist a relative out of the toilet. The visitor stated that the individual had been sitting on the toilet for a long time and that the call bell had been ringing for nearly fifteen minutes. The home must review their response time to call bells in order to minimise distress to the residents. Discrepancies were noted whilst reviewing the medication administration procedure on the first floor. One as required medication was changed to be given regularly on the Medication Administration Record Sheet (MARS), this was not signed and dated and the instruction was not being carried out. Other records kept in relation to medication systems were satisfactory. Staff interviewed were aware of confidentiality of information in relation to residents. Two residents spoken with confirmed that they were confident that the home would provide them with good care if they became terminally ill. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 13 Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 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. The home provides activities to the residents, enables them to maintain contacts with families and friends and ensures that choice is provided in respect of meals and mealtimes EVIDENCE: The visitors’ book evidenced that people visit the home regularly; people were noted visiting the home and interacting with residents and staff in a relaxed and informal way on the day of inspection. Residents spoken with confirmed that they are enabled to maintain contacts with their relatives, representatives and the community. Three relatives met at the home stated that staff are welcoming and that there are no restrictions. There was evidence of completed social life profile of residents on admission, which provided staff with information about residents’ likes and dislikes. Whilst a weekly plan showing a variety of activities was noted at different location around the home only four resident were noted playing a game of Domino on the first floor. A few residents were noted in lounge on the ground floor listening to soft music. Some residents noted sitting in their rooms stated that they preferred to relax in their rooms. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 15 The home’s activities person stated that some residents refuse to participate in activities and that their choice is respected. The manager stated that the home is undergoing a refurbishment and that the present activities room will be moved to a bigger and brighter room in other to provide the residents with more choices. The home will also review the activities plan to include individual participation for all residents. A cross section of residents spoken with stated that they have a choice of when to get up and retire. One resident stated I get up at six am and I go to bed when I like. A review of the menu evidenced that the residents are provided with varied meals and are enabled to choose their meals by providing them with the menu the day before. Residents spoken with confirmed this and that they enjoyed their lunch. The kitchen was not inspected on this occasion however the manager stated that the kitchen floor has recently been refurbished and two pieces of kitchen equipment had been replaced. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 16 Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that the home is able to protect them from abuse EVIDENCE: The home has a complaints policy, which is displayed in the entrance of the home. The Complaint policy is also included in the Service Users Guide to enable the residents and their representatives to make a complaint if they are not satisfied with the services provided at the home There were two recorded complaints since the last inspection. The home manager satisfactorily investigated these complaints and actions taken were recorded. The manager confirmed that the complainants were satisfied with the outcome. A verbal complaint received from a relative in relation to unsatisfactory care of a resident and concern raised in a comment card from another individual was followed up. The care record of the identified resident was viewed and it confirmed that there was no care plan in place for a specific health need. The resident also confirmed that they were not happy with the care they were receiving at the home. This issue had been discussed in Standard 8. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 18 Residents spoken with stated that they would contact the manager if they had any complaints. Various interviews with staff evidenced that they are aware of how to enable the residents to complain. The home had a policy and procedure on the Protection of Vulnerable Adults from Abuse. Staff have received training on this and are aware of the Whistle Blowing policy which will enable them to report any bad practices without reprisal. The home also has the Guidance on reporting abuse of adults from South Gloucestershire Community Care Department. The Manager had clear knowledge of the protocol to follow in the event of any reported abuse. Residents spoken with stated that they felt safe at the home. The record of a new staff member contained evidence of Criminal Record Bureau checks before commencement of employment. Personal Identification Numbers of registered nurses were noted to be verified with the Nursing and Midwifery Council to ensure that the residents are adequately protected. One resident spoken with stated that they voted at the last election by postal vote. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a safe, well maintained environment, comfortable bedrooms and specialist equipments suitable for residents needs. However it fails to provide sufficient toilet and bathroom facilities for the residents. EVIDENCE: At the last inspection a requirement was made in relation to an unpleasant odour, which was noted in a residents bedroom. This requirement had not been met. The manager stated at a discussion that the flooring together with two other bedrooms would be changed to a more appropriate one. The home is waiting for the contractors to provide a date for work to commence. The requirement remains in place. Failure to meet a requirement could lead to enforcement action. Whilst touring the building, it was noted that the general environment was fairly clean; some residents were noted sitting in the well furnished comfortable lounges and looked well cared for. The bedrooms were personalised, colour coordinated and furnished to a required standard. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 20 However, some of the bedroom windows were noted to be dirty and need to be cleaned. All the residents spoken with stated that they liked their bedrooms. Whilst the toilets and the bathrooms have manual handling equipment to assist with the residents needs, it was disappointing to note that they were used for storage of equipment. The home must provide appropriate storage facilities to ensure that residents’ toilet and bathroom facilities are not compromised. The laundry facilities were found adequate. The area was found clean and tidy with good flooring. Domestic staff met on duty had knowledge of infection control and have attended training on Control of Substances Hazardous to Health to enable them to attend to chemical emergencies. The maintenance book was up to dated and all jobs undertaken were recorded. There was a service record for hoists to ensure that the residents are safe whilst staff are assising them with any handling needs. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 21 Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 22 Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service The homes recruitment process demonstrates safeguards are in place and ensures staff competency and training, however it fails to provide adequate numbers of care staff times. EVIDENCE: The inspection followed up the concern raised in one of the comment card in relation to insufficient numbers of staff at the home. A random review of the rota showed that the home had adequate numbers of staff mix on most of the dates, however, was one care staff short on 23/04/06 morning. The manager was unable to provide a satisfactory reason why this had happened. The manager must ensure that adequate numbers of staff mix must be at the home at all times to ensure that the residents needs are adequately met. The home has a robust recruitment procedure to ensure that suitable staff are employed to meet the residents needs. The records of recently recruited staff members contained two satisfactory references, Criminal Record Bureau (CRB) disclosures and relevant qualification to ensure that the residents are protected. The home also has a satisfactory induction programme for new staff members. All staff spoken with confirmed that they have attended various training to include, manual handling update, nutrution, dementia, First Aid and Protection of vulnerable Adults from abuse. A selection of staff records confirmed the Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 24 above training. there was also evidence to show that nine care staff have completed National Vocational Qualification (NVQ) at level 2 and 3, three care staff have almost completed NVQ 2 and four care staff are soon to commence the course. One staff member spoken with stated that staff work as a team to ensure that the residents needs are met. Registered nurses meet regularly to discuss ways to improve care, the last meeting was 7/04/06. Issues recorded include medication, new care manual from the organisation care planning, residents advocacy. Notice of general staff meeting scheduled for 28/04/06 was displayed in the reception. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well managed home, the health and safety practices offer protection to the residents EVIDENCE: The registered manager, Mrs Janet Miller was met at this inspection, was very welcoming and showed clear understanding of the inspection process. The registered manager is a first level nurse and has attended many courses to include wound assessment update, nutrition and First aid. The manager stated that she has recently commenced the Registered Managers Award. The residents and staff spoken with made positive comments about the manager and her ability to manage the home. One resident stated manager is good ,she comes to see us regulaly, One staff member stated “Jan” is approachable, she will listen. The manager stated at a discussion that the home has an open door policy and residents and their families take advantage of this to discuss any of their concerns at any time. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 26 The manager stated that she is aware that improvements need to be made at the home in terms of the overall care of the residents and has communicated this through staff meetings. The manager feels supported by the regional manager and have supevision to enable her to perform the duties effectively. A thank you letter from a relative in relation to care given to the individual was noted in the file in the mamagers office. One comment card from a relative stated “ The staff are very friendly, welcoming and concerned. They keep me well informed of anything I need to know and will ring me up if necessary.They are all kind and patient with mum and other residents and do a difficult job with affection for residents.” Records of staff supervision evidenced that some staff have recieved regular supervision, however two staff members spoken with stated that they have not received any supervision and one staff member had received one supervion in over a year. The manager is reminded that staff must have regular supervision to enable them to review their care practices and have support where there are shortfalls. Safeguards in relation to health and safety seen were up to date and offered protection to the residents. Record of accident to residents were clearly written and reviewed and risk assessment along with care plans reviewed in line with change in need. The manager was very clear about how the home reviews the quality of its services. They include the regulation 26 visits by the provider, monthly care plan reviews and regular tour of the building to discuss any concerns with the residents and their reperentatives. Record of residents monies was found to be satisfactory and were securely locked away along with other residents information. The home has policies in relation to various aspects of the services provided at the home to include health and safety, medication ,Accidents and Protection of Vulnerable Adults from abuse. Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 27 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 3 X 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 3 Oak Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 28 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. 7 Standard OP10 Regulation 12 Requirement Staff must answered call bell promptly in other to minimise distress to residents and ensure that their dignity is respected. To ensure residents needs are met, staff must be supervised regularly, Adequate numbers of staff mix must be working at all times in line with the staffing notice to ensure that residents’ needs are adequately met. Sufficient numbers of lavatory and bathing facilities must be provided to meet the residents needs. In addition adequate storage facilities must be provided at the home. Identified resident’s room must be free of offensive odour and all parts of the home must be kept clean. Alteration to the residents’ Medication Administration Records Sheet must be signed and dated Care plans must be developed for identified residents’ specific DS0000020252.V290672.R01.S.doc Timescale for action 27/04/06 6 5 OP36 OP27 18 18 27/05/06 27/04/06 3 OP21 23 27/05/06 4 OP26 16 27/05/06 2 OP9 13 27/04/06 1 OP7 15 28/04/06 Oak Tree House Version 5.1 Page 29 needs. 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 Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Tree House DS0000020252.V290672.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!