Inspection on 10/05/07 for Oakhurst Nursing Home

This inspection was carried out on 10th May 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 Oakhurst Nursing Home 2 Oak Mount Manningham Bradford West Yorkshire BD8 7BE Lead Inspector Pamela Cunningham Key Unannounced Inspection 10th May 2007 11:30 Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 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 Nursing Home DS0000068151.V330097.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 Adults 18-65. 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 Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakhurst Nursing Home Address 2 Oak Mount Manningham Bradford West Yorkshire BD8 7BE 01274 544279 01274 495999 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) European Care Lifestyles (B) Ltd Mr Cecil Ronald Jackson Care Home 30 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (30), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Oakhurst Care Home is registered to provide nursing care and support for up to 30 residents who suffer from enduring mental health problems. Qualified psychiatric nurses, and trained care staff provide twenty-four hour care. Oakhurst is situated in the Manningham area of Bradford, close to Lister Park. It is owned and managed by European Care Lifestyles (B) Limited and bus connections lead to Bradford, Bingley, Keighley, and Skipton. Oakhurst Care Home provides a community setting. The property is a mid to late 19th century residence, previously a convent, and is located on a quiet road. The home has a passenger lift that extends from the basement to the top floor. The bedroom accommodation is on four levels in the home. This consists of twenty single rooms, thirteen of which have ensuite facilites, and five double rooms. There are also five bathrooms one shower room and one visitors room. Communal space includes a large dining room, and two large lounges. A residents kitchen is also provided. Service users and staff prefer the term residents, therefore this term has been used throughout the report. On the day of the visit fees charged for care provided were £632:62 pence per week. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One visit was made to the home on 10th May 2007. This was the first inspection since the present owners acquired it. The home did not know that this was going to happen. Feedback was given to the manager. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents. Before visiting the home the inspector asked for information from the manager (the pre inspection questionnaire – PIQ) which asks about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by whom, menus used, staff details and training provided. Prior to the inspection twenty service user and 20 relative/visitors comment cards were sent to the home to be given to residents, their relatives and other visitors to find out what their views of the home were. At the time of writing this report nine resident responses had been returned. However as these had been completed by the staff, with residents’ instructions, and responses were in the form of ticked boxes, it was difficult to gain a real picture of how the residents’ life in the home was. However, comments were mainly positive. Three of the residents said they were not asked if they wanted to move into the home, Many of the respondents said they thought the home was always clean and fresh, that they were given enough information about the home before they decided to move in, and that they could do what they wanted to do. They said the staff treated them well, and that they knew who to speak to if they were not happy. In order to find out how well staff knew residents, care plans were looked at during the visit and residents and staff were spoken to. Other records in the home were looked at such as staff files, training records and accident records. The nurse in charge from 2pm onwards could not locate the complaint record book and therefore this could not be looked at to establish how complaints were handled, and how effective the system was. However, during feedback, the manager said a record was kept of any complaints in the form of a hard back book. A sample of the homes polices and procedures were also looked at. What the service does well: Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 6 The home has a very stable staff team, run by an experienced manager who has an in depth knowledge of all the residents needs having cared for them for many years, and to some people who have very complex needs. The service has a very homely feel to it and individuals are supported to make decisions and choices. The home receives excellent support from the local healthcare team and outreach services and there is no problem with asking them to visit the home. Not all the residents attend some type of day care, and these who do not are encouraged to take an active part in the community within a risk management framework. Adequate nutritious meals are provided, and residents said they enjoyed the food. The home has a residents committee, and any suggestions made at the monthly meetings are taken on board, if it is reasonable, and safe. The environment is constantly improving, with four new single rooms almost ready for moving in to, and planning permission having been granted to convert all the first floor rooms to single ensuite rooms. The care staff are encouraged to read the care plan documentation, and this is good practice. What has improved since the last inspection? What they could do better: It would be good practice residents care needs were re assessed at times and care plans rewritten to make sure any new identified health care needs are incorporated into the planned care. Base line risk assessments such as nutritional risk assessments, moving and handling assessments and tissue viability risk assessment could be done on admission so that there is base line to work from in case of any deterioration in the residents’ general health. Risk assessments could also be reviewed on a regular basis, as some were four and five years old. Religious preferences should be identified in the care documentation, so that during end of life situations the resident can be treated, as he would wish and by the church of his faith, Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 7 The nurse call system is still not fully operational, and regular fire drills need to take place. This needs to be addressed as soon as possible as the lack of an adequate emergency call system in the home could compromise the health, safety and well being of the residents. 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 Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, and 5 People who use the services experience good outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. The people who use the services and their relatives have enough information about the home to decide if it will meet their needs. EVIDENCE: The Statement of Purpose and function is completed. The manager said it was ready to be passed to head office for approval, and once approved a copy of this and the service user guide will be forwarded to the CSCI. Certain residents spoken to during the inspection said they were given enough information about the home before moving in, others were not. However, many of these residents were admitted to the home between 1991 and 2001, before the transition to the National Care Standards commission, and therefore the home at that time were only required to produce a brochure or leaflet. Trial visits are encouraged, and all residents have contracts of residency. Needs assessments were seen in the care documentation chosen for review and case tracking. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience adequate outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. Although the people who use the services individual health and personal care needs are met, this is not always documented in the care plans. EVIDENCE: I looked at four sets of care plan documentation. All residents were identified by photograph. Pre admission assessments of needs had been carried out prior to the resident moving into the home, however, one of these was barely legible. In three sets there was no religious preference documented. If possible this needs to be identified so that the residents religious wishes can be guaranteed at end of life situations. Risk assessments were present where a risk to the resident had been identified; however, base line risk assessments such as Waterlow (tissue viability) and nutritional risk assessments had not been done. The risk assessment for smoking seen in one set of documentation written on 04/04 Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 11 had not been reviewed, and the smoking risk assessment for another resident written on 2/05 was reviewed next on 07/05, but not since then. Risk assessments are not a once and for all exercise, and should be regularly reviewed to identify any less or further risk to the resident. Information in all four sets of care plan documentation identified special needs and were well written, however one set of documentation identified the care plans had not been reviewed since 27/7/05. The other three sets of documentation were reviewed last on 27/06/06 and were therefore late for review. Some of the handwriting in certain care plans were signed by the resident showing resident involvement in the planning of care. One set of care documentation also contained an activity record. Daily records of care given (daily progress sheet) were documented, but again in some instances the writing was not very clear, and was difficult to read. Residents I spoke to said they were involved in decision-making, and said that most of the time their ideas were taken on board by the manager. They said they attend residents meetings, and can “bring up anything they want to discuss at the time.” One resident who has lived at the home for 14yrs said he enjoyed being given the opportunity to live his life as independently as he wanted, but at the same time he realised they have to have systems in place to ensure they are safe. He said “the manager is very good, and treats me as a person with a mental illness, and not the other way round.” Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16 and 17. People who use the service experience good outcomes in this area This judgement has been made using a range of available evidence including a visit to this service. Residents are encouraged to be part of the decision making process and make choices about their lifestyle. Their social needs are met. EVIDENCE: Although the residents’ are encouraged to develop independent living skills many of them are reluctant to do so, and care plans reviewed did not identify residents’ abilities and responsibilities. These should be agreed by the residents and co-worker and would result in staff providing a more consistent team approach. The residents would also have a clearer understanding of their responsibilities and staff responsibilities. Many of the residents attend day care centres including Cellar Project, Walker House. MIND. Springfield Day Centre, Heaton House and Shipley College. This was confirmed by speaking to the residents, and in particular one who attended a day centre during the inspection. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 13 Meals and mealtimes were discussed with the nurse in charge in the afternoon, and with some of the residents. The nurse who said she normally works night duty said there was no food available after suppertime, and that the only food available were crisps and cups of tea. She also said that the residents could get a takeaway meal if they wanted to. However, two other members of the care staff said residents could have tea and toast if they were hungry at night, and that the kitchen was always available. There is also a residents’ kitchen that the residents are encouraged to use and keep clean, however this was locked at the time of the inspection. The residents are also going to be encouraged to make light meals and snacks for themselves. Food that was available for supper was quite substantial. Food from the previous meal was plated up and covered, along with freshly baked sausage rolls and bread and butter. Special diets are provided where necessary. I spoke to a number of the residents as I walked around the home. On the whole they are pleased with the food provided, and said they could have a choice of what was on offer for the main meal of the day, as long as they told the cook before 12:30, which is a reasonable request. Residents I spoke to said they are encouraged to be part of the local community and are supported to maintain family links. Some of the residents also go out to the local shops and pubs as long as they tell the staff where they are going, and when they will return. One resident I spoke to said he goes home to his parents every weekend and really enjoys it as he “gets spoilt.” He also said he was going away on holiday for a week with his parents this summer. Daily routines certainly promote independence, and this was evidenced by one of the residents having stayed in bed until lunchtime, and others having got up at times to please them. The home addresses cultural diversity as some of the staff are employed from other cultures whose first language is not English which is helpful when situations arise between residents whose cultures differ, as was experienced during the inspection. All the residents have a key to their personal space. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 People who use the service experience adequate outcomes in this area This judgement has been made using a range of available evidence including a visit to this service. Staff and management work closely with health care professionals to make sure residents’ health needs are met, however, medication recording systems have weaknesses and compromise health. EVIDENCE: Residents’ healthcare needs are met. Certain residents have specific problems and these are dealt with by visits to hospital to see appropriate consultants. Evidence was seen in the care documentation of consultants’ reviews. Records of other professional visits are also documented. Systems are in place to monitor health care needs. The home works closely with consultant psychiatrists and out reach services to make sure residents’ mental health needs are met. Residents are registered with a dentist either of their own choice or an NHS dentist. An optician and chiropodist regularly visit the home. This was clearly evidenced in the care documentation. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 15 Flu vaccinations are also offered, and certain residents have these. Where residents have declined the vaccine this is documented in the care documentation. Residents are weighed monthly, however it is documented that one resident’s weight is over the maximum, which the stand on scales is set at. It is therefore recommended this be reported to his GP and other ways sought to monitor his weight. The same resident also has a problem with excessive food intake, but professional help has been sought regarding this. Privacy and dignity is addressed, and this was confirmed by comments received from the residents spoken to during the visit. Those care staff who either have or are completing NVQ training have had some instruction on how to handle end of life situations, and this was confirmed by one of them during the visit. Others however who are not undertaking, or who have not achieved NVQ 2 have not had instruction. The medication system was checked. The home uses a monitored dose system of medication control. Each resident receives their medication from heat sealed blister packs directly from the pharmacy the home uses. All residents are identified by photograph. On checking the system it was noted that when medicines are received into the home they are not counted in and the amount entered onto the pre printed MAR (medication administration record sheet.) Neither are medications that arrive in the home out of the normal monthly cycle, such as when residents have been to hospital for medication reviews. This was discussed with the manager who assured me all medications were counted and the amounts received entered onto an electronic database in the homes computer. Homely remedies were discussed as the home has a stock bottle of Paracetamol. The manager said the home does not have a homely remedies policy, but he would write one. He was also advised to discuss the homely remedies with the GP’s. A selection of the homes policies were checked, amongst them the companies medication policy. This was adequate, however it needs to confirm that all FP10 prescriptions are signed by the home prior to being forwarded to the pharmacy. The manager did however say this was happening. He also needs to make sure the medication procedure describes the system in use in the home, as at present it doesn’t. During the course of the visit I observed a medication round during which I had concerns about the practices, and fitness of the nurse in charge of the afternoon shift, which could place the residents at risk. She did not follow good practice or safe practice guidelines. Medications were not signed for as she gave them; she was advised this was bad practice, which she agreed with. This, and other concerns were discussed with the manager during feedback. A letter confirming our discussion, with action needed to address the concerns Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 16 was sent to the manager following the inspection. The concerns were also discussed with the Director of Mental Health Services for the group. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Both standards were assessed. People who use the service experience good outcomes in this area This judgement has been made using a range of available evidence including a visit to this service. Residents are comfortable in approaching staff and the management team to discuss concerns and complaints and these are investigated properly. EVIDENCE: There have been no complaints made directly to the Commission. The home has a complaint procedure that is displayed in the entrance hall, however it needs to contain the correct address of the Commission local office in Rodley. The information in the PIQ (pre inspection questionnaire) said the home has had 4 complaints, however these were before the new owners took over responsibility of the home, and have since been dealt with appropriately. Residents spoken to say they don’t usually complain, but when they do they receive mixed responses from the staff. That some of the staff listen to what they say and others don’t. But on the whole they said they felt well treated by the staff, and it was evident throughout the day that residents’ were comfortable talking to staff. Although the complaint log could not be located during the inspection, the manager told me during feedback that a log is kept of all complaints in the form of a hard back book. The Adult Protection policy was looked at and is appropriate. Staff spoken to during the inspection said they had received training on abuse, were aware of Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 18 the different types of abuse and said they would report any suspected abuse to the senior member of staff on duty at the time. They were also ware of POVA. (Protection of Vulnerable Adults) Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30. People who use the service experience good outcomes in this area This judgement has been made using a range of available evidence including a visit to this service There is evidence that the environment has improved. Some areas of the home are very nicely decorated and have good quality furniture and fittings. Other areas are in a poorer condition, but building and decoration work is on going. EVIDENCE: During the tour of the premises I could only look in the rooms on the ground and first floor, as the nurse in charge told me she was unable to use the stairs to access the rest of the home, and the passenger lift was out of order. I spoke to the manager about the lift that said it had been damaged by a resident, and that arrangements have been made to have it repaired the week of the 14th May. He also said that planning permission had been granted to convert all the first floor rooms to single ensuite rooms. Apart from the stairs leading down to the main kitchen that had a dirty banister and stairs, the home was seen to be clean and with no noticeable Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 20 odours. The main kitchen was clean and tidy with food seen prepared for the residents supper. There is also a resident’s kitchen on this level, however as this was locked, residents were unable to use it to make themselves drinks as they wanted. The dining room has an institutionalised look, and does not look very inviting. One of the dining chairs padded sets was also broken and needs repairing, and the dining tables were showing signs of cigarette burns. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. People who use the service experience good quality outcomes in this area This judgement has been made using a range of available evidence including a visit to this service. The team work well together and staff feel supported. Communication is good. The recruitment process is satisfactory. EVIDENCE: The home benefits from a well-established staff and management team, some of them having worked at the home since 1994. Staff spoken to during the inspection said they were having formal supervision, and described the training they had received. Training files were also looked at which gave information about the training staff have received. The home has a training schedule, and the manager said he would forward an up to date copy to the CSCI. Staff also said they had a proper induction. They were aware of POVA, and said they would report suspected abuse to the senior staff. Communication in the home is good and staff said they learned about the residents’ immediate needs at handover times. One member of the care staff team said she was encouraged to read the care documentation by the manager. This is good practice. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 22 Rotas were checked and up to date copies obtained. The manager said agency staff are never used and that his own team of staff fill in any shifts that are necessary if anyone goes off sick. However due to the lift being out of order at the time of the visit, the current level of staffing on night duty could severely restrict the ability of the service to delver person centred support, and the manager should take adequate steps to address this. The manager also said one of the senior nurse on day duty had attended a one-day workshop provided by Age Concern on supervision and coaching. Training in supervision and coaching is also to be extended to other qualified staff so that he could be assured formal supervision for all the carers, including those on night duty. Training in equality and diversity has also been provided, and five staff attended in January 07. Recruitment records were looked at for two people. Information, which is required to be held in the home, was available. Application forms and references were satisfactory. Notes of interviews were also present. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area This judgement has been made using a range of available evidence including a visit to this service. The home is well managed and the service benefits from having a knowledgeable and competent manager, however care planning and risk assessment could be improved. EVIDENCE: The Registered Manager has worked at the home in a managerial position since 1999. He has a nursing qualification (RMN) and holds a management qualification. A deputy manager who has also worked at the home many years supports him in this role. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 24 On speaking to the residents and staff it is quite evident the manager is very popular with them, and has in-depth knowledge of individual residents. Staff spoken to also said he was very approachable. Information in the PIQ (pre inspection questionnaire) said Policies and procedures have all been updated as recently as 02/07. However there are three policies the home does not appear to have developed. These are continence promotion, racial harassment and pressure relief. These were discussed with the manager during feedback. Information in the PIQ also said all health and safety checks had been done, however the home is not carrying out regular fire drills. Information in the PIQ said, “As Oakhurst is compartmentalised, the Fire Safety Officer does not recommend fire drills.” Under the National Minimum Standards Care Homes Regulations however, Regulation 23(4)(e) it is required that regular fire drills take place so that all staff and residents are aware of the procedure to be followed in the case of fire. On the day of the visit the passenger lift was out of order. Combined with the fact the home does not have an effective emergency call system in place concerns were raised regarding the safety of the residents, however the manager informed me the left had been repaired, and had been operational since 14/05/07. Oakhurst Nursing Home DS0000068151.V330097.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 Adults 18-65 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 X 3 X X 2 X Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? New service 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 YA6 Regulation 15 Requirement The registered provider must a. Ensure risk assessments are reviewed more regularly and b. Ensure documentation in both the care plans and daily records of care are clearly legible. The registered manager must ensure safe working practices are carried out at all times regarding the dispensing of medication, and the signing of MAR charts at the time medication is given. To ensure the residents are not placed at risk. The registered provider must ensure if at all possible, the religious needs of the service users are identified and documented in the care plan documentation, so that at the end of their lives they can be cared for as they would wish and by a church of their own faith. The registered provider must ensure there is an effective emergency call system in all areas of the home. DS0000068151.V330097.R01.S.doc Timescale for action 10/07/07 2. YA20 18 10/07/07 3. YA21 18 10/07/07 4. YA42 12 01/09/07 Oakhurst Nursing Home Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA6 YA17 YA19 YA20 Good Practice Recommendations Re assess residents’ needs and re write care plans at intervals to make sure health care needs are identified. Ensure the residents kitchen is readily available for their use at all times. Ensure all residents are able to be weighed monthly either in the home, or make other arrangements to make sure their weight is monitored. Ensure the medication procedure in the home describes the system in use, and that a homely remedies policy is developed. Oakhurst Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Nursing Home DS0000068151.V330097.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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