CARE HOMES FOR OLDER PEOPLE
Oakendale House 17 Rose Terrace Ashton Preston Lancashire PR2 1EB Lead Inspector
Ms Susan Dale Key Unannounced Inspection 10:30 16th October 2007 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 Oakendale House DS0000066053.V346377.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. Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Oakendale House Address 17 Rose Terrace Ashton Preston Lancashire PR2 1EB 01772 720937 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) Mrs Maninder Kaur Singh Mr Raja Singh Vacant post Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the CSCI The home is registered for a maximum of 15 service users in the category of old age, not falling in any other category (OP) over 65 years of age. 29th August 2006 Date of last inspection Brief Description of the Service: Oakendale House is situated in the residential area of Ashton, Preston and is located close to local amenities and a bus route providing easy access to the centre of Preston. The home is registered to provide personal care to fifteen oervice users of both sexes. The home is not purpose built and provides accommodation over 3 floors; access to all parts of the home and garden is provided by a lift and ramps. The home does not provide nursing care and care provided is generally for service users who are fairly independent however, in the event of the service user becoming ill and requiring additional help every effort would be made to accommodate them. The aim of the home is for all service users to have specialist individual care whilst still maintaining their dignity and an optimum degree of independence and activity. Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The visit was unannounced and the focused mainly on key standards. The inspector was able to speak to service users, staff, and the two managers and examine various records. Surveys were provided to service users, relatives/friends and care professionals prior to the inspection. One survey was returned from a service user, one from a relative and one from a social worker; all the responses were positive; the results were taken into account as part of the inspection. A tour of the premises took place. What the service does well:
The home is only registered for a small amount of service users and is not purpose built; this creates a homely atmosphere that suits service users who are fairly independent. The staff also benefit from the homely atmosphere and appear to work well as a team. The main cook provides nourishing meals and makes sure the service users have fresh vegetables every day; there are no restrictions on the budget and those service users spoken with confirmed that meals were generally good although it was difficult to please everyone. A care professional confirmed that the home had been responsive when she had asked for information about a service users health and asked for a general practitioner (GP) visit. Training is excellent with the majority of staff obtaining a National Vocational Qualification (NVQ); training is ongoing. There are 13 care staff and 9 staff have a National Vocational Qualification (NVQ) in Care; a further 6 staff are due to commence NVQ training. The building complies with the requirements of the local fire service and environmental health department. The manager has carried out a fire risk assessment that has been commended by fire safety officers who visited the home. The home has the Investors in People accreditation and this has been recently reviewed and been given an excellent report. Comments from service users and a relative as follows: “The care home provides a supportive and friendly atmosphere, I’m impressed by it.” “All the girls are very good here.” Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 6 “I have no complaints.” What has improved since the last inspection?
At the last inspection it was unclear which documentation was the care plan. A new format has been devised that clearly sets out individual daily requirements called the Residents Personal Programme. The manager has undertaken a review of everyone’s care needs and summarised the details. The care plans are now being reviewed on a monthly basis. The provision of medication have been significantly improved; they are now stored in a suitable trolley that is locked to the wall when not in use. This has helped carers to be more organised when giving medicines and as a result the whole system of administration and recording has significantly improved. A controlled drugs register has been obtained and care staff have received formal training and observed whilst providing medication by the manager; the details are recorded in their personal files. There are several new activities, including a booking for a theatre group performing, ‘Drop in, Tune in and Drop Off’ at the weekend. A clothes show had taken place and a beauty session was taking place at the time of the site visit. A hairdresser visits the home once a week. Bingo takes place on a Sunday and Tai Chi twice a month for an hour. One of the staff reads poetry out loud once a week. There are plans to visit the illuminations and to a pantomime at Christmas in the Guild Hall. There are also plans to attend an amateur production produced by a member of the staff. Since the last inspection, the manager has undertaken training on the Protection of Vulnerable Adults and is aware of the procedures to follow in the event of any abuse being recognised. Staff spoken with confirmed that they had been provided with training on the subject of abuse and whistle blowing. A record is now kept of any required maintenance of the home. This is now being carried out; all staff make a note of any maintenance requirements and the details are recorded and overseen by the manager and owners of the home. The staff records were examined; at the last inspection new staff had commenced employment prior to clearance by the Criminal Records Bureau (CRB) or the Protection of Vulnerable Adults Register (POVA). The application form has been improved and is now legible. The process of recruitment had improved in that appropriate written references had been obtained. There is now evidence of an annual appraisal and supervision of staff on a regular basis and staff meetings had been taking place. The registered provider now carries out monthly visits and writes a report on the conduct of the home under regulation 26 of the Care Homes Regulations.
Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 7 A copy of this report has been provided to the Commission for Social Care Inspection (CSCI). Accidents and incidents occurring at the home, as listed under Regulation 37 of the Care Homes Regulations are also now being sent to CSCI. What they could do better:
The Statement of Purpose is kept in an office in the basement of the home and is therefore not accessible, as it should be, to service users, staff, relatives or any interested party. The details within the Statement of Purpose should be kept up to date with the current staff and their qualifications. It was recommended that any contact with other health professionals such as General Practitioners (GP’s) and Chiropodists are recorded separately. The details recorded on the Medication Administration Record (MAR) should be checked regularly and a date and signature recorded on the MAR sheet each time the check takes place. Service users and relatives and a social worker have made comments that they think the activities could be improved upon and that they thought it could only improve if there was an increase in staff. It appears that activities have actually increased but there have not been many actual outings. The owner of the home has indicated that they will be purchasing a vehicle for trips out. There is a need to ensure that care staff providing teas have an up to date food hygiene certificate and that all the staff involved with meals are up to date with current legislation over food handling. In communal bathrooms, any toiletries, bath foam etc should be kept out of reach of any service users in case they should ingest the contents by accident. Staffing levels are low and there is an advert for new staff. The registered manager has retired and there is a need to ensure that the new manager does not work care hours on Mondays and Fridays as she has been doing and works management hour’s full time. The majority of staff are part time; there is a need to ensure that the manager has another full time member of staff to rely upon who will deputise in her absence. There is a need to provide evidence that checks with the Criminal Records Bureau (CRB) including a check of the Protection of Vulnerable Adults (POVA) Register have been carried out prior to new staff commencing. The format of the one to one supervisions was discussed with the manager, as the current format was not suitable. It did not provide any information about individual service users or staff training needs. It was recommended that the format should be similar to the annual appraisal but not in such depth.
Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 8 A recommendation was made that in order for more effective management of the home it would be helpful for a computer to be purchased with access to the Internet that would be useful for professional advice and improved communication links. 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. Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 9 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 Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 10 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): 1&3 Quality in this outcome area is adequate. Information about the services provided by the home should be kept up to date and be readily available. A full assessment is undertaken prior to commencement at the home. The home does not provide intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A Statement of Purpose and Service User Guide is available that provides information about the services provided. The documentation has been amended to reflect the recent change of ownership. There is still a need to keep the other details as listed in Schedule 1 of the Care Homes Regulations up to date including information about the staff, manager and their qualifications. The Statement of Purpose is kept in an office in the basement of the home and is therefore not accessible, as it should be, to service users, staff, relatives or any interested party. There is a need to keep the details up to date and as directed at the last inspection readily available to service users, staff and visitors to the home.
Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 11 The records belonging to service users show that an initial assessment is carried out that covers all areas. A member of the management team visits the prospective service user at home or in hospital to confirm whether they will be able to meet their requirements. The assessment looks at physical and emotional needs, likes and dislikes and any potential risks connected with their care. The assessment takes into account any cultural diversity and looks at the individual with wishes recorded about any religious requirements or their death. The home does not provide Intermediate Care. Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 &10 Quality in this outcome area is good. Service users are provided with an appropriate care plan that meets physical and health requirements. Appropriate medication policies and procedures are in place to ensure the protection of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection it was unclear which documentation was the care plan. A new format has been devised that clearly sets out individual daily requirements called the Residents Personal Programme. The manager has undertaken a review of everyone’s care needs and summarised the details. Signatures had been obtained where possible from service users or their representative over the care plans or where permission had to be gained over providing medication in front of other service users. The care plans are now being reviewed on a monthly basis. Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 13 A record of weight had been recorded although some of the details require up dating. There was a separate sheet for visiting health professionals that was not being used and a recommendation was made that visits and any contact with other health professionals such as General Practitioners (GP’s) and Chiropodists are recorded separately. An Optician was visiting the home at the time. There were good records of daily or weekly events for each service user and a communication log of any significant events is kept for the staff to read as they come on duty. During the inspection staff were observed to protect the privacy and dignity of service users and those spoken with confirmed that they are treated well by the staff and had no complaints. At the last inspection, there were some problems connected with the provision of medication. The home now handles medicines more carefully and the organisation of the medicines has significantly improved. Medicines are now stored in a suitable trolley that is locked to the wall when not in use. This has helped carers to be more organised when giving medicines and as a result the whole system of administration and recording has significantly improved. An audit of the medicine administration is carried out on a regular basis; it was recommended that the details recorded on the Medication Administration Record (MAR) are regularly checked and a note and signature recorded on the MAR sheet each time the check takes place. A controlled drugs register has been obtained and care staff have received formal training and have been observed whilst providing medication by the manager and the details recorded in their personal files. Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 &15 The quality in this outcome group was good. The home provides activities that meet the expectations and capabilities of the service users and visitors to the home are made to feel welcome at all times. A varied menu is planned and provided that provides service users with nourishing meals according to their wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users spoken to confirmed that a flexible approach is taken with regard to daily living and activities. Meals can be taken at different times and in service users own rooms if preferred. Service users’ interests are recorded at the initial assessment and consideration is given to the capabilities of the individual concerned. A local priest visits the home on a weekly basis and a vicar on an occasional basis. Staff confirmed that activities have improved since the change of ownership but there are still not very many trips out. Service users and relatives have made comments that they think the activities could be improved upon and that they thought it could only improve if there was an increase in staff.
Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 15 There were several new activities planned including a theatre group performing, ‘Drop in, Tune in and Drop Off’ at the weekend. A clothes show had taken place and a beauty session was taking place at the time of the site visit. A hairdresser visits the home once a week. Bingo takes place on a Sunday and Tai Chi twice a month for an hour. One of the staff reads poetry out loud once a week. There are plans to visit the illuminations and to a pantomime at Christmas in the Guild Hall. There are also plans to attend an amateur production produced by a member of the staff. Service users usually make Christmas Cards and local school children visit the home at Christmas to sing carols. A comment from a service user and a relative on the surveys indicated that the meals could be better. A varied menu is planned that provides service users with nourishing meals according to their wishes. The cook was spoken with and she confirmed that she makes sure the service users all get fresh vegetable every day and the meat is of excellent quality. The main cook only works three days a week and finishes at 1.00 pm; teas are provided by the care staff. Additional cooks are employed on the other days of the week. Although this is good in that there is always a cook available, it is difficult for the three cooks to operate as a team because they never see each other. There is also a need to ensure that the care staff providing teas have an up to date food hygiene certificate and that all the staff involved with meals are up to date with current legislation over food handling. There were a few comments from service users and relatives about meals and indicated that there was a lack of fruit. The manager and other service users confirmed that fruit was available at any time. Services users spoken with confirmed that they are able to receive visitors at any reasonable time and in private. Service users are encouraged to handle their own financial affairs for as long as possible. Information about the advocacy service is available as necessary. Comments received from relatives: “The care home provides a supportive and friendly atmosphere, I’m impressed with it.” From a service user: “All the girls are very good here.” Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 16 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): 16 &18 Quality in this outcome group was good. Policies and procedures are in place to ensure that service users are protected from abuse. Evidence needs to be provided to show that staff are familiar with the policy and procedure to follow in the event of any abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which contains all necessary information. Several complaints had been recorded with an investigation taking place appropriately. There have been no complaints made to the Commission for Social Care Inspection (CSCI). Since the last inspection, the manager has undertaken training on the Protection of Vulnerable Adults and is aware of the procedures to follow in the event of any abuse being recognised. Staff spoken with confirmed that they had been provided with training on the subject of abuse and whistle blowing. Any valuables belonging to service users are kept secure and staff are not allowed to be involved in the assisting or benefiting from service users’ wills. Oakendale House DS0000066053.V346377.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): 19 & 26 The quality in this outcome group was good. The home provides a comfortable safe environment that meets the needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The accommodation is not purpose built and any environmental risk is considered at the initial assessment for each service user. Service users who are physically more active are offered accommodation that is suitable for their capabilities. The garden is accessible to all service users via a ramp. There is a step between the lounge and conservatory that could be difficult to manage for some of the service users. The building complies with the requirements of the local fire service and environmental health department. The manager has carried out a fire risk assessment that has been commended by fire safety officers who visited the home.
Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 18 At the last inspection there was a need to ensure that a record is kept of any required maintenance of the home. This is now being carried out; all staff make a note of any maintenance requirements and the details are recorded and overseen by the manager and owners of the home. The manager is able to replace and repair items within the home up to a certain amount and anything that may be more costly has to be passed to the owners of the home for their approval. There have been a few comments from surveys: Comments included: “Needs re-decoration. There is no one to do any jobs.” “Staff have to do cleaning jobs as well as caring. Some of the staff have left because of this.” A relative commented that: “There is a lack of maintenance on the property.” A tour of the home took place and all areas of the home were clean and tidy, there was no evidence to show that there was a lack of maintenance. The home does not employ a handyman; the home employs a gardener who according to the staff has not turned up recently. It was noticed that there were some toiletries in one of the communal bathrooms and it was recommended that all toiletries, shampoos, bath foam etc should be stored where service users cannot access them, as there is a risk that they could be ingested. Oakendale House DS0000066053.V346377.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): 27, 28, 29 & 30 Quality in this outcome area is adequate. There were sufficient trained staff on duty according to the number and needs of the service users. Recruitment of new staff has been strengthened but requires to be evidenced. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were 2 staff on duty at the time of the site visit and the manager shortly joined them. The home is currently short of staff and an advert has been placed in the local paper. The majority of staff are part time and work additional hours as requested. The registered manager is retiring and there is a need to ensure that the new manager (not registered) does not work care hours on Mondays and Fridays as she has been doing and works management hours full time. There is also a need to ensure that the manager has another full time member of staff to rely upon who will deputise in her absence. The staff records were examined; at the last inspection new staff had commenced employment prior to clearance by the Criminal Records Bureau (CRB) or the Protection of Vulnerable Adults Register (POVA). The application form has been improved and is now legible. The process of recruitment had improved in that appropriate written references had been obtained and a record had been kept of a POVA First check and CRB check but there was no evidence or dates to support the checks. According to the manager the CRB’s
Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 20 are with the owners of the home. There is a need to provide evidence that all checks have been carried out prior to staff commencement. There are 13 care staff and 9 staff have a National Vocational Qualification (NVQ) in Care; a further 6 staff are due to commence NVQ training. There was evidence on the staff files of induction training and further training, including Moving and Handling, Food Hygiene, Fire safety, Abuse and First Aid. Oakendale House DS0000066053.V346377.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): 31, 33, 35, 36 & 38 Quality in this outcome area is good. The home is managed effectively for the benefit of the service users. The new manager must apply to be registered with the Commission for Social Care Inspection (CSCI). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The original part time registered manager of the home is retiring and a second manager has been working alongside the registered manager to ensure the home is managed on a full time basis. The second manager will be taking over the management of the home on a full time basis and as requested at the last inspection, must apply to be registered with CSCI. The new manager is in the process of completing the Registered Manager’s Award (RMA). Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 22 Staff confirmed that they feel well supported by the managers and the registered providers who took ownership of the home within the last 18 months. There was evidence that the manager has given a lot of support to staff and all staff have received individual one to one supervision and annual appraisals. The format of the one to one supervisions was discussed, as the current format was not suitable in that it did not provide any information about individual service users or staff training needs. It was recommended that the format should be similar to the annual appraisal but not in such depth with a signature obtained each time from the staff and supervisor. A record is kept of any financial transactions on behalf of service users. Staff meetings have been taking place. Health and safety policies and procedures are in place and risk assessments are carried out for each individual service user. The registered provider is not in day-to-day control of the home and as required at the last inspection now carries out monthly visits and writes a report on the conduct of the home under regulation 26 of the Care Homes Regulations. A copy of this report has been provided to CSCI. A recommendation was made that in order for more effective management of the home it would be helpful for a computer to be purchased with access to the Internet that would be useful for professional advice and improved communication links. Any accidents and incidents occurring at the home, as listed under Regulation 37 of the Care Homes Regulations are being sent to CSCI. As detailed in previous sections of the report, staff that provide meals/teas need training to comply with food hygiene regulations. Possible hazards in bathrooms such as bath foam or toiletries should be removed out of reach of service users. There was evidence of meetings held with service users to look at the services provided by the home, in particular, meals and surveys have been provided in order to examine and ensure quality standards are maintained. The home has the Investors in People accreditation and this has been recently reviewed and been given an excellent report. Oakendale House DS0000066053.V346377.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 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 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Timescale for action Evidence must be made available 31/10/07 of checks undertaken with the CRB on new staff to ensure service users are protected. The manager must apply to be 31/12/07 registered with the Commission for Social Care Inspection in order to meet regulatory requirements. Requirement 2 OP31 9 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP1 OP8 OP27 OP27 Good Practice Recommendations The Statement of Purpose should be kept up to date and available to service users and any visitors to provide up to date information about the home and its services. Any communication or visits by health professionals should be recorded separately for ease of information about a service user health. Staffing levels should be increased to meet the requirements of the current service users. The manager hours need to be full time and one of the
DS0000066053.V346377.R01.S.doc Version 5.2 Page 25 Oakendale House 5 6 OP36 OP31 7 8 OP38 OP38 care staff should be full time in order to deputise for the manager in her absence. The format for the one to one supervision of staff should be altered to include the details as listed in standard 36.3 of the Care Homes Regulations. The manager would benefit from access to the internet to keep up with professional advice and maintain communication links with the owners of the home and CSCI. Any staff that provide meals should have an up to date Food Hygiene Certificate to ensure food safety regulations are met. Any toiletries or bath foam etc should be kept out of reach of service user to ensure their health and safety. Oakendale House DS0000066053.V346377.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway 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
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