Inspection on 15/05/07 for Oakcroft Nursing Home

This inspection was carried out on 15th May 2007.

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

Oakcroft Nursing Home 07/01/09

Oakcroft Nursing Home 27/03/08

Oakcroft Nursing Home 15/01/07

Oakcroft Nursing Home 19/05/06

Oakcroft Nursing Home 03/03/06

Oakcroft Nursing Home 05/09/05

Oakcroft Nursing Home 31/03/05

Oakcroft Nursing Home 09/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Oakcroft Nursing Home Oakcroft 41-43 Culverley Road Catford London SE6 2LD Lead Inspector Pam Cohen Unannounced Inspection 15th May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oakcroft Nursing Home DS0000007037.V339426.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. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakcroft Nursing Home Address Oakcroft 41-43 Culverley Road Catford London SE6 2LD 020 8461 5442 020 8698 0636 oakcroftnursing@btinternet.com 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 John Moore Mrs G B Moore Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 28 patients, frail elderly persons aged 60 years and above (female) and 65 years and above (male) 15th January 2007 Date of last inspection Brief Description of the Service: Oakcroft Nursing Home provides care for up to 28 older people and caters for respite stays as well as long-term care. The home is a detached house with three storeys close to Catford train station and local shops and services. The area is also well served by buses to central and south London. There is accessible off road car parking space for up to 6 cars at the front of the building. On the day of inspection there were 10 vacancies according to the home’s current registration. However as the double rooms were being used as singles at the time, this translates to 2 vacancies. The weekly fees are £599 per week Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during the day of 15th May. The manager was not available on that day and so the inspector returned the next afternoon to talk with her. The inspector checked documentation and care plans and spoke to people using the service, visiting relatives and staff. She also had an opportunity to speak to the registered provider. The maintenance man accompanied her on a tour of the premises. Following receipt of the commission’s draft report, the home replied and provided a consultant’s report to evidence improvements that had been made since the inspection. However these improvements cited cannot be commented on, until the next inspection. What the service does well: What has improved since the last inspection? What they could do better: The home needs to have a Statement of Purpose and Service User Guide available before admission. Staff also need to ensure that all prospective residents have their needs properly assessed. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 6 Care plans need to cover all areas of need, and where there is assessed risk they need to detail how to manage this risk. Tissue viability and Moving and Handling needs must always have care plans. Residents need greater stimulation and need to know that their individual wishes on how they spend their day are known and respected. They must also have direct access to cash on a daily basis. The manager needs to be clear about issues concerning restraint. There is not yet adequate communal space. Recruitment practices in the home need to be improved in line with legislation and new staff must have proper induction. All staff must have adequate training in the needs of the residents. Residents’ health and safety in several important areas which are fire safety, Moving and Handling and Control of Substances hazardous to Health is not being protected 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. Oakcroft Nursing Home DS0000007037.V339426.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 Oakcroft Nursing Home DS0000007037.V339426.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): 1,3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home encourages visits before admission but residents, prospective residents and their relatives do not have access to information about the home. Not all prospective residents have a full assessment of their needs and therefore cannot be sure that those needs can be met. EVIDENCE: The home no longer has a Statement of Purpose or Service User Guide in use, and so prospective residents and their relatives do not have access to the necessary information needed to know whether they wish to move into the home. Two people had recently moved into the home. One of these had a good pre-admission assessment. The other however did not have a full assessment and there was not enough information on file to assess whether their needs could be met in the home; indeed that part of the assessment had not been filled in. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 9 Relatives of one of the people who moved in recently confirmed that they had had the opportunity to visit the home. Oakcroft does not offer intermediate care. Oakcroft Nursing Home DS0000007037.V339426.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): 7.8.9.10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents cannot be sure that all their care needs will be assessed and documented or that all their health needs will be met. They are also not protected by risk assessments where needed. Some areas of dealing with medication do not properly protect residents and they cannot always be confident that their dignity will be upheld. EVIDENCE: The home has moved over to a new format for care plans and the inspector checked seven of these. One was completed to a level that showed that most of that person’s support needs had been assessed but the other care plans did not. They did not assess the emotional or social needs of the person but only looked at physical needs. When looking at personal care they were not filled in with any detail of people’s individual wishes for such things as, for example, what time they liked to get up or if they preferred a bath or shower. The care plans did not assess arrangements for dealing with people’s finances to ensure they had access to their money. They also did not assess the cognitive needs Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 11 of the person and the inspector spoke to people who evidently had special support needs in this area that were not part of their care plan. There was no evidence that relatives are consulted about care plans and relatives who spoke to the inspector confirmed this. As at the last inspection, there are people living in the home, whose risk of falling has been assessed as high. However, this does not lead to care plans where the risk of falls is analysed and then strategies planned to minimise the risk. Also people who have moving and handling needs do not have care plans to cover how this should be safely done. A resident was seen to be disturbed and showing challenging behaviour but this was not documented with an assessment of support needed and advice to staff on how to minimise and deal with the behaviour. Bed rails are still being widely used with no proper risk assessment; this has led to two people trying to climb over those rails. People are also still being transported in wheelchairs even though their mobility assessment makes it clear that they can walk with a Zimmer frame or with support. Health care is not always being properly documented, monitored or acted upon. A resident who had had a pressure sore had a treatment regime documented that had not always been followed; she did not have a care plan for skin care. Other residents were assessed as at high risk of skin break down, but they did not have a care plan for this area. Continence assessments are not carried out by a specialist nurse and one family felt that their relative’s individual continence needs were not being met. There was evidence of routine dental care but no evidence of referral for physiotherapy or occupational therapy. A person who had been recently admitted after having a stroke was receiving little or no stimulation. The home’s medication policy has been updated to include the sections required by the commission’s pharmacy inspector. Residents’ medication needs have also been reviewed. Medication was checked but as before it was not possible to check whether the administration chart had been correctly filled in as amounts of stock held were not recorded. Neither was the home recording any medication that was returned to the pharmacy, as their policy states should happen. One person’s medication administration chart did not record whether a medication administered weekly had been given for the past two weeks. It is a matter of great concern that when the inspector returned the next day she found that this record had been changed. Administration charts should have the safeguards of photos of residents and notes of any known allergies but not all photos were on the charts and the area for allergies was not filled in. Residents and relatives who spoke to the inspector felt that they were treated well by staff and the inspector saw many examples of kind and dignified interactions. However she also saw medication being given without speaking to the person who was receiving it and people being fed meals with no words spoken or with the carer speaking to other people while doing it. These are not practises which respect the dignity of service users. The telephone is in the lounge with no hood round it, and so privacy cannot be assured for private phone conversations. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. Residents do not get adequate stimulation from taking part in activities which they enjoy; they do however benefit from as much contact as they wish from visitors. Individual choice based on assessed wishes is not yet properly supported. Residents enjoy a good choice of food. EVIDENCE: There is still no structured activities programme in the home, based on an assessment of what people living in the home enjoy doing, and are able to do. Activities are planned to take place between 3pm and 5pm each weekday. On the first day of the inspection five people were enjoying a game of dominoes with staff and one had taken part in some colouring. On the second day one person went for a walk with a member of staff. The activities record book shows this level of activity to be normal and this means that, as could be seen, most people spend most of the time doing little. One of the people living in the home had had an assessment from a psycho-geriatrician who recommended that increased stimulation would decrease her distressed behaviour but this has not been happening. Relative’s surveys seen commented on this lack of activity and stimulation. It is good that there is now only one television in the Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 13 lounge, but it was on all day and there was no indication that most people could see or hear it or had any input into choosing what they saw. It was noted that the day before there had been a birthday celebration for someone living in the home. Religious representatives also visit the home. Relatives confirmed that visitors continue to be made welcome in the home at any time. Service users can bring in personal possessions for their rooms. However, systems are not yet in place to enable service users to have access to their money on a day-to-day basis. Also the lack of detail about individual wishes in care plans means that it is not clear that people are supported to exercise as much choice and control over their daily lives as they wish or are able. When asked, service users said that they enjoyed their food and there has been an improvement in food provision since the last inspection. There was choice at all meals and the food was home cooked with fresh vegetables. Fresh fruit was also available at all times. The home should however, still consult with a dietician to make sure that adequate nutrition is being supplied. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be confident that their complaints will be listened to and investigated. However they cannot be confident that people living in the home will always be protected from abuse or restraint. EVIDENCE: There is a complaints policy for the home and relatives who were asked said they would know how to complain. Two complaints have been made since the last inspection and both have been properly recorded and investigated. The home’s vulnerable adults policy has been updated in order to cover all necessary areas. The Commission has received one complaint which is being investigated by Lewisham Social Services Adult Protection team. The senior social worker in the Adult Protection team had, in the six months prior to this inspection, spoken to the previous manager of the home and followed up in writing, the fact that using bed rails without proper risk assessment and consultation is a form of restraint. The present manager confirmed she had seen this letter. However, the practise is still continuing although the manager had stopped two uses of bed rails where recording showed they were clearly dangerous. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 15 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): 19, 20,21,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a comfortable, well maintained and mainly safe home. However their need for communal space is not met. EVIDENCE: The home has a good location on a side road close to shops and public transport facilities and has a large, accessible and well-kept garden. Maintenance is ongoing and modifications needed to ensure safety have been made, except for the fire exit to the side of the building which remains a danger. The programme of painting and re-carpeting bedrooms continues; eight have been completed so far. None of the bedrooms have en-suite facilities but there are a proper number of bathrooms with assisted baths, shower facilities and toilets. The communal space however, remains inadequate with only one room for all activities. The provider again re-stated Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 16 his intention to remedy this, with plans to add on extra space in a conservatory to the back to the house. On the day of inspection the home was clean and hygienic throughout. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 17 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): 27,28,29,30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are supported by an adequate amount of staff with a good level of NVQ training. However they are not protected by the recruitment practices of the home, nor the induction and training of staff in their specific needs. EVIDENCE: The rota showed that the home deploys an adequate number of nursing and care staff on duty at all times of the day and night. Care should be taken to ensure that, when staff swap shifts, the names of the actual staff who worked the shift are recorded. The number of care staff with NVQ level 2 training exceeds 50 . However, a programme for other training is not yet on a proper basis, with staff appraisals to find out their training needs, and also looking at the needs of the resident group. The files of five staff who had been recruited in the last six months were checked and showed significant shortfalls in the recruitment process that safeguards residents. Vacancies were not always advertised to ensure equality of opportunity. The employment record of applicants was not checked for explanations of gaps in employment, nor was it properly scrutinised for discrepancies of information. Not all applicants had two references returned before they started work and none of the references were from the applicants’ most recent employer. There was also not proof of fitness to work on all files. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 18 Some of the newly recruited staff had little or no experience but there is not at the moment a proper induction process in the home. People are also working without proper Moving and Handling training. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36,38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A start has been made in monitoring quality and listening to the views of residents and their relatives. However, residents still have no direct access to their monies. Residents’ health and safety in several important areas is not being protected. EVIDENCE: In the past year there have been two changes of management in the home. The present manager has not yet been registered. She is qualified and experienced and staff, residents and relatives who spoke to the inspector, felt she had made improvements. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 20 The provider has undertaken one person-in-charge visit and a survey to find out the views of residents and their relatives has started to be sent out. An annual development plan is still needed. There is as yet no appraisal system for staff. The manager has started formal supervision with the staff but has not yet been able to do this at the necessary level. Staff were enthusiastic about the weekly training sessions she holds and this is to be commended. The home has not yet reviewed their policy in order to ensure that service users have access to their own cash at all times for any purchases that may be needed. The manager is aware of the issue and is intending to move it forward. There are some significant health and safety issues. Moving and Handling training, risk assessing and care planning for residents with moving and handling needs is not happening. There is also not a fire risk assessment of the premises or evacuation procedure in line with new legislation. One fire exit continues to be unsafe. Urgent requirements were left for both these issues. The cupboards for storing substances hazardous to health are not signed and the one in the home was left open with the keys in. There are also not data sheets for all the products used. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 21 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 1 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 2 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 1 2 X 1 Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 4(1) (a,b,c) 5(1)(a-f) (2) 14(2)(a,b) Requirement Timescale for action 31/07/07 2. OP3 3. OP7 15(1) 15(2) (b,c,d) 16(2)(m) 4. OP7 14(1)(a) 15(1) The registered person must ensure that the home has a Statement of Purpose and Service User Guide The registered person must 31/07/07 ensure that all service users’ pre-admission assessments cover all aspects of care needs in the detail needed for the home to confirm that it can meet those needs. Target dates of 31/07/06 and 31/03/07 not met. The registered person must 31/07/07 ensure that all residents’ social and leisure needs’ assessments are completed in consultation with service users or their representatives and kept under review Target dates of 31/01/06, 30/06/06 and 31/03/07 not met. The registered person must 31/07/07 ensure that the care needs of service users suffering from dementia are fully assessed. Target dates of 31/07/06 and 31/03/07 not met DS0000007037.V339426.R01.S.doc Version 5.2 Oakcroft Nursing Home Page 23 5. OP7 15(1) 6. OP7 13(4)(b,c) 7. OP7 13(1)(b) 4(b,c) 8. OP7 15(1) 9. OP8 12(1) 13(1) 10. OP9 17(1)(a) 11. OP9 13(2) The registered manager must ensure that individual service users abilities to manage their own personal finances are taken into account in the care planning process. Target dates of 31/01/06, 31/05/06, 31/08/06 and 31/03/07 not met. The registered person must ensure that any risk areas for service users should be fully assessed and documented. Target dates of 31/03/05, 31/10/05, 31/07/06 and 31/03/07 not met. The registered person must ensure that no service user is transported in a wheel chair unless the need for this has been assessed by an appropriate professional and the wheelchair is satisfactorily maintained. Target dates of 30/07/06 and 31/03/07 not met. The registered person must ensure that all service users or their representatives are consulted about the review of their care plans and sign their plan to reflect agreement. Target dates of 31/07/06 and 31/03/07 not met. The registered person must ensure that residents who are at risk of developing pressure sores have a care plan to detail necessary intervention The registered person must ensure administration of medication is recorded contemporaneously and that the records are not changed at a later date. The registered person must ensure that stocks of medication are recorded so that administration can be checked. DS0000007037.V339426.R01.S.doc 31/07/07 31/07/07 31/07/07 31/07/07 30/06/07 30/06/07 30/06/07 Oakcroft Nursing Home Version 5.2 Page 24 12. OP9 17(1)(a) 13. OP9 13(2) 14. 15. OP10 OP12 12(4)(a) 16(2) (m,n) 16. OP18 13(6)(7) 17. OP19 23(2)(b) 18. OP19 23(4)(b) 19. OP20 23(2)(e) (h,I,j) 20. OP29 19(1)(a) (bi.ii)(c) Target date of 31/03/07 not met The registered person must ensure that unused medication is disposed of in line with the home’s policy. The registered person must ensure residents’ medication administration charts have photos attached and allergies noted. The registered person must ensure that residents are always treated with dignity. The registered person must ensure that a programme of activities is developed based on service users’ assessments as required above. Target dates of 31/10/06 and 30/04/07 not met The registered person must ensure that bed rails are only used in accordance with the guidelines laid out in the letter from Lewisham Social Services Adult Protection team The registered person must ensure that the intention to decorate all bedrooms is carried out. Target date of 31/07/07 not yet reached The registered person must ensure that the ground floor fire exit is made safe to use Target date of 31/03/07 not met The registered person must ensure that adequate communal sitting, recreational and dining space is provided. Target date of 31/07/06 not met. Target date of 30/06/07 not yet reached The registered person must ensure that they operate a DS0000007037.V339426.R01.S.doc 30/06/07 30/06/07 31/07/07 31/07/07 30/06/07 31/07/07 30/06/07 30/06/07 31/07/07 Page 25 Oakcroft Nursing Home Version 5.2 21. OP30 18(1)(a,c) (I,ii) (18)(1) (a,b,c) 22. OP30 23. OP33 24.1 (a,b) 24. OP35 12 (2,3)23(2 m) 25. OP36 (18)(2) thorough recruitment procedure ensuring the protection of residents. The registered person must ensure there is an induction programme for new staff in line with NTO guidelines. The registered person must ensure that the manager puts into place a staff training and development plan to ensure the needs of the service users can be properly met. Target dates of 31/03/05, 31/07/05, 30/11/05, 31/05/06, 31/07/06 and 31/03/07not met. The registered person must ensure that an annual development plan and a quality assurance system for measuring satisfaction with the service are put into place. Target dates of 30/04/05, 31/12/05, 31/05/06 and 31/12/06 not met. Target date of 30/06/07 not yet reached and it was noted that a start was made on meeting this requirement. The registered person must ensure that the home’s policy for service users’ finances are reviewed to take into account the need for service users to manage their own finances if they so wish and are so able. This will entail ensuring there are procedures for properly dealing with personal allowances if the service user wishes this to be held for them by the home. Target dates of 31/07/05, 30/11/05, 31/05/06,30/11/06 and 31/03/07 not met. The registered person must ensure that all care staff receive DS0000007037.V339426.R01.S.doc 31/07/07 31/07/07 30/06/07 31/07/07 31/07/07 Page 26 Oakcroft Nursing Home Version 5.2 26. 27. OP38 OP38 13(5) 23(4) 28. OP38 13(3)(4) supervision and appraisal in accordance with the requirements of this standard. Target dates of 31/07/05, 31/10/05, 30/04/06, 31/07/06 and 31/03/07 not met. The registered person must ensure that that moving and handling in the home is safe The registered person must ensure that al necessary actions are taken to ensure fire safety within the home The registered person must ensure that all actions needed to ensure the safety of substances hazardous to health are taken 13/06/07 13/06/07 30/06/07 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 OP10 OP15 OP29 OP31 Good Practice Recommendations It is recommended that arrangements should be made for residents to make and receive phone calls in private. It is recommended that the home consult with a dietician to ensure that the diet provides good nutrition for residents. It is recommended that all job vacancies be advertised in order to comply with Equal Opportunities legislation It is recommended that the registered person should consider providing additional temporary or permanent management support, to enable the development of the service, as outlined in the requirements of this report. Oakcroft Nursing Home DS0000007037.V339426.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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. 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