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Inspection on 03/03/06 for Oakcroft Nursing Home

Also see our care home review for Oakcroft Nursing Home for more information

This inspection was carried out on 3rd March 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is friendly and welcoming, and some service users commented that they are glad to be living at the home as they feel comfortable there and are near to their relatives. All of the service users have needs assessments though some need updating. There is good attention to care planning in respect of health needs and good links with external health care professionals. There is a good level of cleanliness throughout the home. There are adequate numbers of staff to provide care and support and service users said that they are friendly and helpful. The home has made good progress in helping care staff to get qualified and improve their skills.

What has improved since the last inspection?

There are better care plans in place for service users when they first come to the home, and assessments now include some details about social and leisure care needs, though this still needs further improvement. The homes management had asked the pharmacist to visit to check the medication system and the pharmacist report said that medication is generally well managed. Service users, their families and staff have been updated about how to raise concerns or complaints with the homes management, and the Adult Protection policy has been updated to better protect service users, although some additional information is still required. Two service users said that they had been informed and knew that they could always speak to the homes manager. The manager has investigated concerns raised by some relatives that some service users were being asked to go to bed earlier than they might want to. The manager said that she found no proof that this was happening but she has told staff that service users should only go to bed when they want to. Good records are now being kept of the names of visitors to the home and the reason they visit, so that service users and visitors are better protected. Equipment such as spare wheelchairs are now being stored safely.

What the care home could do better:

There needs to be further improvement in the information in assessments and care plans regarding service users` histories, social and leisure activity interests, and a commitment in planning to meet these needs. A comment from all service users and relatives at the last inspection was that service users are left for a long time without any structured activities. One relative had said; "Look around and you will see a lot of people are bored, and are falling asleep out of boredom." Another had said: " There are no structured activities, I don`t blame the staff but there are really no games or activities in the home and there are never any outings". Although there has been an improvement in including some information in assessments there still needs to be an improvement in planning such activities for each service user, and training for staff in how to do this. Service users abilities to manage their own finances must also be included in their assessments and care plans. There must be a review of service users needs and abilities to take their own medication, to make sure that service users are given the opportunity to manage their own medication if they wish to and are able to. Service users rooms need to be fitted with a lockable cupboard for storage of personal valuables and medication (If needed). The staff lockers in the service users` toilet area must be moved to enable service users to feel that this is a private area. The home needs to plan to reduce the number of rooms being shared by service users, and to have a separate dining area. There needs to be more work done to plan staff training and to develop systems for seeking service users views, about how the home is run and acting on their opinions.

CARE HOMES FOR OLDER PEOPLE Oakcroft Nursing Home Oakcroft 41-43 Culverley Road Catford London SE6 2LD Lead Inspector Sean Healy Unannounced Inspection 3rd March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oakcroft Nursing Home DS0000007037.V280727.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. Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 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 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 Ms Rajmati Bachan 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.V280727.R01.S.doc Version 5.1 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) 5th September 2005 Date of last inspection Brief Description of the Service: Oakcroft Nursing Home provides care for up to 28 older people, up to three of whom may have a physical disability. It caters for respite care as well as longterm care. The home provides support for a number of people who use wheelchairs; currently they occupy 14 of the 28 places. Support needs catered for includes dementia and mild mental health support. The home is staffed on a 24-hour basis, consisting of a manager, nine nurses and twenty-two care staff and currently there are no staff vacancies. There is one staff nurse and four carers available between 8am and 9pm and one nurse and two care assistants providing night waking support. It is a large two-storey building close to Catford train station and local shops and services. The area is also well serviced by buses to central and south London. There is accessible off road car parking space for up to 6 cars to the front of the building. The ground floor is wheelchair accessible throughout, consisting of five single accessible bedrooms, a modern kitchen, a joint livingroom/dining room looking on to the back garden, two single toilets and one bathroom all of which are accessible. There are also toilet facilities for staff, a small reception/office and the provider’s office situated on the ground floor. There is a modern elevator servicing the first and second floors suitable for wheelchair users. On the first floor there are four single bedrooms and four double bedrooms, two toilets and one accessible bathroom, a sluice room, laundry room and a small staff tearoom. The second floor consists of four double bedrooms, three single bedrooms, three single toilets and one accessible bathroom. All bedrooms have a sink but none are en-suite. There is an accessible garden and patio to the rear of the home. Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted over one day on the 3rd March 2006. The registered manager facilitated the inspection. Four service users and one family contributed their views. Four staff and the registered manager provided their opinions on how the home is managed and what is running well, and what needs to be done to make improvements. The inspection included a tour of the home and examination of records on care plans of six service users, building maintenance, and staff training and supervision records. Observations were made of staff working with service users in the living room/dining room area where many of the service users were present throughout the inspection. What the service does well: What has improved since the last inspection? There are better care plans in place for service users when they first come to the home, and assessments now include some details about social and leisure care needs, though this still needs further improvement. The homes management had asked the pharmacist to visit to check the medication system and the pharmacist report said that medication is generally well managed. Service users, their families and staff have been updated about how to raise concerns or complaints with the homes management, and the Adult Protection policy has been updated to better protect service users, although some additional information is still required. Two service users said that they had been informed and knew that they could always speak to the homes manager. Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 6 The manager has investigated concerns raised by some relatives that some service users were being asked to go to bed earlier than they might want to. The manager said that she found no proof that this was happening but she has told staff that service users should only go to bed when they want to. Good records are now being kept of the names of visitors to the home and the reason they visit, so that service users and visitors are better protected. Equipment such as spare wheelchairs are now being stored safely. 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. Oakcroft Nursing Home DS0000007037.V280727.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 Oakcroft Nursing Home DS0000007037.V280727.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): 1,3 and 6 Prospective service users do have complete information to make an informed choice about where they live. Service users do not have complete assessments of need prior to moving into the home, which means that social care needs and leisure activity needs are not fully catered for. Service users referred solely for intermediate care are helped to be independent and return home. EVIDENCE: The home’s Statement of Purpose and Service User Guide have been updated to reflect the needs requirements of National Minimum Standard 1. These now include: description and sizes of rooms, complaints procedure, contract details, accessibility, service users views of the home regarding quality and management, age range and criteria for admission. However it is recommended that the date of this review, and any future reviews are included in these documents, together with information about who was involved in these reviews. (Refer to Recommendations OP1) All service users have an assessment of need, which is normally provided by social services, and caters in the main for service users health and assessed Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 9 emotional care needs. Work has been done to include in these assessments information regarding social care needs, social interests, and life histories, to aid meaningful reminiscence. However this work needs further improvement to include more information regarding friends, family and leisure activities. The work also needs to be extended to all service users. There also needs to be information included in these assessments regarding service users abilities and wishes to self medicate, and financial support needs and abilities. (Refer to Requirements OP3) The home provides respite care for referrals from the local authority, and provides good and sensitive support, based on good assessment information provided by social services and the homes own assessment system. Oakcroft Nursing Home DS0000007037.V280727.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, 9 and 10 Service users’ health and personal care needs are set out in a personal care plan and are being met; however, social care needs are not properly planned which results in low activity and boredom. Service users are not properly assessed or supported regarding their ability to manage their own medication, and don’t always feel that they are treated with respect and their rights to privacy upheld. EVIDENCE: As at last inspection: The home does ensure that all service users have a care plan which addresses well the areas of health and personal care support. The home also has good written plans and practices in place to fully support health care needs, involving are range of appropriate health care professionals. However care plans showed a lack of knowledge and plans for social and leisure activity individual to service users personal experience and desires. There was a lack of information about places the person enjoyed visiting, people they knew and would like to keep contact with, and social activities they would enjoy. Generally there were short lists referring to activities such as; “enjoys watching TV, reading, relaxing” but little information about what the person Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 11 likes to watch on TV, or likes to read, or what relaxing means. This area of care planning must be improved. (Refer to Requirements OP7) Many service users are independent in the management of their finances, or have family take responsibility for this where they are in need of support. However care plans do not mention service users abilities in this area, or any support needed in managing small amounts of money left in the care of the homes management for expenses such as hairdressing or outings. Service users needs or abilities regarding self-medication included in care plans, nor is their agreement for the home to manage their medication included, although none of the home current service users self medicate. Service users or their representatives have not signed their care plans. All of these areas must be addressed by the management of the home. (Refer to new and repeated Requirements OP7 and OP9) The registered manager had been required to ensure that care plans were completed for two-service user who had recently moved in, at last inspection, and this was done. Care plans were adequate for a service user, who had recently moved in. Risk is managed by including areas of concern in care plans such as risk of falls. However the home does now use a separate system for assessing risk, which would involve a process of involving appropriate people in the assessment, and which would better demonstrate whether alternatives had been considered, and an agreed statement whether the risk is acceptable an manageable. The home must look into separating risk assessment from care plans in order to better demonstrate good assessment and review practices are being applied. (Refer to Requirements OP7) The home has now reviewed its medication policy to include self-administration decisions and procedures. However service users continue not to have a lockable space in their rooms for this purpose. The manager confirmed that it is the intention of the home to ensure service users rooms are equipped with a lockable space. This issue must be addressed. (Refer to repeated Requirements OP9) At two previous inspections the home was asked to move staff lockers, and coat hanging facilities, from the service user’s bathroom area. This still has not been done. The manager said that they had almost sorted this out, but the alternative site was deemed as a fire risk by the visiting fire officer, preventing this work from being completed. An alternative site has now been identified the manager said the lockers would be moved. (Refer to repeated requirement OP10) Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 Service users do maintain contact with their families, but there is poor awareness of service users friends and community contacts, which can lead to feelings of isolation. Service users are helped to exercise control over their lives. EVIDENCE: Service users can have visitors at all times during the day and evening. At last inspection visitor had said that they had been asked not to come during the busy morning times. It was asked that If this was the case, that the home must clarify this to the visitor concerned, and reflect this practice in the homes policy in the homes policy. This has not yet happened. (Refer to Repeated Requirements OP13) Service users can and are allowed to manage their own financial affairs without interference from the home. However the homes assessment system does not adequately assess capacity or support needs in this area. (Refer to requirements under standard 3 of this report) Advocacy support information is made available to service users, and many relatives are involved in the care planning process. All service users records are kept on site and are fully available to them. Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 13 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 Service users can be confident that their complaints will be acted on and taken seriously, but they may not always feel that they are protected from abuse by the home’s policy. EVIDENCE: All service users and their relatives, and members of staff, have been informed about the homes complaints policy and procedure. There have been no complaints recorded since the last inspection. The home has now got a copy of the local authorities current Adult Protection policy, its own policy has been revised and updated. However improvements still need to be made to this policy to include how staff should respond and act in the event of an allegation being made. There is no reference in the policy to a requirement for staff to record what has been said, to keep the person safe, to avoid investigating the allegation themselves, to report immediately to the homes senior management, or regarding the need to maintain confidentiality. There needs also to be better reference to the reporting of allegations to the local authority’s Adult Protection team. (Refer to repeated Requirement OP18) At last inspection one service user described being made to get up earlier than he would wish to, and another described being actively prompted to go to bed earlier than she wanted to, saying that; “They put me to bed at 7pm, but I was used to going to bed at 10pm when I was at home”. The homes management has now looked into the allegation of such practices, and instructed staff of the Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 14 need for consulting with service users regarding their wishes about bedtimes, and on acting on service users expressed wishes. Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 and 24 The home is safe, well maintained and hygienic, but the layout is not completely suitable for it’s stated purpose, resulting in overcrowding in some bedrooms and the living room area. Service users’ bedroom furniture may not be reflective of their requirements. EVIDENCE: The following was discussed at last inspection and is still relevant: The home is located in a quiet road near to Catford town centre, which can become busy at school-times but otherwise is in a good location. It is bright airy and well maintained throughout. London fire brigade has passed the premises as safe. All service users are happy with the accommodation and all of the grounds and garden are well maintained. However there is a current problem regarding the size and use of the living room and the number of people sharing bedrooms without choosing to do so. The living room also doubles as a dining room but this causes a crowding problem and many service users were seen to be eating their lunch while seated at their armchairs. The homes management agrees that this issue needs sorting out and has begun discussions with an architect regarding the best option for sorting this out. Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 16 Sixteen of the 28 service users when fully occupied would be sharing bedrooms. This represents 43 occupancy in single rooms rather than the recommended 80 . Again the manager and owner have agreed that there needs to be a reduction in shared occupancy and there is now an opportunity to begin to address this problem. (Refer to repeated Requirements OP19, still within timescale) The sizes of the rooms are now stated in the homes Service User Guide. The bedroom furniture provided by the home for all service users does not include two comfortable chairs, a table and a lockable space and there was a requirement for these facilities to be provided. The manager explained that some service users do not want all of these items, but there is no evidence that this has been formally agreed. (Refer to Repeated Requirements OP24) Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 30 Service users have sufficient numbers of staff available but their skills mix needs some changes to better address social care planning and involvement of service users. Sufficient numbers of staff are qualified, but It is not possible yet to determine whether staff are trained and competent to do their jobs, which may result in poor service delivery. EVIDENCE: The home employs nine nursing staff, and 23 care staff, six of whom are part time, to provide support for the current 18 service users. There is an adequate number of staff available to provide for nursing and care needs, and there are two full time kitchen staff and a number of other part-time and full-time domestic staff employed to keep the home clean and ensure that laundry is well managed. There is a rota available which clearly shows the daytime and night cover, and there are extra staff on duty to cater for busy times such as the early morning and mealtimes. The majority of care staff are experienced, but there is a need to ensure that there is a culture of planning with service users, in a way that includes their expressed needs, and in planning in an individual way for social and leisure needs. Staff need to be trained in methods of doing this and enabled to set about doing this for themselves. (Refer to Requirements OP27) The home operates a system for training staff, which includes access to the local authority training. However staff do not have individual training and development profiles without which it is difficult to ensure that all training is up Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 18 to date, and relevant to service users care and support needs, or that it fits in with the homes own development plan. This area of planning was previously required to be implemented at the last two inspections, but this has not yet happened. (Refer to Repeated Requirements OP30) There is an appraisal system in place, which is not effectively used for evaluating and planning staff training needs, which the manager recognises as an area for improvement, which would help to facilitate the above requirement. More than half of the care staff employed have either completed or have almost completed NVQ level 2/3 in care. Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 37 The home is managed by a person who is fit to be in charge, but it cannot currently demonstrate that it is run in the best interests of service users, which may result in important decisions being made without their involvement. The home cannot fully demonstrate that service users’ financial interests are safeguarded by the homes policy. Staff are not always consistently supervised, which can lead to inconsistent or bad practice. EVIDENCE: The home is managed by a qualified nurse of many years experience in the care of the elderly. The manager is also qualified to NVQ Level 4 in care and management, and reports directly to the owner/registered provider who visits the home regularly. However a number of the homes key systems such as social care planning, risk assessments, service user consultation, and staff supervision and appraisals, are not being currently efficiently implemented. It may well be that there are a lot of priorities to manage, and that there is also a need for the manager to have skills development in some of these areas. It Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 20 also may well be the case that some additional management support is needed in either a temporary or permanent basis, to enable the manager to deal with these development areas. (Refer to Recommendations OP31) As was the case at the last inspection, the home does not have an annual development plan or quality assurance system for consulting service users on their views of how the home is managed. There are no adequate service user surveys being conducted to inform decision-making. Service users and relatives confirmed that such consultation is not taking place, resulting in low levels of structured activities, and concerns about lack of outings, and concerns about bedtimes and personal well being which go un-noticed by the homes management and staff. There have now been two previous requests to address this issue, but as yet no progress has been made. It is vitally important that this issue is addressed soon to ensure that service users begin to be meaningfully involved in the homes development. (Refer to repeated Requirement OP33) As was the case at last inspection, the homes assessment and planning system does not adequately include assessment of individual service users abilities or wishes to manage their own finances. Service users interviewed were not clear on their rights regarding responsibilities for their finances, and two people said they would like to know more about their finances. There have now been two previous requests to carry out a review of the homes policy, which has not been done. (Refer to repeated Requirement OP35) At the last two inspections a requirement had been made for the home to ensure that all staff receive regular formal supervision at least six times a year. The manager said that this is still not happening but showed that some work has been done to implement a new supervision system, which has not yet properly got started. Staff confirmed that supervision is not happening with consistent regularity. (Refer to Repeated Requirement OP36) Records of visitors to the home are now being well maintained. Equipment such as movable scales and wheelchairs are now being stored safely. Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 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 3 X 2 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 2 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X 3 2 X X STAFFING Standard No Score 27 2 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 2 3 Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 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 OP3 Regulation Requirement Timescale for action 30/06/06 2 OP7 3 OP7 14.2 a & b The registered manager and provider must ensure that all service users’ assessments of need are revised to include: social and leisure care needs, financial abilities and support needs, and individual service users abilities and wishes regarding self medication. 15(1) The registered manager must ensure that individual service users abilities to manage their own medication are taken into account in the care planning process. This was the subject of a previous requirement at the last inspection, Timescale of 31/01/06 unmet. Timescale now revised. 15(1) 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. This was the subject of a previous requirement at the last inspection, Timescale of 31/01/06 unmet. Timescale now revised. DS0000007037.V280727.R01.S.doc 31/05/06 31/05/06 Oakcroft Nursing Home Version 5.1 Page 23 4 OP7 15.2 b,c & d 16.2 m 5 OP7 15.1 6 OP7 13.4 (b,c) 7 OP9 12(4) 23(2)m 8 OP10 23.3(a)ii The registered manager and provider must ensure that all service users care plans include individual social and leisure care needs as discussed in this report under Standard 7. This must be done in consultation with each service user or their representative. The registered manager and provider must ensure that all service users or their representatives are consulted about the review of their care plans and sign their plan to reflect their agreement. The registered person must ensure that any risk areas for service users should be fully assessed and documented. This was the subject of a previous requirement at two previous inspections, Timescale 31/03/05 and 31/10/05 partially met. Continued failure to fully meet this requirement may result in enforcement action. Timescale revised. The registered manager must ensure that each service users room be equipped with a lockable space suitable for storage of medication. This was the subject of a previous requirement at two previous inspections, Timescale of 30/06/05 and 30/11/05 unmet. Continued failure to meet this requirement may result in enforcement action. Timescale now revised. The registered person must ensure that staff lockers and coat hanging facilities sited in a service users’ bathroom are moved. DS0000007037.V280727.R01.S.doc 30/06/06 30/06/06 31/05/06 31/05/06 30/04/06 Oakcroft Nursing Home Version 5.1 Page 24 9 OP13 4.1 (c) Sch.1 10 OP18 13.6 11 OP19 23.2 e,f,g,h,l This was the subject of a requirement from two previous inspections, Timescale 31/08/05 and 31/10/05 unmet. Continued failure to meet this requirement may result in enforcement action. Timescale revised. The registered provider and manager must clarify the homes visitor’s policy to service users and staff especially in relation to any restrictions on times of visits. This was the subject of a requirement at last inspection, Timescale 31/10/05 unmet, now revised. The registered person must ensure that the adult protection procedure is revised to develop more fully what action must be taken in the event of an allegation being made. This is the subject of four previous requirements, Timescales of 01/05/04, 31/01/05, 30/06/05 and 30/11/05 partially met. Continued failure to comply fully with this requirement may result in consideration being given to enforcement action. Timescale revised. The registered person must ensure that plans for any new extension address the following issues: a] increase the proportion of single bedrooms, b] increase the amount of storage space for equipment, c] increase the amount and range of communal space for service users. This is the subject of three previous requirements. Timescale ongoing as extension has not been completed. DS0000007037.V280727.R01.S.doc 30/04/06 30/04/06 31/03/06 Oakcroft Nursing Home Version 5.1 Page 25 12 OP19 23.2 (e) 13 OP24 16.2 (c, d) 14 OP27 18.1 a 15 OP30 18.1 (a,b,c) The registered person must ensure that the Commission is kept informed of plans for extending Oakcroft This is the subject of three previous requirements. Timescale ongoing. Plans for extending are progressing. The registered person must ensure that all rooms have two comfortable chairs and a table, locks on the door and a lockable space inside. Any variations to this must be recorded on individual service users care plans and signed by them. This is the subject of a previous requirement from the last two inspections, Timescale 31/07/05 and 30/11/05 partially met. Continued failure to fully meet this requirement may result in enforcement action. Timescale revised. The registered manager must ensure that training for nursing and care staff is scheduled regarding methods of planning for service users social and leisure care needs, and in involving service users in these activities. 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. This was the subject of three previous requirements. Timescales 31/03/05, 31/07/05 and 30/11/05 unmet. Continued failure to comply with this requirement may result in enforcement action. Timescale revised. DS0000007037.V280727.R01.S.doc 31/03/06 31/05/06 30/06/06 31/05/06 Oakcroft Nursing Home Version 5.1 Page 26 16 OP33 24.1 (a,b) 17 OP35 12 (2,3)23(2 m) 18 OP36 18.2 The registered person must 31/05/06 ensure that an annual development plan and a quality assurance system for measuring satisfaction with the service be put into place. This was the subject of a previous requirement of the last two inspections, Timescale 30/04/05 and 31/12/05 unmet. Continued failure to meet this requirement may result in enforcement action. Timescale revised. The registered person must 31/05/06 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 providing a lockable space in all rooms and ensuring there are procedures for properly dealing with personal allowances if the service user wishes this to be held for them by the home. This is the subject of a requirement from the previous two inspections, Timescale 31/07/05 and 30/11/05 unmet. Continued failure to meet this requirement may result in enforcement action. Timescale revised. 30/04/06 The registered person must ensure that all care staff receive supervision in accordance with the requirements of this standard. This is the subject of two previous requirements, Timescale 31/07/05 and 31/10/05 unmet. Continued failure to meet this requirement may result in DS0000007037.V280727.R01.S.doc Version 5.1 Page 27 Oakcroft Nursing Home 19 OP37 12.4 a enforcement action. Timescale revised. The registered manager must ensure that the homes record of complaints is removed from the communal area and is stored in a confidential manner 31/03/06 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 Refer to Standard OP1 OP31 OP31 Good Practice Recommendations The registered manager should include in the homes Statement of Purpose the date of review and details of who was involved in each review The registered manager should consider personal further training in current methods of: risk assessment, staff appraisal and quality assurance processes and procedures. The registered provider should 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.V280727.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Oakcroft Nursing Home DS0000007037.V280727.R01.S.doc Version 5.1 Page 29 - 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. 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