Inspection on 27/03/08 for Oakhurst Grange

This inspection was carried out on 27th March 2008.

CSCI found this care home to be providing an Good service.

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 Grange 14/06/06

Oakhurst Grange 19/10/05

Oakhurst Grange 27/05/05

Oakhurst Grange 07/10/04

Oakhurst Grange 26/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

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 Grange Goffs Park Road Crawley West Sussex RH11 8AY Lead Inspector Elizabeth Dudley Unannounced Inspection 27th March 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oakhurst Grange DS0000024184.V359351.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 Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakhurst Grange Address Goffs Park Road Crawley West Sussex RH11 8AY 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) 01293 536481 01293 612452 www.bupa.com BUPA Care Homes (CFHCare) Ltd Ms Frances Brenda Deane Care Home 120 Category(ies) of Dementia (60), Dementia - over 65 years of age registration, with number (60), Old age, not falling within any other of places category (60), Physical disability (30), Physical disability over 65 years of age (30) Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 120 service users accommodated in the four units divided as follows:Resper and Balcombe Units accommodating a total of 30 persons in each, categories Dementia aged 50 to 65 (DE) and Dementia over the age of 65 years (DE(E). Charlwood and Copthorne units accommodating a total of 30 persons in each unit who may be in the categories of Older Person (OP), Physical Disability aged 50-65 (PD) and Physical Disability over the age of 65 years (PD(E). 14th June 2006 Date of last inspection Brief Description of the Service: Oakhurst Grange is a care home registered to provide nursing care for 120 Service Users aged 65 years and over, 30 of who may have dementia. The home was purpose built and consists of four separate 30-bedded houses, Copthorne, Charlwood, Balcombe and Rusper. Each house is single storey and each has its own garden area. Under the current registration Copthorne, Charlwood and Balcombe provide general nursing care and Rusper house provides nursing care for people with dementia. There is a further building which houses the reception area, administration offices, laundry and kitchen facilities. Each of the homes has a unit leader. Mrs F Deane is the Registered Manager of the home. The home is situated within a residential area, close to the town centre of Crawley. The Registered Provider of the home is BUPA. The CSCI was informed on the 27th March 2008 that the current fees for the home range from £450 to £960 per week. Other services such as hairdressing and chiropody are not included in the fees and these are available from the home. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection took place on the 27th March 2008 over a period of six and a half hours, and was facilitated by the deputy manager and the clinical manager for mental health. On this inspection two of the four units in the home were inspected. Of these one was the nursing unit for those residents with mental health needs of the older person, and one was the general health nursing unit, which has four palliative care beds. A brief visit was made to the residential unit, which provides personal and social care to older people with mental health needs. Methods used to collect information about the home included examination of documentation in the home, observation of staff working with residents, serving of lunches, and conversations with residents, staff and visitors to the home. Six residents were spoken with in depth and gave their views on life in the home and brief conversations were held with four others. Two visitors and eight staff were spoken with. Documentation examined included care plans, personnel files, staff training and supervision records, catering records and health and safety files. Prior to the inspection ten surveys were received from residents and relatives of residents in the home, these provide information about the daily life in the home. The Annual Quality Assurance Assessment, required by the CSCI, which gives an overview of what has been achieved in the home and issues to be addressed, was received by the CSCI prior to the inspection. This accurately reflected the current status of the home. This was used as part of the inspection process. Comments received from residents, visitors and staff were mainly positive. Residents said ‘The staff are very polite and kind’. ‘There are plenty of activities and outings and the food is good’. ‘ He was in another care home before Oakhurst Grange and I thought the care was good, but there is no way that this could be compared to the standard of care he is now receiving’. ‘ The staff are excellent and the overall standard of the home is maintained by the regular staff, I am always reassured when regular staff are on duty as I know they will understand mother’s needs’. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 6 Visitors said that staff made them welcome and kept them informed of the residents progress. Some residents, visitors and staff, particularly from the mental health nursing unit voiced concerns about the lack of sufficient staff on duty, saying that the staff were always very busy and sometimes the unit was short of staff. Staff said that there was insufficient staff on duty over a twenty-four hour period to meet the complex mental and nursing needs of the residents on this unit. The home is currently undergoing a change of management. The current registered manager is taking up a post at another home within the company and a new manager has been appointed. Both the new manager and the registered manager are currently working part time at the home until the change is completed. A clinical manager with the relevant qualifications is in place for the mental health units. What the service does well: What has improved since the last inspection? Care plans have been improved by the utilisation of a new system. The system was developed by BUPA and is know as QUEST. Use of this system aids staff to make appropriate decisions relating to the assessed needs of the residents and promotes efficient care delivery to ensure these needs are met. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 7 In the past year the home has bought new equipment, which includes profiling beds, these are beds, which are fully adjustable but have a more domestic appearance than normal hospital beds. The home has reduced the use of agency staff and is in the process of recruiting more staff. The Annual Quality Assurance Assessment states that retention of staff has improved. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oakhurst Grange DS0000024184.V359351.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 Grange DS0000024184.V359351.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): 1,2,3,4,5,6 People who use the service experience good quality outcomes in this area. The information about the home available to prospective residents is informative and in a format suitable for residents in all units of the home. A thorough preadmission assessment ensures that prospective residents are aware of whether the home can meet their health and personal care needs, and allows them to decide whether this home will give them a quality of life that they expect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Service User Guide and Statement of Purpose provide information about the home in a manner, which is clear and informative. The style of these Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 10 documents would allow them to be used with ease by all residents in all units in the home. A few minor amendments will be needed on employment of the new manager and this was discussed with the deputy manager. Residents receive a contract or terms and conditions on admission to the home. Prospective residents are assessed by the manager or senior member of staff and encouraged to visit the home before they decide whether they wish to live there. They receive written confirmation of the homes ability to meet their needs. Four preadmission assessments were examined and these were comprehensive and detailed, these are used in the formation of the care plan. The home accepts residents for respite care but not for intermediate care. Oakhurst Grange DS0000024184.V359351.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): 7,8,9,10,11. People who use the service experience good quality outcomes in this area The standard of care planning and delivery allows residents to receive the care that is suited to their specific needs. The standard of medication administration safeguards the residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six care plans across three of the units were examined. The standard of care planning was generally very good, and staff had addressed all aspects of the care required. Care plans included life histories, nutritional, pressure damage, wound care charts and other relevant information. Generally all parts of the care plan had been reviewed on a monthly basis and formed in consultation with the Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 12 residents or their representative. All care plans were in the new QUEST format used in BUPA homes, were person centred and holistic. Risk assessments were in place. Daily records showed that the delivery of care was in line with the planned care, nursing charts such as fluid balance and turning charts were up to date and present in the rooms of those residents that required this. Registered nurses have received ongoing training and are skilled in venepuncture, syringe drivers, male catheterisation, enteral feeds and other procedures. Residents seen were generally well cared for but two residents on the nursing unit required mouth care and the standard of mouth care was discussed with the deputy manager and senior nurse on duty on the unit that day, they will address this. The home has a retained General Practitioner but residents can keep their own General Practitioner. Community Psychiatric nurses visit the EMI units. The time taken to answer call bells is presently being monitored. Residents spoken with were pleased with the care they were being given and the attitude of the staff saying that they were treated with respect and dignity and their privacy was respected and the staff were ‘ very nice’, ‘ so polite’ and ‘ always call the doctor when we need them’ Relatives spoken with said that the standard of communication from staff was good. Over the past year there have been concerns raised over the prompt answering of call bells, this is now being monitored. The standard of medication was good with all medications signed for on administration. Controlled drugs were stored and recorded accurately. There was discussion with the senior nurse on the EMI unit who voiced concerns that they had received no guidelines on disposal of controlled medication under the new pharmacy regulations, the deputy manager agreed to address this. There are 4 palliative care beds in the Copthorne Unit. Staff have received training in the Gold standards framework (a nursing tool for care of the terminally ill) but have not commenced the Liverpool Care pathway (a pathway of pain relief used in the last days of life). The deputy manager will make enquiries regarding this. Residents nursed in bed were comfortable with appropriate pressure relief aids and charts recording nursing interventions. Letters complementing staff on their care of residents receiving end of life care were seen. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 13 Some ‘end of life’ care plans had not been completed and wherever possible this should be done. The guidelines regarding resuscitation decisions have recently been amended and it is recommended that the deputy manager liaise with the hospice or local end of life care specialist nurse regarding up to date information. Oakhurst Grange DS0000024184.V359351.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. People who use the service experience good quality outcomes in this area The home provides choice and variety for residents both in activities and at mealtimes. Care plans do not always show residents preferences in times of rising and retiring, which could lead to their choices in this area not being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are four people employed to provide activities across the units and these take place on a Monday to Friday basis. Staff provide activities at weekends and some entertainers visit on these days. There is a large range of activities varying from one to one sessions with residents who do not leave their rooms to craft sessions and outings in the home’s own transport. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 15 Programmes of activities are provided on the notice boards in all the units and it is recommended that these be produced in a format, which is suitable for ease of use by residents. It is not clear how residents who stay in their rooms are informed of activities although some staff said that they inform them verbally. One relative commented in a survey that the ‘home could be improved by increasing the number and duration of social activities to fill the time that the residents spend doing very little’. However most residents spoken with said that there were sufficient activities, although three residents were not aware of what activities were taking place. Residents have a choice over times of rising and retiring but preferred times were not in the majority of the care plans. The night staff get up some residents in one unit but staff gave assurances that it was only if the residents asked for this. There is an open visiting policy and visitors spoken with said that they are made welcome at any time. Religious services are held and both C/E and R/C ministers visit the home. The menus provided were nutritionally balanced and gave choices to residents. The inspector saw lunches being served in the EMI unit. Staff interacted well with residents who needed assistance and the food appeared appetising and well presented. The meals are taken from the main kitchen into the various units, menus are displayed and there are two choices of menu at each meal. Individual preferences and choices are provided for. Residents spoken with said that the food was very good. There were adequate staff on duty to assist residents and no residents were seen having to wait for assistance at this inspection. The home runs a ‘ Nite Bite’ system, which allows residents to have a choice of snacks during the night. Cakes and puddings are mainly home made and there was evidence of fresh fruit and vegetables. The kitchen was very clean and all catering staff have the food hygiene certificate. Oakhurst Grange DS0000024184.V359351.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. People who use the service experience good quality outcomes in this area. Documentation seen showed that residents can be confident that any complaints they may have will be dealt with in an open, transparent and timely manner. Staff have received adult safeguarding training and were aware of their responsibilities towards those in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy is displayed on the notice boards and in the Service User guide. The home has had 27 complaints since the last inspection. There was documentation to show that these had been addressed in an open, transparent and timely manner. Most Residents spoken with knew how to make a complaint and were confident that these would be addressed in a confidential manner. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 17 Discussions were held with the deputy manager over the importance of referring small injuries, if their cause was unknown to adult safeguarding. She gave assurances that this would be done in the future. Staff have attended safeguarding training provided by BUPA. It is recommended that senior staff attend the safeguarding training given by social services as opposed to only the in house training that is given. The adult safeguarding policy in this home correctly identified the reporting protocol to be used in line with multi agency guidelines. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26. People who use the service experience good quality outcomes in this area. Residents live in a comfortable and clean home with pleasant communal facilities and gardens. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three units in the home were seen at the inspection. These were all comfortable and clean and on one level, providing a lounge/ dining room in each unit and all units having access to individual safe gardens. Resident’s rooms are comfortable and made homely with residents own possessions. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 19 Radiators do not have covers and although these are cool touch exteriors some that were felt were quite hot. Discussions were held with the deputy manager regarding contacting health and safety executive regarding risk assessments for these and she agreed to do this. It was also noted that since 2005 inspectors have been asking the provider to risk assess the door locks on residents doors, especially in the dementia unit this has not been done. A requirement has been made around this. Likewise it was unclear whether residents have the choice of whether to have a key or not and this should be included in the preadmission assessment and keys given under the auspices of a risk assessment. This was discussed with the deputy manager. Water temperatures had been monitored and were within the recommended parameters. There was adequate equipment including assisted baths, hoists, pressure relieving equipment and adjustable beds. Two residents surveys said that maintenance of wheelchairs needed attention. Staff have received training in infection control and there are sufficient gloves and disposable aprons in place. Oakhurst Grange DS0000024184.V359351.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 People who use the service experience adequate quality outcomes in this area. Not all areas of the home have sufficient staff over a twenty-four hour period to meet the varying needs of the residents. Robust recruitment processes safeguard the residents in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides the same amount of staff over a twenty-four hour period for each unit. Discussions with staff and observations on the units showed that this is insufficient staffing for the EMI nursing unit and at times, especially when doctors rounds are taking place, insufficient to meet the needs of the residents on the general nursing unit. This unit would also need extra staff due to the palliative care beds and the high level of dependency of terminally ill residents. Relatives commented in discussion and surveys received about the staffing levels; “I think that there could be more staff on shifts as it seems very stretched at times and this would help with more quality time for residents”. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 21 Staffing needs reviewing in line with the dependency levels of residents on all the units throughout the home and a requirement has been made around this. The home provides a training programme, commencing with the induction course on commencement of employment and progressing through to National Vocational Qualification level or 3 in care. Nine members of care staff (12 ) have achieved this qualification and the home should encourage staff to undertake this in order to achieve the National Minimum Standards quota of 50 . Both qualified nurses and care staff are also able to participate in a range of training provided by BUPA, which is relevant to the care required by the residents. Other staff receive sufficient training relating to their roles in the home. Few of the registered nurses in daily charge of the mental health units are registered as mental health nurses. It is recognised that there is difficulty in recruiting mental health nurses to work in care homes and it is recommended that general nurses are encouraged to undertake dementia training recognised by the Nursing and Midwifery training, to enhance their skills and knowledge in this area, and to ensure that the care given to these residents is in line with current researched practice. The clinical manager of the mental health units is a registered mental health nurse and is available for guidance for the staff. Six personnel files were examined, these contained all documentation as required by regulation. One member of staff has commenced work under supervision whilst waiting for the Criminal Records Bureau check to be received, but a Protection of Vulnerable Adults check is in place. Oakhurst Grange DS0000024184.V359351.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): 31,32,33,35,36,37,38. People who use the service experience good quality outcomes in this area Management systems within the home safeguard the residents and ensure that the service provided meets their needs and expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is in the process of undergoing change of management. The registered manager will be moving to another BUPA care home and the new manager is currently working part time in the home prior to taking up the post full time, the home is being adequately managed during this transition time. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 23 Residents spoken with said that the home was good, that they see the manager and that any queries or concerns they have are dealt with. The company has an annual quality monitoring process in place. This includes sending out surveys to residents and their relatives to gauge the level of satisfaction with the service given. These are collated and used to inform the services offered by the home. It is recommended that other stakeholders including health and social care professionals are approached for their views on the home. A resident survey stated, “Oakhurst grange is open to feedback and act upon it”. Resident and relatives meetings are held and comments received at these are acted upon. The home also holds staff meetings, which are specific to the work the staff undertake in the home on a regular basis. Staff said that they can make their views known and they had some influence on the standard of services provided. The Annual Quality Assurance Assessment required by CSCI was received prior to the due date and accurately identified what was happening in the home and the plans for the coming year. Regulation 26 visits (monthly visits by the provider or a representative of the provider required by regulation) have been taking place and copies were seen in the home. At present these do not reflect the views of residents or staff spoken with and it is recommended that interviews with residents and staff are included in this record. This is required by regulation and is part of the CSCI guidelines. Some of the policies and procedures used in the home have not been amended since 2006 and are due to be reviewed. Whilst the home does not act as appointee for any residents, some money is kept for residents use in an interest bearing bank account. The records for this were seen and were in order. The business plan for the home was not seen on this occasion, but all relevant insurances were in place and the registration certificate reflected the current management of the home, the provider should notify the CSCI when the change of management takes place in order that the certificate can be amended. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 24 All members of staff receive formal supervision at intervals directed by the National Minimum Standards and have received the mandatory training in health and safety matters. The Annual Quality Assurance Assessment showed that all utilities and equipment have been serviced regularly. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 25 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 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 3 3 Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 26 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 OP27 Regulation Reg 18(1) Requirement Timescale for action 30/06/08 2 OP38 Reg 13(4) That staffing is reviewed to take into account the dependency and needs of the service users in the home. That the locks on doors to 30/06/08 service users accommodation are risk assessed and measures taken to ensure the safety of residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP38 Good Practice Recommendations That registered nurses working on the mental health unit receive suitable training relevant to the work that they undertake. That the manager liaises with health and safety executive regarding the monitoring of the temperatures of the cool touch radiators in the units. Oakhurst Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Grange DS0000024184.V359351.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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