Inspection on 30/05/06 for Oak Tree Lodge

This inspection was carried out on 30th May 2006.

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

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

Other inspections for this house

Oak Tree Lodge 25/07/07

Oak Tree Lodge 10/02/06

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 Tree Lodge 114 Lyndhurst Road Ashurst Southampton Hampshire SO40 7AU Lead Inspector Sue Maynard Unannounced Inspection 09:00 30th May and 2nd June 2006 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 Lodge DS0000066314.V289682.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 Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oak Tree Lodge Address 114 Lyndhurst Road Ashurst Southampton Hampshire SO40 7AU 023 8029 2311 023 8029 3817 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) Carewise Homes Limited Mrs Margaret Patricia Duncan Care Home 19 Category(ies) of Dementia (19), Mental disorder, excluding registration, with number learning disability or dementia (19), Old age, of places not falling within any other category (19) Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 Brief Description of the Service: Oak Tree Lodge is a registered care home providing personal support and accommodation for up to nineteen older people with Dementia and Mental health needs. Carewise Homes Limited owns the home, and Mrs Margaret Duncan is the registered manager. The home is situated just off the main road that runs through the village of Ashurst, with close proximity to Lyndhurst and other areas of the New Forest. Accommodation is provided large detached extended house with four shared and eleven single bedrooms, on both the ground and first floor, access can be gained to the first floor by a staircase and passenger lift. There is a dining room linked to a large lounge, a smaller second lounge is situated off the dining room. There is a very small garden to the front of the building. Fees for the care provided by the home are from £385-£420. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days with a total of twelve hours spent in the home. The inspection was unannounced and was the key inspection for 2006/2007. One inspector conducted the inspection. The manager was not available on the first day of the inspection. The deputy was on duty and was able to provide the inspector with much of the required information and documentation. The manager was on duty for the second visit to the home. The atmosphere in the home was relaxed and staff were very friendly and approachable. The residents appeared to be very happy, with a lot of laughter heard, and well cared for. As part of the inspection process the records for four residents were examined and four staff records were examined also. The inspector spoke to both residents and visitors to the home on both days. All those spoken to were very satisfied with the care and services that were being provided. What the service does well: What has improved since the last inspection? Since the last inspection all the bed linen in the home has been replaced. Some new beds including one specialist nursing bed. New armchairs have been purchased for the lounge. The kitchen has been refurbished with new cupboards and equipment provided. New curtains have been supplied for many of the bedrooms and replacement curtain poles are being provided. There are plans in place to convert a currently disused bathroom into a “walk in shower” room with wheelchair access. It was planned for this work to be done the week following the visit to the home. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 6 The manager reported that since she has been in post she has increased the supply of gloves and aprons for the staff to use as previously the supply was insufficient for the staff to work safely and possibly putting the residents at risk from the spread of infection. The manager also reported that increased staff training has been arranged, but at this time there is no formal training programme. Staff are being supported to undertake their NVQ training at levels 2 and 3. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. A pre-admission assessment is undertaken which assures people moving into the home that their needs will be met. The home does not have the facilities or the resources to provide intermediate care but can offer a short-term stay for service users in need of respite care. EVIDENCE: A full pre-admission assessment is undertaken by the manager for all prospective new residents prior to them coming to live in the home. These are Social Services additional assessments where necessary. The assessment looks at all aspect of the prospective residents health care needs, both physical and psychological and provision is made in the document to demonstrate that information has been included from previous carers, family members and other health care professional. The information obtained forms the basis that identifies the care needs of the prospective resident and whether these needs can be met by the home. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 9 Prospective residents are invited to spend a day in the home before making their decision to live in the home permanently. The service has a statement of purpose, which provides basic information about the service and is made available to the resident in a standard format. In the previous report it was stated that the home provides Intermediate Care. The home does in fact only provide respite care for residents who are need of care for a limited period, usually up to two weeks, if suitable accommodation is available. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Care plans and risk assessments do not reflect accurate and up to date information for their care and may put the residents at risk. The lack of individual nutritional assessments to accurately monitor weight gain or loss and what action has been taken puts residents at risk. Members of staff who do not adhere to the home’s procedure for the accurate recording of medication put the residents at risk. Staff training ensures that the residents are treated with dignity and that their privacy is maintained at all times. EVIDENCE: Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 11 Positive comments made about the good standard of care in the home from residents their families and the staff. However documentation and the recording of the care provided was not adequate. The records for four residents were examined. All the records contained the personal details of the resident including details of date of birth, contact details of next of kin, name of GP and details of Social Service care manager, where appropriate. Many of the other assessment documents including an assessment that should have been completed on admission to the home were found to been only partially completed or blank. All care plans seen were not completed appropriately and only identified a problem. There was no documented action plan to address the problem and no evidence of the expected out come. There was no evidence that the resident or their representative had been involved in the drawing up of the care plan. A daily report document was in place but these had not been completed on a daily basis. For one resident who had who had multiple health care needs there were no regular daily records to document the possible changing health care needs. It was documented that a piece of equipment in use for this resident had on several occasions been mal-functioning. There was no documentary evidence of what immediate action was taken until the equipment was repaired or replaced. In one assessment for this resident they were identified as being at “high risk” in January 2006. The actual risk was not identified and no review or update had been undertaken since then. None of the records examined provided evidence that nutritional assessments had been undertaken. There were no records that demonstrated that the residents were weighed regularly and any significant weight gain or loss recorded and reported to the resident’s doctor where necessary. Reviews and updating of assessments have not been undertaken. All these issues were discussed with the manager on the second day of the visit to the home. She acknowledged that the documentation in the records was no to a satisfactory standard. The manager is new to the post, only coming to the home when the new owners took over in January 2006. She is aware of the many issues to be addressed throughout the home and stated that reformatting of residents’ documentation is one of her main priorities. Positive comments made about the good standard of care in the home from residents their families and the staff The manager confirmed that the residents are registered at one of the local health centres with a doctor of their choice. For residents who are registered with a doctor from outside of the local area they may continue you to remain registered with their doctor if he/she is agreeable and is prepared to visit the home when necessary. A hairdresser visits the home regularly. Her visits provide hair care services for many of the residents both male and female. One resident makes his own arrangements and continues to visit the barber that he had prior to coming to live in the home. An optician visits the home and treats all those residents who wish to have their eyes tested. Some residents make their own arrangements and attend local opticians. The manager reported that Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 12 at this time there is a problem accessing domiciliary dental services. For those residents who are unable to visit their own dentist there is no dental care can be offered at this time. The manager confirmed that she is making enquiries in the local area to try and obtain this service for the residents but so far has had no success. The home is well supported by the community nurses from the health centres. They visit regularly to provide assessments for wound care and change dressings as required. They also provide support for the staff in the event of a resident being terminally ill. They monitor pain control for these residents and notify the doctor if the medication is insufficient. The home has policies and procedures for the administration of medications and all the staff have recently had training from the local pharmacy adviser. Further training is also arranged for July 2006. The medications are kept secure in a locked trolley, the keys to this trolley are held by the senior care assistant or the manager. Medication record sheets were examined. Errors were found in some of these. On one sheet it was noted that all the dates had been erased using correction fluid. No satisfactory explanation for this was given. Many of the sheets had gaps where staff should have signed once the medication had been given. There were no entries on the sheet to state why the medication may not have been given. On three sheets the original signature entered on the sheet appeared to have been over-written by another member of staff. All these errors were brought to the attention of the manager and her deputy. No satisfactory explanations could be given. The manager stated that she would investigate the errors and identify the member of staff who was on duty at the time the error had occurred. She assured the inspector that the member of staff would be made aware of the home’s procedure for the administration of medication and would ensure that the member of staff was supervised until they had received further training. Visitors and residents spoken to during the visit to the home confirmed that the staff were very respectful and polite to them at all times. The inspector observed staff knocking on bedroom doors before entering. Staff interaction with the residents was always cheerful and there was a very positive response form the residents. There was a very happy and relaxed atmosphere in the home. A visitor to the home told the inspector how pleased she was with the change and improvement in the general atmosphere of the home over the past two months and that her relative who she visited regularly had become more outgoing and communicative. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management of the social and recreational programme is creating a positive, varied and interesting life for the residents, which meets their expectations for living in the home. The residents are supported and encouraged to make choices about how they live their lives including choosing from a daily menu that provides them with a well balanced and varied diet. EVIDENCE: The home provides activities for the residents three afternoons a week by someone employed to organise these. Some of the activities include external entertainers including a local theatre company and a group of singers. There is no formal programme of activities available so residents and their families are not always aware of what has been organised. Residents spoken to said they enjoyed the activities organised for them and that the staff often played cards or games with them. The manager told the inspector that she takes some of the residents out in her car for a drive around the New Forest and these outings may include stopping for an ice cream or a cream tea. The manager confirmed that she has the appropriate motor insurance to enable her to take the residents our. The staff have attended training for caring for residents for Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 14 dementia but at this time they have not received training for providing appropriate activities for residents with dementia. The manager is aware of this and stated that she will ensure that this training is made available to the staff. The home has no restriction on visiting to the home. Visitors spoken to by the inspector confirmed that they are made welcome at any time. One visitor commented that they found the security of the home frustrating at times and sometimes had to wait for the door to be opened, but appreciated the necessity for it and that it was there to keep the residents safe. At this time the home has no links with any community groups. The manager is hoping to establish some links over the forthcoming months. Currently representatives visit the home from the local Roman Catholic Church who visits some of the residents. The manager has made contact with a representative from a local Anglican Church and is hopeful that they will visit the home on a regular basis. Routines of the home are planned around the residents’ needs and wishes. The manager and staff encourage the residents to take control of their life and to have the confidence to discuss what makes them happy and comment on what improvements could be made. Residents spoken to confirmed that they are able to choose when they get up and go to bed. They confirmed that the staff always offered them choices about where they wished to spend their day and at no time were they forced to leave their room if it was their decision to remain there. The home provides the residents with a varied and well balanced diet. The residents spoken to confirmed that they told on a daily basis what is on the menu and the alternatives that are available. One resident said that they could never remember what they had ordered. This was discussed with the manager and it was agreed that the daily menu would be written on a small blackboard where the residents would be able to see the menu for the day. The meals served during the visit where well presented and appeared to be well balanced with a variety of fresh vegetables. An individual member of staff appropriately supported residents who required some assistance with their meal. The residents have a choice of where they may eat their meals. The manager is hoping that the dining area will be re-sited in part of the current lounge area to provide a larger dining area that will provide more space for the residents. The cook keeps a record of all the food provided and if any of the residents have refused their meal. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The complaints procedure for the home ensures that residents and their families are assured that their complaints will be listened to and acted upon appropriately. Lack of accurate knowledge, training and information for staff to be able to report an incident of abuse will put residents at risk. EVIDENCE: The home has a complaints procedure and keeps a record of any complaints received. The records demonstrated that one complaint that had been received by the home had been dealt with appropriately. Visitors spoken to by the inspector confirmed that they were aware of the complaints procedure but had never had to use it. They stated that the manager is very approachable and they would discuss any issues with her directly. On both days of the visit to the home a copy of the Hampshire Adult Protection Procedure was not available. Some members of staff spoken to were not fully aware of the correct procedure to be followed in the event should an incident of abuse take place in the home. The manager was reviewing the copy of the home’s current adult protection procedure that had not been reviewed for four years. The updated document did not give the correct information for staff to follow. The manager confirmed that training for the staff had been arranged to take place in October and December 2006. This was discussed with the inspector. New staff who have recently been employed will be receiving adult Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 16 protection training as part of their induction programme. The manager has agreed to ensure that the staff are made aware of the correct procedure to be followed and will also ensure that the Hampshire Adult Protection procedure remains on the premises at all times. Staff spoken to had some knowledge of the procedure to follow when reporting an incident of abuse but were not aware of the other agencies to be informed before notifying the manager or person in charge. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Systems are in place that ensures that the residents live in a clean, safe and well-maintained environment. EVIDENCE: During a tour of the building the inspector noted that many areas were in need of redecoration. This was discussed with the manager who reported that the new owners of the home are planning many improvements for the home, including the addition of a conservatory to the front of the building and redecoration of bedrooms and communal areas throughout the building. There are also plans to alter the configuration of the communal area on the ground floor once the conservatory is built. This will provide a larger dining area and a second lounge area, which will provide residents with a quiet area away from the television. New armchairs have been provided. New bed linen has been provided. New curtains have been hung in many of the bedrooms but unfortunately the existing curtain rails are not strong enough to hold the heavier material. The manager reported that she has ordered new curtain poles. There are plans to convert an Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 18 existing bathroom into a shower room that will allow wheelchair access. The kitchen has been refurbished and was found to be very clean and well organised. During a tour of the building the inspector noted that there were many communal toiletries in the bathroom. These were brought to the attention of the acting manager who said that they would be removed. On the second visit to the home these had been removed and each resident had been supplied with a small basket container in which his or her toiletries had been stored. On the second day of the inspection during a further tour of the building the inspector noted that window restrictors were not in place on windows in two upstairs rooms. This was brought to the attention of the manager who immediately arranged for these to be replaced that afternoon. The Commission received evidence that the repairs were done. The home employs a cleaner who works each afternoon five days a week. The home on both days of the visit was found to be clean and tidy. Odours noted during an inspection in February 2006 were not present during this visit. A visitor to the home commented that the home was always clean which they thought reflected the general high standards in the home. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staffing rotas demonstrate that the numbers and skill mix of staff on duty currently meet the needs of the service users. Appropriate training is provided for all staff employed in the home. However a formal training programme that identifies the specific learning needs of the staff will ensure that appropriate training is given to the staff. The safety of the residents is protected by the procedures that are in place for the recruitment of staff. EVIDENCE: Six new members of staff have recently been recruited to work in the home. Residents spoken to stated that they considered that there was always enough staff on duty to meet their needs and they appeared to know what they were doing. On the first day of the visit to the home the manager and one other member of staff were off sick. The deputy manager was unable to find an additional member of staff to come on duty for the morning. Staff spoken to said that they were able to cope and that the care of the residents would not be compromised. The residents appeared to be happy and appeared well cared for. On the second day of the visit all the staff were on duty as identified in the staff rota. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 20 Staff employed at the home are undertaking NVQ at levels 2 and 3. Currently 2 staff members are undertaking Level 3 and 3 have achieved Level 3. Five of the new members of staff will be commencing Level 2 in September 2006 and one staff member will complete Level 2 in August 2006. Staff recruitment records were examined and were found to be in order. Application forms had been completed and written references obtained. Appropriate police checks with the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults register (POVA) had been undertaken. Staff confirmed that they had received mandatory training for fire safety, safe moving and handling of the residents, basic food hygiene and infection control. A formal training programme was not available but the manager was able to provide the inspector with evidence that training was arranged for the staff. The manager has agreed that she will implement a formal training programme for all members of staff to identify when training sessions have or will take place. The manager is accessing some training for staff through the Partnership in Care Training (PACT) arranged by Hampshire County Council. All the new members of staff are undertaking their induction training within the Skills for Care guidelines and attend training sessions arranged through a training facility with Southampton City Council. Training for the staff has also been arranged for Infection control and safe administration of medications. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager is able to demonstrate that she is suitably qualified to ensure that the home is well run and that the needs of the residents are met. The implementation of a quality assurance survey will ensure that the home is run in the best interests of the residents. Close monitoring of practices within the home safeguard the health, safety and welfare of residents, staff and visitors to the home. EVIDENCE: The manager, Mrs Margaret Duncan, has been in post since January 2006 when the home was taken over by new owners. She has worked as a Registered General Nurse. Mrs Duncan holds a diploma in management and Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 22 has undertaken a diploma in Dementia awareness. Her other qualifications include, the Registered Managers award and she holds a certificate in Social Care. Mrs Duncan is registered with the Commission as the manager for the home. Since the change of ownership of the home the manager has not undertaken any formal quality assurance surveys but has spoken regularly to residents and visitors to the home to ensure that they are satisfied with the services and care being provided. The inspector was shown a copy of a questionnaire that was due to be sent out to the families of the residents for them to complete and where possible in consultation with the residents. This is a comprehensive survey that will give the manager and the owner’s detailed feedback about the opinions of those people who visit and use the service. The manager confirmed that she would submit the results to the Commission. The manager has recently complied a newsletter for the home that is to be sent out to the residents’ families’, bi-monthly to provide regular updates of what is happening in the home. Visitors and residents spoken to said that they had no complaints about the services provided by the home. At this time the manager has not undertaken formal staff meetings but hopes to do so as part of her plans for the future. Staff meet with her on an informal daily basis and any changes or important information is passed on at this time. Staff confirmed that they were always made aware of any general changes in the home and are regularly updated on the condition of the residents. The home is not responsible for any resident’s monies. Accident records for the home were examined. These were found to be in order. Records of any accidents or incidents were recorded in both the accident book and the daily records of the residents. Two accidents recorded that residents had sustained skin damage as the result of a fall. These had not been notified to the Commission under Regulation 37 of the Care Standards Act 2000. This was brought to the attention of the manager who assured the inspector that future incidents would be reported. Records demonstrated that staff regularly undertook fire safety training and that the fire safety equipment and alarm system was regularly checked and tested. The fire safety officer visited the home in January 2006 and the recommendations made at the time of the visit have been complied with. A fire risk assessment was undertaken in January 2005. A further assessment is booked for June 2006. Staff confirmed that they have received training for safe moving and handling. The manager and her deputy are to undertake a “train the trainers” course for moving and handling which will allow them to provide this training to staff in the home. On the day of both visits to the home the kitchen was found to be very clean and well organised. A recent visit by the environmental health officer did not identify any major issues. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 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 X X 3 X X 1 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X 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 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement Each resident must have a detailed individual plan of care to ensure that all aspects of health, personal and social care are identified and are met. Nutritional assessments must be undertaken and regularly reviewed for all residents. Records must be maintained of weight gain or loss and actions taken. The registered manager must ensure that all staff responsible for administering medications adhere to the correct procedure for the recording of medications. All medications administered must be signed for. Records must not be altered. The registered manager must ensure that all members of staff are aware of the procedures to be followed to report an incident of abuse. Suitable training must be in place to ensure this. All accidents, injuries and incidents of illness and communicable disease must be reported to CSCI DS0000066314.V289682.R01.S.doc Timescale for action 01/08/06 2 OP8 17(1)(a) Schedule 3 01/08/06 3 OP9 17(1)(a) Schedule 3 01/07/06 4 OP18 13(6) 01/07/06 5 OP38 37 01/07/06 Oak Tree Lodge Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP13 OP18 OP15 OP12 Good Practice Recommendations Links should be established with the local Anglican church to allow residents to maintain their religious worship if they so wish. A copy of the Hampshire Adult Protection procedure should be available on the premises at all times. The menu should be prominently displayed to allow residents to be aware and reminded of the choice of food is available to them each day. The programme of social activities should be displayed to enable both residents and visitors to the home to be aware of the activities that have been arranged. Oak Tree Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lodge DS0000066314.V289682.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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