Inspection on 09/04/08 for Oakdene Nursing Home Limited

This inspection was carried out on 9th April 2008.

CSCI found this care home to be providing an Adequate service.

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

Oakdene Nursing Home Limited 27/04/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Oakdene Nursing Home Limited 32-34 Stamford Road Lees Oldham Lancashire OL4 3LH Lead Inspector Sandra Buckley Unannounced Inspection 9th April 2008 09:15 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 Oakdene Nursing Home Limited DS0000068691.V361576.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. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakdene Nursing Home Limited Address 32-34 Stamford Road Lees Oldham Lancashire OL4 3LH 0161 624 4594 0161 633 0904 susan.hopkinson@regencyhomesltd.co.uk 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) Regency Homes Limited Mrs Susan Theresa Hopkinson Care Home 37 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (37) of places Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 37 service users to include: *Up to 37 service users in the category of OP (Old age not falling within any other category); *Up to 9 service users in the category of DE (E) (Dementia over 65 years of age). 27th April 2007 Date of last inspection Brief Description of the Service: Oakdene is a detached Victorian house situated close to Lees village, close to amenities and public transport. The home is registered to provide nursing and residential care for up to 37 service users. Accommodation is provided in 15 single rooms, six of which have en-suite facilities. There are 11-shared rooms, two of which have ensuite facilities. At the time of this inspection four of the shared rooms had been allocated as single accommodation. Three of the shared rooms and three of the single rooms are below the National Minimum Standards in respect of size. The home provides adequate toilets and bathrooms, situated close to bedrooms and communal areas. The ranges of fees charged are £343 to £610. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes This was a key inspection that included a site visit to the home. The manager was not told beforehand that we were coming to inspect; this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit information was taken from various sources, including observing care practices and talking to people in the home. The manager, relatives and some members of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. Comments from questionnaires returned from residents and their relatives are also included in this report. The CSCI requires the home to complete an annual quality assurance assessment (AQAA) in order to demonstrate the level of care provided. The manager had completed it, however more detailed information was required in order to assess practices in the home fully. This was discussed with the manager at the time of this inspection when they were advised how to complete this document for future inspections. Comparisons were made with this document at the time of inspection. On this inspection the outcomes for people in the home did reflect that indicated by the manager in the AQAA, especially in relation to daily life, personal care and protection. However, the manager had recognised what improvements could be made and was taking steps to address issues. There have been three safeguarding investigations at the home since the last inspection. We are satisfied the manager had taken appropriate action in line with Oldham Council Safeguarding policy. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The complaints procedure has been improved to provide a 24-hour phone number should relatives or people in the home have any concerns. One person said “I would see the manager if I were not happy”. Recruitment procedures have been improved and files have been streamlined since the last inspection. Improvements have been made in care planning; however, there were still issues in relation to care planning recording. A new dryer has been purchased and a system introduced for infection control. A maintenance person has been employed full-time to keep abreast of repairs and redecoration. A new larger bathroom has been installed with use of a hoist. Plans for a new extension and refurbishment of the home were available for inspection. Meal times have been reviewed in line with people’s wishes. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The lack of full details being recorded in the assessment procedure may result in peoples needs not being met. EVIDENCE: The manager undertakes a professional needs assessment prior to people being admitted into the home, however a professional needs assessment is not always obtained. We looked at three files in depth and the information recorded. We noted that some information was incomplete, for example, history of diverticulitius and hiatus hernia had no dates recorded of when these conditions first presented. In some instances, documentation was not dated. A professional assessment of need obtained from the referring agency would clarify any issues. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 10 Information regarding facilities and services the home offers is provided to each person and retained in their rooms. The home’s annual quality assurance assessment stated this was also available in large print and recognised the need to make this available in other languages if required. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The lack of detailed care planning linked to assessments may pose a risk to people in the home, in that, some people’s needs may go unmet. EVIDENCE: We looked at the care plans for three people. As we have said earlier, the assessments of people’s needs required more detail, and this also applied to care planning. For example, daily notes showed that a person was receiving appropriate treatment but no care plan was in place to ensure this was maintained. Care plan recording varied in detail and files would benefit from organisation and streamlining in order to provide an audit trail linked to assessments, care planning and reviews. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 12 More detail was required in reviews of care and update in care plans. Accident records were retained on individual files and an emergency procedure policy was in place. The manager completes a monthly audit of accidents; however, these did not reflect the time and place of the accident, making analysis difficult. Staff would benefit from more detailed information on the personal needs of people in the home. For example, if a person has a pace-maker fitted or is prone to trans ischemic attacks and strokes, information should be documented in care plans as signs and symptoms giving staff instructions on how to recognise and what action should be taken in any event. Risk assessments had been completed and people were weighed on a regular basis. Three files examined showed that all the people had gained weight and nutritional screening was implemented if recognised as a need. The three staff interviewed gave examples of maintaining people’s privacy and dignity, for example, making sure clothes weren’t dirty and tights to be worn if wished. Staff are aware of the need for privacy and dignity when toileting and bathing. People in the home were complimentary about the care they received saying, “Staff treat me well” and “staff make sure I am covered up and respect my privacy” and “Staff come if I ring my bell”. Others said, “The podiatrist does my nails” also that they had recently seen the dentist. However, professional visits were not always recorded. The manager did take action to contact specialist consultants in relation to people who may present with challenging behaviour and the management of this. There was evidence gained through staff interviews and record keeping that although handovers took place, there was, at times, a failure in communication and record keeping that needs to be addressed. The manager demonstrated an awareness of this issue and was looking at ways to improve matters; staff said they had confidence in the manager to improve things. There is a trained moving and handling facilitator and sufficient equipment in the home to meet people’s needs, e.g., turntables, hoist, moving and handling belts and slide sheets. Medication records and systems for audit were well maintained. One person was self-administrating medication and although a risk assessment had been completed, this was not sufficient to show mental capacity, how audit checks would be maintained and record keeping. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. A range of activities was available for people to participate in, if they wished, and people’s choices were respected to provide a flexible lifestyle. EVIDENCE: In some instances, the preferences of people in the home were recorded; one staff member gave examples of how they respected people’s preferences in how they liked to dress, etc. A key worker system is in operation. When asked to explain their role in this, staff said, ‘Ask family if they are okay, if anything is needed and look after clothes in wardrobes. Also make sure birthdays are recognised, cards and parties, etc.’ On relative questionnaire said “My husband’s sight is very impaired and they have provided him with an extra large screen television.” Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 14 Also “I haven’t seen any evidence that anyone is restricted in any way at Oakdene.” Another relative comment received stated, “There does not seem to be much in the way of diversionary therapy”, and “Most of the time my mother is well cared for with the new owners but we are starting to have some serious issues about my mother’s diet and feeding times. Although we have expressed our concerns to the manager, they are not taking on board and acting on it.” The residents’ committee meeting minutes stated that arts and crafts were to resume and mealtimes were discussed because people felt meal times were too close together. The result of this has been that tea times are now later and are the duty of evening staff to avoid any rush to get tasks completed. People decided that they still wished the main meal of the day at lunch time and a lighter meal for tea. Staff asked people what they would like at tea times, offering several choices. It was noted that a choice of meal at lunch was not offered, although the manager told us that the kitchen staff knew the preferences of people in the home and their likes and dislikes. People would benefit from menus being on display, which reflected choices and is informative to people should they forget. We dined with people in the home and found the food to be tasty and appetising over the lunch time period. However, tea times were disorganised, with food being put on the table prior to people sitting down which resulted in people going into the dining room and eating what was there, rather than wait for starters or soup. The manager acknowledged that this was unfortunate and that they would address this issue immediately. People in the home said, “The food is always good” and “Food is good but there is only a choice at teatime” also “I enjoy my dinner and like all the meals”, “Food is excellent I have a choice of a hot meal at tea time as well”. One person said “ I choose to have mine later on about 6pm”. The manager had stated in the AQAA that they have made the following changes as a result of listening to people using their services. We have changed the mealtimes to suit the needs of the residents better. Side salad is now put on with the sandwiches. Activities programme has been reviewed to reflect the interest of our current service users. One person had craftwork displayed in their room. The home’s notice board stated that exercises take place and a pat dog visits that people enjoy. The hairdresser was in the home at the time of inspection and people looked well presented. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 &18. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People are protected from abuse by the home’s policies, procedures and staff training, and people are confident that any complaints they may have will be dealt with appropriately. EVIDENCE: The home’s complaints procedure is displayed in the entrance hallway. A copy of this is also included in the service user guide, which each person has within his or her room. Questionnaires returned from people in the home stated they knew how to make a complaint. One person said, ‘I would see the manager if I were not happy.’ Another said, ‘I am aware how to make a complaint.’ One relative said, ‘I have been informed how to make a complaint, although the home has not been consistent in responding to concerns.’ The manager said the complaints procedure has been refined to allow people to make a complaint “out of hours” should they have any concerns. The home’s AQAA stated that in the last 12 months they had recognised a problem in identifying and recording complaints and abuse which as now been addressed and incorporated into staff training. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 16 All complaints and outcomes were recorded; CSCI and the home had received one complaint in relation to staffing and hours worked. The manager recognised over the Christmas period a number of staff were absent through sickness, which resulted with agency staff being used in the interim. There are 22 staff employed, 15 of whom have received training in the protection of vulnerable adults, with the remaining seven awaiting the training course at the time of this inspection. There have been three protection of vulnerable adults investigations since the last inspection. These resulted in two staff dismissals and disciplinary procedures. CSCI is satisfied that the manager acted appropriately in these instances and followed the recommended guidelines under Oldham Council’s Protection of Vulnerable Adults policy. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People are provided with a good standard of accommodation, which meets their needs, is safe and well maintained. EVIDENCE: Oakdene provides a safe and clean environment for the comfort of people in the home. A handy man is employed 36 hours a week and is responsible for maintaining and decorating the premises. Accommodation is provided in 15 single rooms, six of which have en-suite facilities. There are 11 shared rooms, two of which have en-suite facilities. At the time of this inspection, four of the shared rooms had been allocated as single accommodation. Several people were interviewed in their rooms; we noted that a number of people choose to do this rather than join the larger community. People said they were happy with their rooms and environment. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 18 All communal areas and 11 bedrooms were inspected. Bedrooms had been personalised by people bringing in favourite possessions from home. Two of the bedrooms inspected had just been decorated, a new carpet and bedroom furniture had been provided. Parts of the communal areas, e.g., toilet flooring was in need of replacement. The manager said plans had been submitted for an extension to the premises that would also include refurbishment of the premises and replacements to the failed double-glazing in the small conservatory area situated at the front of the home. The plans were available for inspection. Improvements had been made to the laundry area new dryers and an otex system put in place to prevent infection. There had been an exchange of use with the hairdressing room and bathroom that provided a large bathroom with hoist for people with a disability and a smaller, less frequently used hairdressing room. Another change of use is the lounge and dining room that has provided a larger lounge for people to relax in. At the time of this inspection there were some odours in isolated areas of the home. The manager said this was due to the carpet machine breaking down and which was now being replaced. The manager had recognised in their AQAA that improvements could be made to provide a safe garden area, more en-suite facilities and more appropriate grab rails, together with a new call system that will be addressed during the refurbishment of the home. One resident said, ‘I am warm enough in the home.’ Another said, ‘I have a nice room with a view and I have brought pictures in from home for my room.’ Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff training is given a high profile and recruitment procedures are robust and offer protection for people living in the home. EVIDENCE: There are 27 people in the home and the duty rota for 7th April 2008 was examined. This showed that the manager was available Monday to Friday, 9 till 5, and that a registered general nurse was on duty over a 24-hour period. Five care staff were on duty until the evening period when this number dropped to one nurse and three carers. Domestic and housekeeping hours totalled 101 per week. In addition to this, a cook and kitchen assistant were in post. There is a higher ratio of staff on duty over the morning period, which is the busiest time. A total of 15 staff has completed POVA, moving and handling, tissue viability and MUST training (recognition of nutritional screening). A course of palliative care was due to start on 14th April 2008 and information regarding this was displayed on the notice board. Training certificates were on individual files and the manager completed a matrix of staff training. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 20 There was evidence that the manager and staff have access to Oldham Council Training section working in partnership. One person in the home was a trained moving and handling facilitator and 50 of staff have achieved NVQ level 2 or above. One relative questionnaire said, ‘we have no way of knowing what experience and skills the staff have. I would like to see some way of identifying staff and their position in a staff structure, however, staff try to make Oakdene as homely as possible.’ This is a good practice issue, which the home may wish to address. Another relative questionnaire referred to the use of bank staff on a regular basis and found that when relatives asked questions, agency staff had limited knowledge and were unable to answer relatives’ questions.’ Other comments included, ‘Staff were kind and friendly but it is a pity that so many are agency people that they do not know the patients individually.’ The manager was aware of these issues and said unfortunately it is sometimes necessary to use agency staff due to sickness or short notice. A review of the communication systems in the home would help to address this issue. The manager said recent recruitment in the home to provide a permanent staff team would resolve this problem. The AQAA completed by the manager recognised the need to encourage staff retention. Staff questionnaires returned stated they felt training was given relevant to their role. One said, ‘I feel the service does well, they have a nice friendly atmosphere, staff are friendly and the care that is given is to a high standard. Staff have a lot of training which is up to date.’ Another staff questionnaire said the manager meets with them regularly to give them support. Recruitment procedures demonstrated that all checks have been undertaken to ensure the protection of people in the home. We interviewed three staff who had a good knowledge of people’s needs. One person acknowledged there had been issues raised and staffing problems but said, ‘I feel I can talk to the manager and get things sorted, I have got confidence in her to improve things.’ People in the home were complimentary regarding staff saying, ‘Staff treat me well’, ‘Staff are ok but sometimes I have to wait, they come eventually, they do not ignore me’ and ‘Staff look after me well.’ Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager is qualified to run a care home and takes into consideration people’s views in developing the service. EVIDENCE: The manager is a registered general nurse, other training includes legal and ethical notes and disciplinary process and they have recently completed the registered manager’s award. They have been in post for a year and have previous experience in management. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 22 Staff receive supervision and staff meetings take place. The last meeting was on 10th January 2008 with the agenda consisting of policies and procedures to be read and signed, key worker diaries to be completed fully, mealtime changes and staff to be more vigilant with oral hygiene. Resident meetings are held, the last one being in November when people requested a change of mealtimes that has now been put into place. Quality assurance questionnaires from professionals, relatives, people in the home and staff were available for inspection. The AQAA completed by the manager recognised that systems of communication could be improved. This was also identified on this inspection; see standards 7-10, health and personal care. The manager is presently taking steps to address this. Comments from relatives’ questionnaires were mixed, with one saying, ‘The present management team have been in post for a year and are making improvements all the time.’ Another said, ‘I personally do not think they do anything well.’ The home does not hold finances on people’s behalf. Health and safety checks were carried out on equipment in the home and certificates were available for inspection. Regency Homes Limited area manager is responsible for undertaking Regulation 26 visits to the home. The last visit identified irregularities in the recording of medication, issues with care planning and environment. During this time they spoke to people in the home, relatives and staff, changes were made as a result of this visit. The manager took on board comments made during the inspection with some issues being addressed immediately. Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 24 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 4/5 Requirement Assessments of people’s needs must be completed in full and all paperwork must be signed and dated in order to ensure people’s needs can be met in the home. Care plans must reflect people’s assessments and provide sufficient detail to staff in which to carry out their care duties. Time scale of 31.5.07 not met. Timescale for action 31/05/08 2 OP7 13 31/05/08 Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations Review of communication systems, particularly for agency staff, in order to ensure people’s needs are met. Risk assessments should be better completed for anyone wishing to self-medicate, clearly showing that the person has sufficient understanding of the medication and what to do, and that staff demonstrate they have an oversight that the medication has been administered and is kept safe. Review dining procedures over the teatime period in order to provide more congenial environment for service users. Consider ways in which relatives and people in the home can identify care, agency, and nursing staff and their experience and qualifications. 3 4 OP15 OP28 Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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. Extracts may not be used or reproduced without the express permission of CSCI Oakdene Nursing Home Limited DS0000068691.V361576.R01.S.doc Version 5.2 Page 27 - 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. 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