CARE HOMES FOR OLDER PEOPLE
Oakcroft Nursing Home Oakcroft 41-43 Culverley Road Catford London SE6 2LD Lead Inspector
Sean Healy Unannounced Inspection 5th September 2005 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.V250091.R01.S.doc Version 5.0 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.V250091.R01.S.doc Version 5.0 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.V250091.R01.S.doc Version 5.0 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) 31st March 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 14 of the 28 places are occupied by them. Support needs catered for includes dementia and mild mental health support. The home is staffed on a 24-hour basis, consisting of a manager, one assistant 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 accesssible from the dining room. Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted over a nine-hour period on two separate days on the 5th and 6th September 2005. The inspection was facilitated by the nurse in charge on day one and by the registered manager and provider on day two. Five service users and two families contributed their views, and three staff, the registered manager and the registered provider were interviewed and 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?
Care plans are now completed for two service users who did not have good care plans. The home now provides good food choice for service users and ask service users what they like to eat. The home’s complaints policy has been revised to include advising service users that they can contact CSCI if they are not happy with how complaints have been handled, and also now includes a fixed time of 28 days to deal with complaints. All staff have now had adult protection training to improve their knowledge and ability to protect service users from abuse. A sluice has been removed from service users’ toilets and relocated in a separate area, improving the health and cleanliness of the toilet area. The home’s management has now produced financial accounts to show they are able to afford to maintain a good quality of service. Risk assessments have now been done regarding fire safety and the London Fire Service officer has visited the home and passed it as safe. Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 6 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.V250091.R01.S.doc Version 5.0 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.V250091.R01.S.doc Version 5.0 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 and 3 Prospective service users do not have complete information to make an informed choice about where they live without which they cannot make a fully informed decision. 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. EVIDENCE: The home’s Statement of Purpose and Service User Guide do not fully reflect the needs requirements of National Minimum Standard 1, especially in the following areas; 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. This is an unmet requirement from last inspection. (Refer to Requirements) All service users have an assessment which is normally provided by social services, which caters in the main for service users health and assessed emotional care needs, however all assessments are greatly lacking in information regarding social care needs, such as lists of friends and leisure and
Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 9 social interests and life histories to use as an aid for meaningful reminiscence. (Refer to Requirements) Many service users and visiting family members commented that staff are not well informed about things they like to do. Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 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 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: 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 all of the six plans looked 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 likes to watch on TV, or likes to read, or what relaxing means. Service user activity observed throughout reflected quite a lot of sitting watching TV,
Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 11 without anyone appearing to ask if that’s what people wanted to watch. Few people were engaged in games or reading, and a number of service users and all family members spoken to said that; “ there are little activities, no outings and people are bored”. This are of planning must be improved. (Refer to Requirements) The registered manager had been required to care plans were completed for a service user who had recently moved in at last inspection, and this was done. However there were also requirements that care plans and risk assessments are fully completed on admission of new service users, which is not being fully addressed. On looking at care plans it was clear that there were gaps in planning, for example one assessment read that; “Service user x is a wheelchair user and has a left side weakness”, but care plans simply said that; “ Service user x is immobile, please use hoist”, with no reference or guidance as to any concern regarding left side weakness, or how she prefers to be involved in the transfer. (Refer to repeated requirements) The home was also to review its medication policy to include selfadministration decisions and procedures, and to ensure that each service user has a lockable space in their rooms for this purpose. The manager said a lot of work had been done on the policy but it was not yet completed or available to view. The manager confirmed that none of the service users rooms are equipped with a lockable space. These issues must be addressed. (Refer to repeated Requirements) The home was asked to move staff lockers and coat hanging facilities from the service user’s bathroom area. This has not been done, but the manager said they are in the process of re-siting the lockers. (Refer to repeated requirement) Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 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): 12,13 and 15 Service users do not feel that the lifestyles experienced in the home matches their preferences, or social, cultural, and recreational interests and needs, which is resulting in boredom. 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 do receive wholesome and appealing balance diets. EVIDENCE: The home does not adequately assess or plan for service users social contact or activities. There is little evidence of good links being fostered with the local community, without which service users can feel separate and isolated from the area in which they live. (Refer to requirement standard 7) Service users can have visitors at all times during the day and evening but one visitor said that they had been asked not to come during the busy morning times. If this is the case it must be clarified in the homes policy. (Refer to Requirements) Meals are served morning, midday and evening and the system for involving service users in deciding on contents of meals has improved. Menus are kept in the kitchen and are written on a six weekly rotational basis. Service users
Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 13 are also offered choices each day. All service users spoken to say the food is very good and they get to eat things they like. Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service users cannot always be confident that their complaints will be acted on and taken seriously, which impacts on willingness to complain to improve the service offered. Service users may not always feel that they are protected from abuse by the home’s policy. EVIDENCE: As requested the homes complaints policy has been revised to include details of CSCI and timescales for investigation of a complaint. However it has been six years since a record of a complaint has been recorded, and some service users and visitors said they were not sure whom to complain to if they needed. Some staff described having dealt with a complaint but there was no record of this in the homes complaints book. The homes management needs to be able to demonstrate that all service users and relatives have been informed about the homes complaints policy, and that staff receive training or guidance in how to respond complaints being made including keeping records. (Refer to Requirements) It was asked that the homes Adult Protection policy be revised and updated but this has not been done. (Refer to repeated Requirement) 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 needs to look into the practices for consulting with service users regarding their wishes about
Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 15 bedtimes and be seen to inform its staff on acting on service users expressed wishes. (Refer to Requirements) Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24 and 26 The home is safe and well maintained and hygienic, with suitable washing and toilet facilities, 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 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 recently carried out an inspection and passed it 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. Sixteen of the 28 service users when fully
Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 17 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) The number of bathrooms with assisted baths shower facilities and toilets is adequate. The sluice facility previously sited in service users bathrooms has now been relocated to a suitable area. The sizes of the rooms are not stated in the homes Service User Guide or anywhere else in the homes paperwork. The homes registered manager has been previously asked to ensure that these details are made available but this has not yet happened. (Refer to repeated requirement) 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 Requirements) Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 18 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): 29 and 30 The service users are supported and protected by the home’s recruitment policy and practices. 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’s recruitment processes are thorough with good checklists in use. Files on some long-term employees contain references, which are not well detailed, but this issue has now been addressed and better standard references are now in use. There is a good interview process and staff described being interviewed by two people and undergoing a structured induction. All CRB checks are up to date. 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 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 and still needs to be addressed. (Refer to restated Requirements) Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 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): 33,34,35,36 and 38 The home 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. Service users are safeguarded by the home’s accounting and financial procedures, but cannot fully demonstrate that service users’ financial interests are safeguarded. Staff are not always consistently supervised, which can lead to inconsistent or bad practice. Health, safety and welfare of service users is generally being promoted but some poor record keeping may pose potential risk to service users. EVIDENCE: 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
Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 20 well being which go un-noticed by the homes management and staff. There has been a previous request to address this issue but 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) The homes accounts have now been produced and copied to CSCI demonstrating it’s financial viability. 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 was a previous request to carry out a review of the homes policy, which was not done. (Refer to repeated Requirement) There was a request 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. One staff member said that they could not remember when they last had formal supervision. (Refer to repeated Requirement) Many of the requirements for safe working practices have been put in place and are working well. Appropriate moving and handling equipment is being used and is well maintained. The home has recently been assessed by the London Fire Brigade regarding fire safety and has passed, and a risk assessment and management plan has been produced. Good systems are in use for regular health and safety checks, and the home’s hygiene and cleanliness levels are very good. However records of visitors to the home are being poorly maintained which can represent a risk to service user safety and security. (Refer to Requirements) Equipment such as movable scales and wheelchairs are being sometimes stored in service users bedrooms without consultation and this can cause hazards such as tripping. This practice needs to stop and a place be identified for storage of this equipment. (Refer to Requirements) Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 3 X 2 2 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 3 2 2 X 2 Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 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) Requirement The registered manager must ensure that the statement of purpose and service users’ guide include all of the information required by these regulations. This has been the subject of three previous requirements. Timescales of 01/04/04, 28/02/05 and 30/06/05 unmet. Continued failure to comply may result in consideration being given to enforcement action. 2 OP3 14 The registered manager must ensure that all service users social and leisure needs assessments are completed in consultation with service users and kept under review The registered person must ensure that care plans are completed in a timely fashion with medical and care needs being filled in immediately on admission, with details of social care needs and recreational interests, showing how these are 31/01/06 Timescale for action 30/11/05 3 OP7 15 (1) 30/11/05 Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 23 to be met. Timescale: Ongoing 4 OP7 15(1) The care plans for two service 12/09/05 users must be revised to ensure that all aspects of health, personal care, and social care needs are addressed to ensure safe, risk assessed support and a good quality of social life. This was the subject of an immediate requirement, and was met at the time of writing. The registered manager must 31/01/06 ensure that individual service users abilities to manage their own medication are taken into account in the care planning process The registered manager must 31/01/06 ensure that individual service users abilities to manage their own personal finances are taken into account in the care planning process The registered person must 31/10/05 ensure that any risk areas for service users should be fully assessed and documented. This was the subject of a previous requirement. Timescale 31/03/05 partially met. 8 OP9 12(4) 23(2)m The registered manager must 30/11/05 ensure that the medication policy is expanded to include selfadministration decisions and procedures. Each room also needs to be equipped with a lockable space. This was the subject of a previous requirement. Timescale of 30/06/05 unmet. 9 OP9 12.1(a) The registered manager must make arrangements for the community pharmacist to visit
DS0000007037.V250091.R01.S.doc 5 OP7 15(1) 6 OP7 15(1) 7 OP7 13.4 (b,c) 30/11/05 Oakcroft Nursing Home Version 5.0 Page 24 the home to inspect the homes system for management of medication 10 OP10 23.3(a)ii The registered person must 31/10/05 ensure that staff lockers and coat hanging facilities sited in a service users’ bathroom are moved. This was the subject of a previous requirement. Timescale 31/08/05 unmet. 11 OP13 4.1 (c) Sch.1 The registered provider and manager must clarify the homes visitors policy to service users and staff especially in relation to any restrictions on times of visits The homes management must demonstrate that all service users and relatives have been informed about the homes complaints policy, and that staff receive training or guidance in how to respond complaints being made including keeping records. 31/10/05 12 OP16 22 30/11/05 13 OP18 13.6 The registered person must 30/11/05 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 three previous requirements. Timescales of 01/05/04, 31/01/05 and 30/06/05 unmet. Continued failure to comply may result in consideration being given to enforcement action. 14 OP18 14 (1,2,3,4) The registered provider and manager must look into the homes current practices for consulting with service users regarding their wishes about bedtimes and be seen to inform it’s staff on acting on service
DS0000007037.V250091.R01.S.doc 30/11/05 Oakcroft Nursing Home Version 5.0 Page 25 users expressed wishes. 15 OP19 23 2 e,f,g,h,l The registered person must 31/03/06 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. 16 OP19 23.2 (e) The registered person must 31/03/06 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. 17 OP23 23 1 a 23 2 e, f The registered person must ensure that the sizes of all rooms are available to the public and the commission. This was the subject of a previous requirement. Timescale 31/05/05 unmet. 18 OP24 16.2 (c, d) The registered person must 30/11/05 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. Timescale 31/07/05 partially met. 30/11/05 Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 Page 26 19 OP30 18.1 (a,b,c) 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 two previous requirements. Timescales 31/03/05 and 31/07/05 unmet. Continued failure to comply may result in enforcement action 30/11/05 20 OP33 24.1 (a,b) The registered person must 31/12/05 ensure that an annual development plan and a quality assurance system for measuring satisfaction with the service is put into place. This was the subject of a previous requirement. Timescale 30/04/05 unmet. 21 OP35 12 (2,3) 23(2 m) The registered person must 30/11/05 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 two previous requirements. Timescale 31/07/05 unmet. 22 OP36 18.2 The registered person must 31/10/05 ensure that all care staff receive supervision in accordance with the requirements of this standard.
DS0000007037.V250091.R01.S.doc Version 5.0 Page 27 Oakcroft Nursing Home This is the subject of three previous requirements. Timescale 31/07/05 unmet. 23 OP38 17 .2 Sch 4.17 The registered manager must 31/10/05 ensure that complete records are kept of all visitors to the home including the name of the visitors to ensure service users safety. 24 OP38 23.2 (I,m) The registered manager must 31/10/05 make use of the homes storage facilities and ensure that equipment is not stored in service users rooms or communal areas. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oakcroft Nursing Home DS0000007037.V250091.R01.S.doc Version 5.0 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
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