Inspection on 10/01/07 for Oaken Terrace

This inspection was carried out on 10th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Oaken Terrace 23/02/09

Oaken Terrace 06/01/09

Oaken Terrace 24/08/07

Oaken Terrace 17/02/06

Oaken Terrace 13/10/05

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

CARE HOMES FOR OLDER PEOPLE Oaken Terrace Hollybush Lane Oaken Codsall Wolverhampton West Midlands WV8 2AT Lead Inspector Mrs Joanna Wooller Key Unannounced Inspection 10 January 2007 09:30 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 Oaken Terrace DS0000063270.V324573.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. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaken Terrace Address Hollybush Lane Oaken Codsall Wolverhampton West Midlands WV8 2AT 01902 847575 01902 846974 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) Interhaze Limited Mrs Flora Gumede Care Home 92 Category(ies) of Dementia (17), Dementia - over 65 years of age registration, with number (17), Physical disability (20), Physical disability of places over 65 years of age (20) Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 20 Physical Disability (PD) - Minimum age 60 years on admission 17 Dementia (DE) - Minimum age 60 years on admission Date of last inspection 17 February 2006 Brief Description of the Service: Oaken Terrace is located on an elevated area on the edge of the villages of Codsall and Oaken, approximately four miles from the City of Wolverhampton and stands in its own spacious grounds with spectacular views overlooking the countryside. Oaken Terrace transferred registered provider status to Interhaze Ltd on the 7/02/05, recognising Mr R. Patel as registered person. Mrs Tracey Berry is now the operations Manager. Mrs Florah Gumede is registered as the care manager. The home has four units Henderson (20 elderly physically disabled), Cavell (36 Elderly Mentally Ill), Norton (19 elderly physically disabled) and Nightingale (17 residential EMI). The home is set in a rural location with good road links and nearby rail and bus services and is comprised of mainly single rooms but there are eleven double rooms available. All areas of the home have access via stairs and a passenger lift. There are adequate parking facilities with easy access to each unit. Each of the units is run as separate operations, with an overall management and support services presence. Ongoing upgrade programme continues. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key Mrs Joanna Wooller, Lead Inspector and Wendy Grainger Inspector carried out Inspection. On the day of the visit Mrs Florah Gumede and Mrs Tracey Berry were in the home and the inspectors appreciated their support during the visit. The home had 68 Service Users in the home and some enquiries were being made for the vacant beds. A discussion did take place as to marketing the empty beds. The inspector evidenced care records, all necessary documentation and inspected most of the environment, including the laundry, offices and the Service Users bedrooms. Ongoing building work was evident in Cavell unit. Service Users spoken to at the visit were content. Relatives felt they were able to make choices and their individual needs were being met. 15 Feedback cards were returned to the Commission For Social Care Inspection local office with regard to this service. Most were returned with satisfactory ticks and some had made complimentary comments about the service. Comments included: “I am very happy and satisfied with the care and help given to me by the staff on Henderson Unit.” “A very good home, the staff are excellent.” “Caring staff” “My Mother is very content in the home, we are impressed”. Fees £ 326 to £450 What the service does well: What has improved since the last inspection? The structural work is now complete. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 6 Some redecoration has taken place. 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. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Each individual Service User has been assessed prior to admission to the home to ensure that their needs can be met. EVIDENCE: Twelve Service User case tracked at the visit had been pre assessed prior to admission and Service Users themselves or a representative receive written confirmation that the individual needs can be met whilst in the home. Company documentation is evident as being completed to record the details gained at the pre admission assessment. One lady commented “In the few days that she had been in the home the staff had made her very welcome.” Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 9 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 and 10 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Service Users individual health needs were set out in care plans. Social needs and personal needs were not documented as being met. Medication is given following the policies and procedures. Some issues were raised with regard to staff showing respect and privacy to Service Users, as there was sometimes a language barrier, which was clearly evident. EVIDENCE: Several care records were identified as part of case tracking on each unit. Service Users records were not complete. Monthly weights of some Service Users had been recorded in a weights book but not been monitored. One Service User had lost a considerable amount of weight and one Service User had gained weight but this was not being monitored as the nursing records were incomplete and the information had not been transferred appropriately. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 10 One Service User had been commenced on antibiotics but had not had a short term care plan commenced to monitor the health of the individual. Care plans were not updated monthly, so assessments were not being made to ensure the Service Users individual needs were being met. Service Users did not have social care plans within the care records and some Service Users had no personal care records completed. Some Service Users weights were not being recorded at all due to individual difficulties, but other methods should be sought to ensure the Service Users health is being monitored and with out this information risk assessments such as nutrition and manual handling assessments were also incomplete. One relative had made a comment that her relative had been in her nightclothes in the afternoon and when she questioned it she was spoken to sharply by one member of staff. She also felt that her relative was not toileted enough. Another relative felt they should have been informed sooner with regard to a skin condition, which their relative had had but felt the overall care is good. She felt that the activity lady gave so much to the Service Users. One Service User as identified on the visit to the nurse in charge and the manager, had been in the home for three weeks and had no care plans at all. No issues were raised with regard to the administration of medicines. Storage, medication administration sheets and controlled drugs were checked on all the units. With reference to Service Users privacy, the use of bedroom door locks must be risk assessed and appropriate to the cognitive abilities of the individual. Advice from the fire officer should also be sought for his approval of the type of lock to be used. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 11 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, 14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including speaking to service users, reviewing records and interactions of staff. Service users were offered a choice to continue their social life style from the robust selection of activities provided. There was a flexible system in place for the serving of meals, there was a need to monitor presentation of some meals to ensure they were attractive. EVIDENCE: The inspector was impressed with the activity co-ordinator, her enthusiasm and commitment to provide the service users with a social life style, recognising their needs and interests. Records evidenced that service users had been encourage to maintain their links with the community; both in their spiritual and family life. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 12 Families spoken with were high in the praise of the support they received from the activity people. They were willing to help and support the raffles to raise funds for outings. A minimal number of service users families were spoken with in various units. Each one was complimentary about the home and the care provide to their relative. Each unit had a choice of food on a daily basis; this was evidenced in the units, from the records and observations on the day. The inspector had concerns as to the poor condition of the small kitchen on Norton unit. Food was being stored in open packets under the sink; the cupboard handles were poor in hygiene with a brown substance engrained in the handles; the worktops and plugs were stained and dirty. On Henderson unit it was evidenced that the service users were served with food of their choice. It was a concern that one service user while waiting to be assisted had a bowl of what was identified as the service users lunch left uncovered and going cold. A minimum of two service users on Henderson were offered a meal that had been pureed together served in a dish. Meals should be served and presented in an attractive manner. The catering staff should be pureeing each item separately. These concerns were discussed at feedback with the manager and operations manager. This section of the report will generate requirements. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users relatives/representatives generally felt confident that their individual concerns and complaints are listened to. Staff are trained in the prevention of abuse. EVIDENCE: Visitors to the home chatted to the Inspectors and they felt confident that their concerns were listened to and dealt with accordingly. They were aware of the complaints procedure. Language barriers between staff and relatives had caused concerns for some. One relative on Cavell Unit commented, “some staff were difficult to understand and she was worried that her relative would not understand the staff also”. Four complaints had been dealt with by the home and these are logged in the complaints folder. One complaint had been partially substantiated with regard to an odour on Cavell Unit. Staff are trained and updated on all forms of abuse and they are being encouraged to have a more informed understanding about care of the elderly through training. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 14 Vulnerable Adults Policies and Procedures are in place. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 20 23 24 25 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate. This judgement had been made using available evidence including a tour of the home, sampling each unit. Speaking to staff. Service users were provided with comfortable warm well-furnished lounges and personalised bedrooms. There were concerns regarding the lack of hygiene within all the unit bathrooms. Service users should be protected at all times and have access to a working call system. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 16 EVIDENCE: In general the small bath trays located at the front of the Arjo baths were unacceptable in their hygiene, the baths in general were aged and becoming stained and marked with the constant running of the seats. The only conservative bath on Norton could not be used, as it did not have bathing equipment. Cavell Unit. It was identified that from the sample of bedrooms seen during the tour of the home, some bedrooms had a strong odour of urine. Certain bedrooms were without the means to use the call system; in bedroom 28c the call system was broken. Within this bedroom the sink was not the standard wash hand basin; it would be impossible for the service user to attend to their personal needs. Two beds were fitted with bed guards with no evidence of the protective bumper being in place. The main ground floor bathroom was aged; broken tiles were evidenced, in general it was outdated and would not provide a pleasant environment when relaxing. This area should be part of the next planned upgrading. The communal area was well furnished in a modern style with comfortable leather chairs. Bedrooms contained by choice personal possessions. The staff were observed to interact well with the service users during the inspection they assisted where necessary. Nightingale Unit. The service users were provided with a comfortable communal environment. The unit had a combined dining room /kitchen where drinks were prepared. Bedrooms were personalised to suit individual’s choice. The housekeeping staff maintained a good standard of hygiene within the bedrooms. The bathrooms were clinical, aged and gave concerns in respect of their hygiene. Service users personal items were contained in the top bathroom (near to lounge) The second bathroom off the staff toilet area, had a dirty sink, the Arjo bath water was tested and registered 35 degrees Celsius. It was ascertained that one resident had been bathed in this bath prior to this test. Records evidenced that when the staff had tested the water it recorded 35 degrees Celsius. It is not acceptable to bath a person in this low temperature, staff should be aware of the required temperature. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 17 Norton Unit. The unit was comfortable, light and warm, well furnished and service users spoken with appeared to appreciate the care provided. Bathroom B3 contained stored equipment and other items; the inspectors were told that this bathroom was not in use. Bathroom B2 - the seat on the Arjo was not clean, there was no plug and while the inspector was told that it was used, the other bathroom at the other end of the unit was generally used. This practice was discussed with the person in charge of the unit on the day. The staff must consider the dignity of a service user located near to bathroom B2 when they required the bathroom then they were often transported through the lounge to another bathroom. Bathroom 1 was without a drain plug. In toilet 3 the light was broken, the basin was identified that there was insufficient flow of water from one tap and the other tap was inoperable. This problem did not appear to have been identified or reported by the housekeeping or care staff. Henderson Unit. The unit was comfortable and warm. Furnishing and fittings were evidenced to be in a good condition. One person had bed guards fitted, no protective bumpers were evidenced, the inspector was told that the service user did not require the guard, it was suggested that after an assessment it should be removed. Bedroom 11 was in urgent need of a replacement carpet, which was uneven, worn and had a strong odour of urine. This service user was nursed on the floor near to this odour. A risk assessment identified that the service user had been at risk with bed guards; it was suggested that a crash mattress could be tried in conjunction with a normal bed. At the completion of the feedback the inspectors were informed that the carpet problem in Henderson was being addressed and a new carpet had been ordered. The issues of concerns in the bathrooms and service users call systems in bedrooms should be part of the monthly homes audit and brought to the attention of the relevant person. With each of the unit it was observed that all the Service Users were well presented, clean and tidy. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty should allow the needs of the Service Users to be met; however the documentation did not confirm this. The numbers of staff on duty was satisfactory but the lack of interaction between the Service Users and staff did not display their competence of the staff to deal with the Service Users individual needs especially on Cavell Unit although suitable training has taken place. Staff training was up to date and relevant to the Service User groups at the home. EVIDENCE: Observations took place on all units and there appeared to be a general lack of interaction between the staff and the Service Users. The activities organiser was the only member of staff who was approaching Service Users and interacting with them. Staff appeared to be very task orientated which leads them to overlook the need to individually interact with the Service Users - so just carrying out their individual jobs. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 19 There was evidence that the care staff were being appropriately trained in areas, which related to care of the elderly but it would appear that staff were not applying their knowledge in their line of work. 71 of care staff is trained to NVQ level 2 or above and a further 16 are currently undertaking the training. Staff training is recorded in the individual staff files and also an overview is displayed to ensure no training gaps occur. Recruitment issues were raised relating to meeting the diverse needs of the service users in the home and the need to overcome language barriers of staff with an ethnic background whose first language is not English. This very important issue, which was clearly identified at the visit, must be addressed to ensure that the staff can communicate with the Service Users and that the Service Users feel confident that the staff are able to support them through clear and concise communication. Staff employed at the home must be deemed competent communicators and able to carry out the required needs on their job description. Regular staff supervision must be given to support staff with any type of language barrier so ensuring they are competent to carry out their duties. Criminal Record Checks are gained for all new employees supported initially by POVA checks. Four staff files that were checked appeared satisfactory. A company audit had recently been carried out due to an immigration issue being raised. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home manager who displays professionalism and competence in management skills is unsupported by senior unit managers that appear to be unable to demonstrate leadership for their whole individual unit. The Inspectors were not assured that the home is always run in the best interest of the Service Users. No issues were raised regarding financial safeguarding for Service Users. The health and safety of Service Users and staff is generally considered. EVIDENCE: There were elements of the visit, which demonstrated to the inspectors that the management of the home was in some areas lacking in leadership. Issues Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 21 raised on the day were directly the responsibility of the senior nurses at the home to ensure that a quality service is being delivered. Care records must be audited regularly to ensure compliance with the National Minimum Standards and Codes of Practice and Record keeping in line with the Nursing and Midwifery Council. The Deputy manager and senior nurses are responsible for this task and it was clearly evident that it was not being carried out on all units. There was not enough evidence to prove that the home is run in the best interest of the Service Users, the lack of individualised care records and the lack of interaction with the Service Users did not demonstrate that their individual needs were of any importance. A Service Users and relatives Quality Audit had been carried out and the findings were collated. Generally people were happy at the home but some communication issues were highlighted. One lady’s husbands’ jumpers were all mislaid but eventually one member off staff had found them after asking many other staff for help. Another lady said her husbands belonging were mislaid also he had transferred to hospital without some important possessions. Staff supervision required more close observation on the units whilst staff were going about their duties so ensuring that the staff were working in line with the companies policies and procedures and in a manner, which the Service Users felt comfortable and valued. Financial interests of the Service Users are safe guarded by the policies and procedures in the home. No issues were raised with regard to Service Users monies. The health, safety and welfare of Service Users and staff are generally considered. Moving and handling assessments were completed, however without the weight records being used the scoring was not accurate as with the nutritional assessments also. Basic food hygiene, Manual Handling, Infection Control, Dementia Care, Awareness of medicines and Health and Safety Awareness training had been given to the majority of staff and this training was ongoing until all staff were updated. With regard to health and safety issues the low water temperatures were of note. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 22 Fire training and testing were all in order, as were manual handling and food hygiene. Twenty-six staff is first aid trained. Accidents were logged and Regulation 37 forms were forwarded to the Inspector as necessary. Disposal of waste was all in order and no problems were identified, boiler/central-heating systems servicing had been carried out on 22/12/06 and a gas Soundness certificate is to be forwarded to the Stafford Office. Electrical testing was in order and water temperatures were being recorded throughout the home. Issues with regard to cold water were to be actioned. Risk assessments for safe working environment were in place. Relevant legislation is covered within the Companies Policies and procedures. Oaken Terrace DS0000063270.V324573.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 2 2 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Oaken Terrace DS0000063270.V324573.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 OP15 Regulation 16 (i) Requirement The registered person shall ensure that food prepared and served in a manner to tempt the appetite of the individuals. The registered person shall ensure that the equipment provided at the care home for use by service users and staff is maintained in working order. The registered person shall ensure that all parts of the home are kept clean and reasonably decorated. One bedroom with an odour to be addressed also. The registered person shall ensure that all parts of the home to which service users have access to are so far as reasonably practicable free from hazards to their safety. The registered person shall ensure and encourage that good personal and professional relationships with the Service Users are promoted. Issues regarding language barriers are to be addressed. DS0000063270.V324573.R01.S.doc Timescale for action 10/02/07 2 OP19 23 (2)(c) 10/02/07 3 OP26 23(2)(d) 10/02/07 4 OP24 13 (4)(a) 10/02/07 5 OP7 12(5) (a/b) 10/02/07 Oaken Terrace Version 5.2 Page 25 6 OP8 12 (1) 7 OP10 12 (4)(a) 8 OP14 12 (3) 9 OP27 18 (a) 10 OP29 19 (5)(b) 11 OP31 24 The registered person shall ensure that the care home is conducted to promote and make proper provision for the health and welfare of service users. Service Users weights must be recorded and monitored within The care records to support other relevant risk assessments also. The registered person shall ensure that the care home is conducted in a manner, which respects Service Users dignity by encouraging staff to confidently interact with Service Users. The registered person shall ensure that there is proper provision for the Service Users health and welfare taking into account their wishes and feelings. The registered person shall ensure that staff is suitably qualified, competent and experienced to work at the care home. The staff must not work in a task related way that is very impersonal for the Service Users. The registered person shall ensure that staff employed at the home is competent in all aspects required to perform their diverse duties in a care home prior to employment. Any language barriers must be addressed prior to employment. The registered person shall ensure that with the registered manager they have the competence to manage the care home with sufficient care, competence and skill. Supervision of staff and auditing of systems must be carried out so improving the quality of care provided at the care home including the quality of nursing DS0000063270.V324573.R01.S.doc 10/02/07 10/02/07 10/02/07 10/02/07 10/02/07 10/02/07 Oaken Terrace Version 5.2 Page 26 12 OP33 12(2) 13 OP25 12(1)(b) 14 OP24 12(1)(a) 15 OP38 13(4) (c.) in the nursing home. The registered person shall ensure that the home is run in the best interest of the Service Users and their wishes/choices are promoted. The views of the Service Users and their families once gained must be acted upon and their wishes must be documented within individual care records. The registered person shall ensure that Service Users receive proper provision of care and treatment. Water temperatures must be recorded and within normal limits prior to a general bath being given. The registered person shall ensure that Service Users privacy is promoted; the use of bedroom locks must be risk assessed and appropriate to the abilities of the individuals. The registered person shall ensure that a Gas Soundness certificate is forwarded to the Inspector as soon as possible. 10/02/07 26/02/07 10/02/07 10/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP10 Good Practice Recommendations The use of room identifiers must be formalised. Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Oaken Terrace DS0000063270.V324573.R01.S.doc Version 5.2 Page 28 - 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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