Inspection on 17/02/06 for Oaken Terrace

This inspection was carried out on 17th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 10/01/07

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 Mr Keith Jones Unannounced Inspection 17th February 2006 09:00 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 Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 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 90 Category(ies) of Dementia (50), Dementia - over 65 years of age registration, with number (50), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (50), Physical disability (40), Physical disability over 65 years of age (40) Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 40 Physical Disability (PD) - Minimum age 60 years on admission 50 Dementia (DE) - Minimum age 60 years on admission Date of last inspection 13th October 2005 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 and Mrs Linda Parker as Group Care Director. The previous deputy manager Mrs Florah Gumede has been recently registered as the care manager. The home has four units Henderson (20 elderly physically disabled), Cavell (33 Elderly Mentally Ill), Norton (19 elderly physically disabled) and Nightingale (17 residential EMI). Oaken Terrace is an 89 bedded Care Home offering nursing and residential care. The Home is currently registered to admit 33 Elderly Mentally Ill, 17 residential Elderly Mentally Ill and 39 Elderly service users. 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. There is an ongoing upgrade programme in progress. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day by one inspector, in a professional and cordial atmosphere with the care manager Florah Gumede and senior nursing and care staff on each of the four units. The home was found to be fit for purpose and provided a safe environment for the residents and staff. The last inspection report was discussed, and it was noted that all outstanding requirements and recommendations have been dealt with, or in the process of being dealt with satisfactorily. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users, relatives and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Throughout the entire inspection a sense of homeliness and familiar confidence pervaded into all aspects of daily activity expressed by those people met. A sample review of the administrative arrangements confirmed solid practice and effective management. The upgrade of facilities and of the environment although on going was being completed to a high standard, with a marked effect upon the quality of overall provision of care. A full verbal report was offered at the end of the inspection to the care manager. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: The Home is extremely responsive and sensitive to providing a solid, high quality of care. The care manager has demonstrated her capacity to take an effective leadership role, much appreciated by a loyal and hard working staff. Nursing care is of a high standard with named nurses and key workers actively deployed. The emphasis is on the team spirit and family feel to create an environment conducive to good nursing care practice. Assessment procedures and care planning is of an excellent standard, offering detailed information on each resident’s progress in the meeting of objectives. The housekeeping and support services all contribute to the team approach, and are recognised by the management for their efforts. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 6 Maintenance of satisfactory staffing levels, staff training and supervision are well established in safeguarding the interests of residents. What has improved since the last inspection? 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. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 It is recognised that the Statement of Purpose represents the foundation on which the home operates upon, offering service users and their relatives the opportunity to make an informed choice about where to live. Following an assessment the senior nurse assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. The Home has demonstrated their commitment to promote a partnership of care, to meet the objectives of providing a home to meet individual needs. EVIDENCE: The recently reviewed Statement of Purpose presents an excellent explanation in to the aims and objectives, management and staffing, facilities and services that Oaken Terrace can offer. This gives residents and their relatives the opportunity to make an informed choice about where to live. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 9 Service users are admitted to Oaken Terrace following a comprehensive preadmission needs assessment, carried out by the care manager, with a senior unit nurse in attendance. This assessment initiates the process of care, each individual having a plan of care. Case tracking showed a detailed care assessment, offering substantial information to prospective service users on the services and facilities that the Home can provide to meet their individual and special needs. This was confirmed by speaking to staff and residents. The management style is highly personable and inclusive, generating a warmth and comfortable environment. Relatives are welcome to view the facilities and participate in the planning and assessment of care. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 11 The service users’ assessment provides the base from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has a GP that visits the home frequently and the majority of service users are registered with him. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The inspector observed the free, courteous interaction between service users and staff based on a level of confidence of mutual trust and respect. EVIDENCE: Case records were examined on each unit and found to offer a clear, wellbalanced, up to date and accurate appraisal of requirements. There was a clear consistency in approach throughout. Reviews were done on a minimum of once a month, usually more often, as needs dictate. Case tracking of those residents and discussions with staff, residents and visitors confirmed the depth of care planning supported by a solid foundation of organisation and quality services. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 11 The home has good links with specialist services – continence advisor and tissue viability. A profile of the service user’s social, physical and psychological status offered an individual plan of care to be implemented and frequently reviewed. Each service user’s health, personal and social care needs were seen to be assessed in an individual plan of care that is reviewed monthly, including service users and relatives views, to reflect their changing needs. That review is more frequent, dependant upon the individual’s needs and clinical condition. A tour of the premises evidenced that there was a range of pressure relieving equipment. Examination of service user plans found that all are assessed in relation to pressure sore risk, falls risk and nutritional risk. On all four units the administration of medicines adhered to procedures to maximise protection to service users. The storage was secure with satisfactory added security for controlled drugs. A controlled drug register was examined and found to be in order. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. The Statement of Purpose clearly and openly states that the wishes concerning arrangements after death would be discussed and respectfully carried out. The spiritual needs of service users were recorded and observed by the staff with due respect. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. Service users’ life-styles and interests are recorded in their care plan, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. Personal choice and relative selfdetermination are respected in policy and action. Those who wish to bring in personal possessions are encouraged to do so. Service users were offered a varied and nutritious choice of meals from a 4week rotating menu. Special diets were accommodated with the cook making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it at lunchtime when a very attractive and delicious luncheon was presented. Alternative choices were available and encouraged. EVIDENCE: Discussions with service users and staff clearly identified a relaxed atmosphere in which the service user’s needs were respected. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 13 Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are familiar events to the day they could relate to. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. The Home has the services of an activity coordinator for 25 hours a week, emphasising the importance that the Registered managers have for the socialisation aspects of care. The good standards of catering at Oaken Terrace offered an excellent service, to which service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and excellent choice. An excellent lunch was served during inspection, with choices available, served in a well-furnished and clean dining rooms. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was inspected with the cook and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. A cleaning schedule was in place and seen to be up to date and accurate. All requirements made at the last inspection had been complied with. COSHH signs and notices were in evidence with cleaning chemicals secure, appropriate and under control. In all an excellent department offering a good quality service. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 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): 16,17,18 The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place. EVIDENCE: The complaints policy was seen and records examined. Complaints received had been thoroughly investigated with the full cooperation of the managers and staff. Those issues upheld had been accepted with a positive attitude. All service users had received information on the procedure to complain, including reference to the CSCI. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. There had been one complaint received which was not upheld, although resulting in verbal and physical attack upon the care manager. It was considered that the care manager had presented a professional approach to the allegation and that she handled the attack in a very dignified and positive manner consistent to the professional code of conduct. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 15 Case tracking confirmed the effectiveness of a care manager and staff sensitive to service users needs and readiness to test the robustness of their information and report structures. As part of the process of encouraging self-determination a policy exists to be able to offer advocacy services should they be required. Family involvement has been the usual means of representation in the past. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. This process was evidenced on examination, and case tracking as previously reported upon. The care manager showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 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 - 26 The home was fit for purpose and provided a safe environment for residents. The home was clean, warm and tidy, and had a comfortable atmosphere. The buildings were adequately maintained, but grounds and gardens required some attention. Increased single bedroom occupancy is being constructed. The above has contributed to the satisfaction of the premises as expressed by the residents and their relatives. EVIDENCE: A tour of the four units and service departments, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy, and were being well maintained. It is understood that in the long term an increase in single bedroom occupancy is actively being consolidated. Two new single bedrooms were seen being constructed, as previously agreed with CSCI. The duty rosters on each unit were examined and evidenced that adequate professional, care and ancillary staff were employed. The kitchen, laundry and sluice facilities were seen to be fully compliant with regulation. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 17 A tour of the premises identified that there is a need for the ongoing redecoration to continue. The walls, ceiling and floors in the laundry area have been redecorated, as agreed. The ceiling in the main kitchen has been cleaned and repainted with an impervious finish. The grounds and gardens were seen as requiring some continued work to remove weeds from beds and to cut the grass, all as identified during the previous inspection. It was recognised hat work had begun and showed some profit for the commitment. Bedrooms seen throughout the units were comfortable and residents had personalised them. It was recognised that bedroom furniture had been and still is being renewed on a rolling programme. Residents and relatives expressed satisfaction with their rooms. It was acknowledged that major improvements in facilities on Cavell unit merit recognition. There were several areas in the Home displaying room identifiers with scraps of paper. It was agreed that amore professional finish would aid clarity and décor. Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. It was acknowledged that room 28 c on Cavell is to close off the fire exit, and an alternative exit be sited on the adjacent corridor. Builders working in room 3 are to lock the facility when not working. There are no outstanding issues known from the Environmental Health department. The EHO previously reported items in the main kitchen had been addressed. Bathroom thermometers are to be sited in each communal bathroom. The fire prevention officer and building control officer will need to inspect the premises on completion of the bedroom work currently in progress. CSCI must be informed when this area is completed prior to occupancy, when checks on satisfactory completion/documentation will be carried out. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 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): 27 - 30 Staffing had maintained consistent levels to ensure equilibrium between numbers, skills and qualifications. The care manager informed the inspector of routine staff induction programmes, well established and well designed on which formed the base upon which in-service supervision and training are planned and achieved. EVIDENCE: Three weeks of off-duty were examined on each unit, i.e. 7/02/06 through to 01/03/06. The consecutive duty rotas were examined, providing evidence that the home is managing to maintain numbers, skills and qualifications to ensure the needs of the service users are met. It was recognised that there was a total of 25 empty beds at the time of inspection. In addition to the manager there is a full time deputy manager and three trained nurses on duty on an early shift supported by 13 carers throughout the units. On the afternoon shift there are three trained nurse and ten carers on duty and on the night shift there are three trained nurses and six care staff. Adequate ancillary staff had been provided each week. The records seen evidenced that in addition to the manager the home employed 16 nurses and 36 care assistants, of which 18 (50 ) were trained to NVQ level 2 or above. Twenty ancillary staff were also employed at the home. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 19 Agency staff and nurse bank with agreed overtime and flexible rostering meet identified shortfalls, usually holiday time. At the time of inspection there were 19 carers on level II NVQ course, a further 21 in training. The care manager is confident that the home will meet the necessary level of commitment to the training requirements. Mrs Gumede has successfully obtaining her Registered Managers Award. There are active plans to create a permanent training room and resources to meet an ambitious educational programme, as evidenced with the Staff IN-House training programme for 2006. Documentary evidence confirmed a continuing adherence to the quality of staff selection, recruitment effort and practice. Three staff files were sampled and found to be well organised and up to date, following a review of procedures. It was evidenced that CRB checks have been made and contracts of employment are up to date. On going personal and training records were kept secure in accordance of the Data Protection Act 1998. Policy clearly states an equal opportunity position. Barton House has developed a significant commitment to staff training and education, conducted on a professional footing. Records show a broad spectrum of clinical and allied subjects covered, ensuring that staff fulfil the aims of the home and meet the changing needs of service users. There is a firm agreement for a student nurse allocation. On the day one student spoken to was very positive about her allocation to Henderson Unit. All staff receive training in care issues within the home from registered nurses and trainers. Evidence showed diligent attention to supervised training involving a shared aspect of responsibility between staff and trainer, with the involvement of mentor trained staff. There is a substantial commitment to the supervision and appraisal process. Evidence showed a responsible attention to clinical supervised training, involving a shared aspect of responsibility between staff and trainer, with the involvement of mentor trained staff. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,3,34,35,36,37 and 38 The care manager of the home accompanied the inspector for the day. Flora Gumede has clearly demonstrated her capacity as suitably qualified and experienced to manage the day-to-day care of the service users. The inspector was impressed by the openness and confidence in the observed interactions of staff, relatives and service users. The relationships were seen to be of mutual trust and respect. Evidence was secured to confirm a quality monitoring system has been introduced, based upon audit of standards, care plans and feed back from service users and relatives. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 21 EVIDENCE: It was pleasing to see this standard well met. The care manager has developed a formal approach to monitoring quality across a wide range of activities. This includes a Quality Audit Schedule, care plan review process that is recorded at least once a month, a staff training programme and a risk assessment prevention programme. This includes the setting of objectives, effective budgeting of plans and target dates to aim for. Mrs Gumede has been able to control the management of forward planning in setting objectives on shortterm and long-term planning Evidence was secured to acknowledge achievements, ongoing and planned objectives. Involved within this process are the views of service users and relatives, confirmed at case tracking and informal discussion. Social Workers’ review meetings are often a vehicle for assessing quality. Staff meetings are held monthly. Each service users has a personal file containing contractual, financial and personal information. Several files inspected evidenced a satisfactory standard of maintenance and security. Care plans were drawn up, implemented and reviewed with service users and relatives whenever possible. Case tracking and informal discussion provided evidence that participation is encouraged by the service user themselves, or by their relatives. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment for elderly service users. These included procedures on abuse, complaints and visiting. Service records for water supplies, PAT testing, hoist maintenance and fire equipment were examined. Planned maintenance and risk assessment ensures that essential services linked to utilities and safety, are monitored and serviced on a regular basis. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions organised by a member of staff recognised as a fire safety officer. The fire officer has taken, and will continue to take an active interest in developments and fire safety audits. Accidents were seen to be addressed, risk assessed, actioned and recorded in an effective way, with access to Riddor if needed. No serious accidents have been reported. The Regulations, Standards and Schedules as provided in the Care Standards Act 2000 are recognised and implemented. Records were seen to be generally well maintained, accurate and up to date in accordance with the Data Protection Act 1998. The administration and management of the home is efficient, uncomplicated and very sensitive to the needs of service users. Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 23 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 OP19 Regulation 23(2)(d) Requirement Redecoration must continue, Timescale for action 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP19 Good Practice Recommendations The grounds and gardens maintenance should be improved. On completion of the new bedroom work all required documentation should be forwarded to CSCI, prior to occupation, as agreed. The use of room identifiers be formalised. Building work areas be made safe. Bath thermometers be placed in all communal bathrooms. 3 4 5 OP10 OP38 OP21 Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oaken Terrace DS0000063270.V282196.R01.S.doc Version 5.1 Page 25 - 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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