Inspection on 08/05/06 for Oakhurst Court Nursing Home

This inspection was carried out on 8th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Oakhurst Court Nursing Home 20/08/08

Oakhurst Court Nursing Home 22/08/07

Oakhurst Court Nursing Home 17/10/05

Oakhurst Court Nursing Home 21/06/05

Oakhurst Court Nursing Home 21/09/04

Oakhurst Court Nursing Home 27/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Oakhurst Court Nursing Home Tilburstow Hill Road South Godstone Surrey RH9 8JY Lead Inspector Lisa Johnson Unannounced Inspection 8th May 2006 08:55 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 Court Nursing Home DS0000013343.V293692.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. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oakhurst Court Nursing Home Address Tilburstow Hill Road South Godstone Surrey RH9 8JY 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) 01342 893043 01342 892690 oakhurst.court@virgin.net Oakhurst Court Limited Mrs Pamela Elizabeth Milne Care Home 57 Category(ies) of Dementia - over 65 years of age (57) registration, with number of places Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of beds not to exceed 57. Date of last inspection 17th October 2005 Brief Description of the Service: Oakhurst Court is a large detached property that has been converted to provide accommodation for fifty-seven service users. The home is located in a rural part of South Godstone. Access to shops, church, public transport and other local amenities are a distance away, however transport is provided for service users when required. Part of the accommodation is provided in the original building, with the rest in a number of annexes surrounding the main building. These have been added during a continuous upgrading programme. Accommodation is provided on the ground and first floors and most bedrooms have en-suite facilities. There are two passenger lifts accessing the first floor. The home has a number of sitting areas including a large main lounge area. There is a large dining area which is used for activities as well as serving meals. The home is located in substantial grounds with some of the gardens landscaped and a river runs close to the main entrance. All areas have wheelchair access. There is ample parking available to the front of the home. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection carried out in 2006/2007.The unannounced inspection took place over eight hours and was carried out by Mrs. L Johnson and Mrs. P Milne represented the establishment. A full tour of the premises was undertaken and care plans, staff files and policies and procedures were sampled. The inspector spoke to five relatives and six members of staff. The inspector spoke to three service users and spent time with three other service users who due to communication difficulties were unable to give their views about the care and support that they receive in the home. Other information was gained from observation of service users within the home. The inspectors would like to thank the service users, relatives and staff for their hospitality and cooperation during this inspection. What the service does well: The home was open, and friendly. Staff were observed to be talking to service users with respect and service users were observed to be relaxed in their company. One service user was asked about what it was like to live in the home. He stated, “This is the best home I lived and the staff are good”. “I enjoy spending time in the garden feeding the birds. Other comments received from service users were, “Its nice here”. “I feel at home”. Four relatives were asked about their views on the home and the care provided. Comments received included “The staff are friendly and approachable and they make you feel welcome”. “The staff keep me informed of any changes and developments”. “ I feel confident that I could raise any concerns”. The home has extended its quality assurance questionnaire to include the view of relatives and has implemented a quarterly newsletter. One relative confirmed that she found the newsletter informative. The home has obtained the Investors In People Award, which means that the organisation has been recognised for promoting enhanced skills in management and developing the skills of staff. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? The home has made progress in meeting a number of the requirements that were made at the previous inspection. Stair gates that were situated in the entrance of service users bedrooms have been removed. Progress has been made in reviewing individual care plans. Staff have completed training in safeguarding adults. The medication that was discontinued in the controlled drugs cupboard was returned to the pharmacy. Since the previous inspection a redecoration programme has commenced with a number of bedrooms having been provided with new furniture. A door has been replaced in the upstairs bathroom. The storage for bedpans and equipment has been completed. Toiletries belonging to individuals are now kept in their bedrooms. The practice of using inco pads under chairs for the protection of carpets from spillages has stopped with the carpet now being protected with more appropriate coverings. Grab rails have been placed on the walls where there are steep ramps. Fire drills have been updated. Boiler cupboards were locked. Electrical testing has taken place on a television. A storeroom has been cleared and tidied of rubbish. The accident-logging book now states the time and place of where incidents/accidents have occurred. The registered manager has also responded to some of the recommendations made at the previous inspection including arranging for an independent assessor has visited the home to look at the moving and handling equipment provided. The registered manager now has more supernummary time to carry out her managerial responsibilities and has made some progress in updating the homes policies and procedures. The manager has implemented a relative’s quality audit tool and a quarterly newsletter has been produced. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 7 What they could do better: Progress has been made in updating and reviewing care plans, however there were still some occasional gaps of staff signatures, photographs are required and a further requirement was made that care plans should be agreed and signed by service users and/or their representative. This is to ensure that service users are involved in the planning of their care. The home has been unable recruit an activities coordinator although does provide some activities. However the home should extend its range of therapeutic and leisure activities and provide a programme to service users about the activities which are provided. Comments reflected from relatives confirm that this area that needs improving. A requirement was made that the complaints procedure should be updated, as information displayed in the home was out of date. This is to ensure that service users and their representatives have a clear accessible procedure in place, which explains the process. The home is continuing to make improvements to the décor and fabric of the home. However a carpet, which was stained in one of the sitting rooms, should be replaced. The inspector was informed that the floor in this room is to be replaced. A requirement was made that a programme for the outstanding redecoration and fabric renewal to the home is submitted to the Commission for Social Care Inspection. This is to ensure that service users have a pleasant and comfortable home to live in. During discussion with the registered manager and company secretary it was evident that three new members of staff have commenced employment in the home without a protection of vulnerable adult first check being completed, although they had applied for enhanced police checks and were waiting for these results. The registered manager stated that she was not aware of this process. An immediate requirement was made that issue must be responded to as a matter of urgency. This is to ensure that service users are protected by the homes recruitment policies and procedures. The registered manager actioned this requirement during the inspection and the confirmed outcome was returned for two members of staff. At the previous inspection a recommendation was made that the homes policies and procedures should be updated. The manager has made progress in completing some of these. However a requirement was made that the outstanding procedures be updated for example, the complaints procedure. This is to ensure that the rights and best interests of service users are safeguarded by the homes policies and procedures. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 8 A recommendation was made that individual trays are provided with meals to service users who don’t eat their meal at the table to enhance the presentation of the meal served. The medication cupboard was examined and it was found that there was an excessive stock of creams and ointments. A recommendation was made that the registered manager should review the order of the items. A further recommendation was made that the registered manager should consider providing a separate record book to log any complaints or concerns if they arise. 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. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 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 Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 & 6 The home is able to demonstrate that service users and their relatives are provided with adequate information so that they are able to make an informed choice about the suitability of the home as a place to live. The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. Each service user is provided with written contract/statement terms and conditions with the home. The home does not support service users for intermediate care. EVIDENCE: The home has produced a detailed Statement of Purpose detailing the services that the home is able to offer. Updated copies were provided to the inspector. One relative spoken to stated, “I received a service user guide and I was given lots of information”. Four contracts were sampled which detailed the terms and conditions with the home and extra charges explained. Contracts sampled were signed by the individual or their representative. The registered manager visits prospective service users and completes pre admission assessments. Four assessments were sampled one of which included Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 11 an individual had been recently admitted to the home. The assessments recorded in detail the health, personal, emotional and social needs of the individual. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Each service is provided with an individual care plan, which details the individual’s health, personal, emotional and social needs. Further work is required in ensuring that plans are signed by staff. Service users and/or their representatives should sign their plans where possible to ensure that they are fully involved in the process. Service users are protected by the homes medication policy and procedures. Service users privacy and dignity is respected. EVIDENCE: Four Care plans were sampled and were detailed and comprehensive and progress has been made in reviewing goal plans. However a further requirement was made that staff completing the care plan should sign the document, as there were still some gaps in staff signatures. A further requirement was made that service users and/or their representatives should agree and sign their care plans to ensure that service users are involved in the drawing up of their plan. Moving and handling risk assessments were Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 13 completed and nutritional assessments were completed. Risk plans were available for service users requiring bed rails with permission being gained from service users or their representative. Service users are supported to access a range of specialist resources. This includes the local GP, physiotherapy, chiropody, dietician and an ophthalmic service is provided. The homes medication administration systems were examined and records were maintained adequately. A list is maintained of staff authorised to administer medication and photographs of individuals were available with their medication card. Medicines were stored appropriately including the controlled drugs kept in the home. However one cupboard for storing external lotions and creams held an excessive stock. It was recommended that the manager reviews this issue. Staff were observed to be knocking on service users doors before entering and were seen to be talking to service users respectfully. During the inspection some individuals received visits from friends and relatives who were able to visit in private in service users rooms. Screening was in place in double rooms to maintain privacy. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The home needs to expand its recreational and leisure activities, to meet the individual needs and preferences of service users. Service users maintain contact with their family and friends. Service users are offered a well balanced diet and are supported to exercise choice. EVIDENCE: Since the previous inspection the home has still not been able to appoint an activities coordinator despite advertising for this post. Activities provided in the home include occasional musical entertainment; pets for therapy visit every two weeks. Holy communion is held monthly to meet the spiritual needs of individuals. Care staff provide some activities including ball and soft darts games and supporting service users in playing board games. Service users were clearly enjoying this activity and responded positively to the interaction. A piano is available in the home which one service user enjoys playing. The home is able to provide newspapers. One service user stated, “ I like to read my paper and enjoy going out in the garden”. A hairdresser visits the home, a Christmas party was organised and the garden is utilized in the summer. Due to the absence of a coordinator the home needs to expand its activities to include activities that would benefit service users who have dementia. In the morning there was little activity observed. Two relatives spoken to felt that Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 15 activities needed expanding and this was also reflected in some of the returned quality audit questionnaires. A requirement was made that the registered manager makes further enquiries with a view to expanding activities that meets the aims and objectives of the home and meets individuals needs and preferences. Service users in the home are able to maintain links with family and friends and there is no restriction of visiting times and they are able to visit their relatives in private if they so wish. The lunchtime meal was of a good standard and was nutritious with fresh vegetables being served. The inspector spoke to the homes chef. There is a six weekly menu. The chef stated that when new service users move into the home the likes and dislikes of individuals is discussed with them and special diets are catered for. The lunchtime meal was unhurried and staff were seen to be sitting and interacting with service users who required assistance with eating. However a recommendation was made that meals are served on trays to service users who don’t eat in the dining room to enhance the presentation. Individuals are provided choice with regard to their meals with alternatives being offered if the meal is not to their preference. Records of other meals eaten are documented in the records maintained by nursing staff. Service users are able to bring their own possessions with them into the home. One individual likes to spend time in the garden and to smoke his cigar and his wish to do this was respected by staff. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home needs to update the homes complaints procedure to ensure that service users and relatives have the correct information if they wish to raise a complaint or concern. Policies and procedures are in place for safeguarding adults. The home should ensure that protection of vulnerable adult first checks are completed prior to any new staff being employed in the home to ensure that service users are protected from abuse. EVIDENCE: No complaints have been received since the previous inspection. One relative spoken to stated, “The matron and staff are approachable and I would feel confident if I had to raise any concerns”. Three other relatives spoken to also confirmed that they were happy with the care their relative receives. Comments included, “ I am kept informed of any changes”. “The staff are friendly and welcoming”. A complaints procedure is available in the home and was seen on display in the hallway, however the information needs updating. This is to ensure that service users and their representatives have the information they require if they wish to raise a complaint or concern. A further recommendation was made that the registered should maintain a complaints record-logging book. Staff have received training in safeguarding adults and two staff spoken to were clear in their responses as to the appropriate action they would take if they ever witnessed any abuse. Procedures were available. However the manager should ensure appropriate checks should be completed prior to any Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 17 staff commencing employment in the home. This is to ensure that service users are protected from abuse. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 18 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, 23 & 26 The home is able to demonstrate that progress is being made in improving the communal areas of the home, but further work is required to ensure that service users will have pleasant and comfortable communal areas to live in. Service users live in comfortable bedrooms with personal possessions around them. The home is clean and hygienic. EVIDENCE: The home is situated in a rural road in South Godstone. The home is spacious and a number of sitting areas are available. There is a large pleasant garden, which is well maintained and accessible. One service user said, “ I enjoy sitting in the garden and feeding the birds”. Since the previous inspection the home has made progress in improving the décor and fabric of the home. The dining room has been redecorated giving it a lighter appearance. Corridors have been repainted with handrails highlighted in brighter colours and some curtains have been replaced. However a carpet needs replacing in one of the sitting rooms, which was heavily stained, and dining room furniture needs replacement. The inspector was informed that the Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 19 whole floor is to be replaced in the sitting room. A requirement was made that the registered manager should supply a plan to the Commission for Social Care Inspection outlining the programme for the remaining refurbishment. This is to ensure that that service users have a pleasant and comfortable home to live in. A recommendation was made that signage is provided throughout the home when the decorating is completed to assist service users with specialist needs. A number of bedrooms have been redecorated with new furniture being provided. All bedrooms have en-suite facilities. Service users bedrooms viewed during the inspection were seen to contain personal possessions. The home employs ancillary staff and was found to be clean and hygienic. Appropriate hand washing facilities were in place. Separate laundry facilities were available. Staff have completed training in infection control. A tour of the kitchen was undertaken and appropriate food storage was in place with cleaning schedules being available. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The staffing levels in the home are sufficient to meet the needs of service users. The home is able to demonstrate that service users are supported by trained and qualified staff who are able to carry out their role competently. The home must ensure that adequate checks are completed prior to staff working in the home to ensure that service users are protected by the homes recruitment policy and procedures. EVIDENCE: The staff rota was examined and it was concluded that that staffing levels in the home were satisfactory. The registered manager informed the inspector that she is now able to have more time to work supernummary hours to carry out her management responsibilities. The home employs both registered nurses and care staff. The home also employs ancillary, maintenance, administration staff and a chef. Seventy four percent of care staff have achieved National Vocational Qualifications Level two or above and two further staff are working towards gaining their qualification. The inspector sampled four staff personal files. The registered manager has made progress in ensuring that the information required by statute is being completed. Proof of police checks was available. During discussion with the registered manager and company secretary it was evident that three new members of staff that had been recruited had not had protection of vulnerable Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 21 adult register first checks completed prior to being employed and were still waiting for the outcome of their enhanced police checks. The registered manager stated that she was not aware of this process. This was raised as a serious concern and immediate requirement was made that this issue must be actioned. During the inspection the registered manager persued this issue and the outcome of enquiries made for two members of staff was received and confirmed. A requirement was made that these checks must be carried out for all new staff employed. This is to ensure that service users are protected by the homes recruitment policy and procedures. The home has achieved the Investors in People Award and the home has an ongoing training and development programme for staff. All newly appointed staff receive and complete induction. Certificates for four members of staff were sampled. For example dementia awareness, medication updates, continence management, nutrition, health needs assessment and pressure area care. A training consultant attends the home and a programme for forthcoming training was seen on display in the home. A recommendation was made that the registered manager should maintain a staff-training schedule. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36,37 & 38 The registered manager is able to demonstrate that she has the appropriate qualifications and experience to manage the home and has implemented quality assurance systems. The home is able to demonstrate that the financial interests of service users are protected. Staff receive formal supervision. EVIDENCE: The manager is a qualified nurse and has management experience of running a care home and is able to demonstrate that she undertakes training and development. The manager has completed relevant training in dementia care. The manager has expanded the quality assurance systems to include relatives and about fifty percent of the questionnaires were returned with comments. The home has also implemented a quarterly newsletter which one relative said was informative and enjoyable. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 23 The inspector spoke to the company secretary to look at the procedures for safekeeping service users finances. It was confirmed that no monies are maintained by the home on behalf of service users. An inventory is completed for individual’s property and possessions. All staff have received annual appraisals, which were sampled and were indepth covering a range of areas. Two staff spoken to confirmed that they receive one to one meetings with their supervisor. A range of policies and procedures were in place and the manager has made in some progress in reviewing them. A requirement was made that this must completed with emphasis on updating the complaints procedure. This is to ensure that the rights and best interest of service users is protected. The homes fire book was sampled which concluded that regular fire drills are taking place, equipment checks being completed and that staff are receiving training. The accident book was sampled and was recorded appropriately. Equipment in the home is checked by approved contactors such as hoists. Water checks take place including testing for legionella. Recent visits have been undertaken by health and safety and environmental health. Accurate records are maintained for fridge, freezer and food temperatures. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 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 3 X N/A X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X 2 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 2 Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 25 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 OP7 Regulation 15(2)(a) (c) Requirement Timescale for action 08/06/06 2 OP12 16(m)(n) 3 4 OP16 OP19 17(2) Schedule 4 23 (2)(b) The registered person must ensure that staff sign the care plans. Service users and/or their representatives should agree and sign their plans. (Previous requirement 17/11/05 not met) The registered person should 08/08/06 increase the availability of recreational and therapeutic activities in the home based in individual’s interests and preferences. A written programme must be available to service users. The complaints procedure must 08/06/06 be reviewed and updated. The registered person must supply a refurbishment plan for the outstanding refurbishment programme in the home. The registered person must ensure that POVA register first checks are completed for staff prior to commencing employment in the care home. All policies and procedures in the home must be reviewed and updated. DS0000013343.V293692.R01.S.doc 08/06/06 5 OP29 19(1)(2) (3)(4) Schedule 2 17(3) 08/05/06 6 OP33 08/07/06 Oakhurst Court Nursing Home Version 5.1 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 2 3 4 5 Refer to Standard OP15 OP9 OP16 OP22 OP28 Good Practice Recommendations The registered person should consider supplying trays with meals served to service users who don’t have their meal in the dining room to enhance presentation. The registered person should consider reviewing the stocks of external creams and lotions supplied to the home. The registered person should consider providing a separate record book to log any complaints or concerns should they arise. It is recommended that the registered person should consider providing signs for directions to assist service users. The registered person should consider maintaining a staff schedule record staff training. Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Oakhurst Court Nursing Home DS0000013343.V293692.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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