Inspection on 30/10/07 for Oakhurst

This inspection was carried out on 30th October 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oakhurst 27/08/08

Oakhurst 06/02/07

Oakhurst 06/07/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Oakhurst 4 Courtland Road Paignton Devon TQ3 2AB Lead Inspector Stella Lindsay Key Inspection (unannounced) 30th October 2007 1:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oakhurst DS0000066583.V349275.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. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakhurst Address 4 Courtland Road Paignton Devon TQ3 2AB 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) 01803 524414 01803 524414 Saffron Care Ltd Mrs Sara Watson Care Home 16 Category(ies) of Dementia (16), Old age, not falling within any registration, with number other category (16) of places Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) The maximum number of service users who can be accommodated is 16. One specific service user in the category MD(E) may be accommodated. 6th February 2007 2. 3. Date of last inspection Brief Description of the Service: Oakhurst is an attractive detached house next door to the library, with views across the park, and a short walk from shops and Paignton sea front. There are five steps with a rail up to the front door. Easier access is via the back door. There is not level access around the ground floor, as there are small steps in various places. The home comprises of three storeys: garden, ground and first floor, with the first floor landing and main bathroom being accessed by a chair lift, with four steps to the bedrooms on this floor. The four rooms at garden level have direct access on to the homes garden. The proprietors have recently refurbished two bedrooms on the second floor, but these are not suitable for frail elderly people or anyone with poor mobility, visual impairments, any mental health problem or cognitive deficiency, or history of falling. The home provides accommodation for up to 16 people who are over the age of 65. The home used to provide care for mostly independent, active elderly residents, but most residents now are mentally and physically frail. There is a communal lounge, small conservatory, and dining room available to residents. Fees range from £360 to £426 per week. Information for prospective residents including the most recent inspection report are on display in the entrance hall. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in October/November 2007. It involved a tour of the premises, discussion with the home owners, the Registered Manager, four staff on duty and ten residents. Care records, staff files, health and safety records and the medication system were examined. The home owner had provided information prior to this inspection about the running of the home. Staff and residents’ relatives returned surveys to the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? Care plans have been improved, and have been well considered and written along with residents. Craft sessions have been introduced, enjoyed by several residents. New dining chairs had been provided, which were sturdier, and had arms to enable residents to stand more easily and safely. Seven rooms had been redecorated when the occupant left, and new carpets had been laid. Staff levels had improved, and now the Manager is normally additional to the two care staff on duty at all times, though she works with them at busy times Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 6 in the mornings. At night there is now one awake member of staff, as well as one sleeping in. A grant had been obtained to develop the garden for the enjoyment of residents. What they could do better: Residents who were able to reflect on their conditions felt that their lives had become more difficult over the past year because of the increasing frailty and confusion of fellow residents. This could be eased if additional lounge space were made available, and if staff had more time to attend to different needs. The job description of the Registered Manager must include her responsibility for decisions about admissions and discharges based on assessment of need, so that safe and suitable decisions about admissions are made consistently. Residents must not be offered accommodation that puts them at risk of harm. The bedrooms on the top floor (2nd) are not suitable for frail elderly people or anyone with poor mobility, visual impairments, any mental health problem or cognitive deficiency, or history of falling. The Management must keep the number of staff on duty under review, and always make sure that there are enough staff to care for the residents needs, particularly in view of the admission of people with confusion who require more assistance and supervision. This is so that people get the attention they need at all times. The responsible individual should continue to increase the amount of person centred occupation opportunities in accordance with resident wishes and current best practice. This is so that residents have things that they like to do available to them. The Manager should keep a record of minor concerns and suggestions made, so that she can show what has been done in response. She should also amend the home’s policy and procedure on dealing with any allegation of abuse, so that anyone in charge of the home in her absence would know what to do. The hot water system must be adequate to provide residents with hot bath water when they need a bath. All residents should be able to get to a bath or shower that they can use. An Occupational Therapist should be commissioned to assess the premises, and their recommendations should be put into practice to make the home safer and more enabling for the residents. There should be more choice in communal rooms available for residents to use. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 7 An electric heater had been put in the Sun Room, which is not reached by the central heating. Any free standing heater must be fixed to the wall and covered, to protect residents from potential harm. Many of the bedroom doors were fitted with locks which could be used to lock the occupant in, though there is no evidence that this has ever happened. These locks should be removed so that there is no possibility of anyone being locked in. A suitable piece of equipment should be available to help people up off the floor after a fall, for the safety of both staff and resident. The five year electrical circuit certificate had recently expired. The electrical circuit must be professionally checked and repaired as necessary to protect residents from potential harm. 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. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This service has the right procedures in place, but they are not always well applied. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a Statement of Purpose, which was on display in the entrance hall along with the most recent inspection report for the home. The home owners said that each resident is given a Service Users’ Guide. They also said that they are planning to improve the way they present information, to make it easier for people with cognitive problems to understand. The files of two recently admitted residents were examined. The Manager has an assessment format to help gather the information she needs to ensure a suitable admission. She visits people at their home or in hospital, and invites people for visits, day care, or a short stay if appropriate. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 10 One of the new residents had come for lunch and for day care before moving in. The other had not been able to visit, but their Community Psychiatric Nurse had visited and written a report, and there was a discharge report from the hospital. One resident had been admitted to a top floor room, which is accessed via a steep flight of 16 steps. This person had a visual impairment, a history of falls, and a history of anxiety about confinement. This was unsafe practice. During the course of this inspection they moved to a first floor room that became vacant. The home owner said that they do not always receive full information from professional care workers who are seeking to place a client at Oakhurst, which had led to a difficult situation within the home. A recently admitted resident had been given a ‘Temporary Contract of residence’. This included the room to be occupied, and the procedure whereby either the resident or the proprietors may terminate the contract. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. Personal and health care needs are clearly recorded, and care is given in a person centred way, in spite of inadequate facilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has produced care plans for each resident. She sits with them to record their needs, and how they wish these to be met. These were seen to include the help people need to ‘look good’, help they need with eating and with mobility, night care needs, and particular activities. Care plans are reviewed by the Manager every month, and have to be signed by staff to ensure they have read them. Needs were properly assessed and recorded, but could not always be met, because of shortfalls in the environment, or not enough staff. One need that had been recorded was that a person had a particular need for staff to be able to take them out of the home for a walk sometimes, as they may become distressed at being confined. There were three residents who could not have a bath because they could not get to the bathroom where the bath has a hydraulic seat. They were regularly Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 12 given strip washes by staff. Other residents who were able to use their own en suite facilities said that it was irritating that they had to wait because there was often no hot water when they wanted a bath or shower. One resident who needs much physical care was most appreciative of the attention given by staff, day and night. The medication system was seen to be administered with care. An experienced and competent Carer was seen to give the medication according to the home’s procedure. Further training had been booked, and a pharmacy inspection was expected later that month. There was a suitable system for storing and recording Controlled Drugs, if needed. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. Although activities are offered, there were not enough staff to provide a satisfactory social life for this diverse group of people in an environment which is not yet fully adapted for frail people with mobility problems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some residents were limited in their daily lives by their environment. One person was often confined to their room because they could not always manage the four steps to get from their bedroom to the stair lift. They had been down to the lounge once during the previous week. One resident whose mobility was very limited was pleased to tell the inspector that staff had taken them round the park in a wheelchair during September (about six weeks earlier). As they were occupying a lower ground floor room they had level access to the garden. Some residents said that they stay in their own room most of the time because they find it disturbing to sit with other residents. The home is going through a transitional period, as more dependent residents are admitted. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 14 An activities programme is provided in the home. Professional activity leaders are hired twice a week. Attractive results of craft sessions were on display. Exercise sessions are led in the lounge, and staff give manicures and foot spas. There had recently been a most popular visit by ‘The Animal Man’. One resident said that they ‘love going out in the afternoons, and missed their trips out’. Another said in a comment card returned to the CSCI – ‘There are always activities but I am unable to take part’. Meals are served in two sittings. This suited the current residents, as those who were more independent sat together for the second sitting. Food is kept warm in a bain-marie. Residents were satisfied with the variety and quality of their meals. The home owner said that cooked breakfasts have been introduced at the request of residents. The home is a no smoking area, but a sheltered area is made available for smoking out of doors. Work was beginning on a total redesign of the garden, which should enrich the residents’ living environment and increase recreational opportunities. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. The home has sound procedures for responding to complaints and dealing with any allegation, and residents are protected by the staff’s understanding and good practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A formal complaints procedure is on display in the homes hallway and has been given to each resident in the resident guide. The procedure sets out in detail the procedure to be followed in case of a complaint and the timescales in which a response must be given. No formal complaints concerning the care provided had been received at the home. A Social Worker had been concerned about the manner in which a client had been discharged from Oakhurst, and had raised this matter with the CSCI. It was concluded that the home had worked within its rights and procedures to protect residents and staff. Risk assessments had previously written for them while working with this resident, including guidance from them as to how to help them when distressed. Staff had received training in Challenging Behaviour in Dementia in June of this year. Concerns are dealt with informally. It was recommended that a record be kept, so that people could know what had been done. For example, some residents had not been happy with clothes not being ironed, which was discussed at a staff meeting in May, and a better routine adopted. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 16 The Manager was aware of correct procedure to be followed in the event of any allegation of abuse being made. She should update the home’s written policy, so that any other person in charge of the home in her absence would have the correct guidance. Oakhurst DS0000066583.V349275.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): 19,20,21,22,25,26 Quality in this outcome area is adequate. Oakhurst is an attractive house but it does not currently meet the specialist needs of the people who live there. The home owners have plans for major refurbishment, extension and increase in facilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour was made of the home, which included some residents’ bedrooms, communal areas and service areas. The house is attractive and in pleasant surroundings. A major project to improve the facilities is just beginning. The main problems are with accessibility around the home, bathing facilities, lack of hot water, and laundry facilities. The home owner does his own maintenance work. Staff found that some problems remained after they had reported them. The home owner said that some of the problems could not be dealt with until the major building project is carried out. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 18 More communal space would give residents choice in where they sit and who they spend their time with. The inspector was told that on certain days when people are attending for day care, there are not enough seats for all, though this did not happen during this inspection. Apart from the lounge there is a conservatory and a sun-room. These had previously provided a good choice for residents, but now that some residents are more physically and or mentally frail these areas are either not suitable or not sufficiently separate. When discussing the planned intake of residents with dementia with the home owners in January 2007, the Inspector from the Registration team had recommended the conversion of a ground floor bedroom to another communal lounge, but this had not happened although the room had been vacated during the early autumn. The sun room was not heated. A free-standing heater had been provided, but this must be fixed to the wall and covered if it is to be used, to protect residents from potential harm. This space was also being used as a store room, and was not made very inviting to residents. The dining room is not large enough to seat all residents at one time. Meals are served in two sittings. This suited the current residents, as those who were more independent sat together for the second sitting. New chairs have been purchased. These are very good, being sturdy and with armrests which enable the resident to stand more easily. Unfortunately, they do not tuck under the dining table, and so take up room making it less easy for residents with walking aids to pass. The planned extension will include enlargement to the dining room and kitchen. There are two separate lower ground floor sections, each with their own staircase. Residents who are disorientated may find this confusing, along with the flowered carpets and patterned décor. A stair lift has been installed to one of these stairways. Only one bath was in regular use. There was another bathroom on the lower ground floor, but it did not have a bath seat so remained unused. Some residents had en suite showers that they were able to use, but some were unable to use their shower as no shower seat had been provided. The inadequacy of the hot water system was unacceptable. Residents must be able to have a hot bath when they need one. Residents said it was tepid, and staff said there was sometimes not even enough for one bath. The home owners said they were planning to obtain a new condensing boiler for the whole building. This situation is too important to residents’ welfare to await a major development, and an immediate solution must be put into practice. The communal toilet by the front door is close to the lounge dining room, and in great demand. It would be helpful to residents to have a second toilet easily accessible on the ground floor. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 19 There are small steps at various places around the building, which pose a potential trip hazard. There is a step out from the toilet by the front door, which is a considerable hazard, as a person could easily forget the step is there. A resident fell in that area during this inspection. The inspector saw various handrails and banisters that could be improved, and steps that should be highlighted. It is recommended that an Occupational Therapist be engaged to assess the premises and make recommendations to enhance the safety and independence of the residents. Bedrooms varied in size and aspect. Some were very attractive, and had ensuite facilities. Seven had been redecorated while they were vacant, and were looking very nice. Locks which are suitable for residents to use for their safety and security should be provided, with an entire set being purchased together in order that staff may have one master key to override and gain entrance in an emergency. Several bedroom doors had locks fitted which could theoretically be used to lock a resident in their room, though there was no evidence that this had ever happened, and these should all be removed. The home has no laundry room. The washing machine was outside the kitchen door, and the tumble drier was the other side of the building in a wooden shed. This is unsuitable, and becomes more unacceptable as more frail residents have greater laundry needs and are more susceptible to any breaches of infection control. A new laundry is in the home owners’ planned building project. The hours worked by the cleaner had been increased, and a carpet cleaner purchased, to help counteract odours. This was successful except in one room where there were particular problems. A suitable place should be provided to wash commode pots, as they are currently washed in the only bath. Paper towels must be provided in communal toilets, and in bedrooms where personal care is provided. A recent out break of infection was dealt with effectively. The Manager informed the CSCI, and consulted the Health Protection Unit, and the home was clear within a week. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 20 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 good. Competent and caring staff are employed, and recruitment is on-going to provide sufficient staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A written rota was supplied. This shows that there are two care staff on duty at all times. The Manager works 9- 5 Monday to Friday, and works with the care team at busy times, for example in the morning while people are still getting up and dressed. A cook is employed from 8.30am till 2pm every day, and a cleaner from 9 – 12.30 on five days per week. This was found to be enough to maintain safe levels of care and attention except from 4 – 6pm. If care staff are called away to provide personal care, there must be someone available to give attention to frail residents especially when they are eating. The home owners had already discussed this shortfall with the Manager, and an advert was placed during this inspection. Further consideration should be given to availability of staff during the day, as some assessed needs were not being met, mainly for engagement with activities outside the home. At night there is one awake carer, and one ‘sleeping-in’. This must also be reviewed continually, as residents’ night care needs alter. Two residents needed two staff help them move at the time of this inspection, which included night calls. The manager has the authority to bring in additional staff at times of extra pressure. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 21 Recruitment procedures ensure that staff are fully “Vetted” before appointment. A thorough induction programme is in place, and NVQ training is supported. Five of the current nine carers have achieved at least NVQ2 in care or equivalent. Staff returning surveys to the CSCI all said that their support and training was good. Recent training had covered Challenging Behaviour in Dementia, Care of ageing skin, and Infection Control. The Manager is in touch with the Alzheimers’ Society, for training materials and ideas and resources for improving practice. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38 Quality in this outcome area is adequate. The Directors have employed a highly competent and caring Manager, but some environmental issues remain which leaves people in this home not adequately protected or safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Sara Watson is the Registered Manager. She is an experienced carer and care manager and is qualified to manage the home. She was continuing to further her skills and had attended a counselling course the day before this inspection. The job description of the Registered Manager did not include her responsibility for making decisions about admissions and discharges based on assessment of need. This is necessary, as she is the person qualified to make these decisions in accordance with good care practice. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 23 The Directors, Mr & Mrs Spurle, take responsibility for the building and forward planning of the business. They have produced a Development Plan for the home. There is a quality control system which was introduced to ensure residents have opportunities to influence the way the home operates. This should be further developed. The manager confirmed the home does not deal with any finances for residents. These are dealt with by the person themselves, relatives or through formal procedures such as Power of attorney or court of protection. Professional fire safety training was booked for the week following this inspection. The Fire Safety Officer agreed to visit to make an assessment of fire safety in the home. The gas boilers had been serviced by corgi registered engineers on 5th October 2007. The five year electrical circuit certificate had expired on 07/11/07. There is no hoist in the home, and this would not be suitable because of the many different floors, but a suitable piece of equipment should be available to help people up from the floor after a fall. Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 24 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 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 1 2 X 2 2 1 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 25 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 OP4 Regulation 13(4)c Requirement The Registered Person must ensure that accommodation offered is suitable for the occupant and does not put them at risk of harm. The hot water system must be adequate to provide residents with hot bath water when they need a bath. Any free standing heater must be fixed to the wall and covered, to protect residents from potential harm. Locks must be removed from bedroom doors where they make it possible to lock a resident in their room. The job description of the Registered Manager must include her responsibility for decisions about admissions and discharges based on assessment of need. The electrical circuit must be professionally checked and repaired as necessary to protect residents from potential harm. Timescale for action 30/11/07 2. OP25 23(2)j 31/01/08 3. OP25 13(4)c 21/12/07 4. OP24 13(6) 21/12/07 5. OP31 14(1)a 21/12/07 6. OP38 23(2)b 31/01/08 Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 26 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 OP12 Good Practice Recommendations The responsible individual is recommended to increase the amount of person centred and individualised activity in accordance with resident wishes and current best practice in view of the proposed addition of the dementia care category. The Manager should keep a record of informal complaints/ concerns/suggestions, and what has been done. The Manager should up-date the home’s policy and procedure on dealing with an allegation of abuse. There should be more choice in communal rooms available for residents to use, and the décor should be changed to make the home more enabling for people who may be easily disorientated. An accessible shower should be provided, to give choice and safety in bathing facilities. The Registered Person should obtain an assessment of the building by an Occupational Therapist, and follow their recommendations in order to make the home safer and more enabling for the residents. The Registered Person should keep under review the number of staff needed for safety of residents and good care practice in the home. A suitable piece of equipment should be available to help people up from the floor after a fall. 2. 3. 4. OP16 OP18 OP20 5. 6. OP21 OP22 7. 8. OP27 OP38 Oakhurst DS0000066583.V349275.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Oakhurst DS0000066583.V349275.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!