Inspection on 13/04/07 for Oaklands

This inspection was carried out on 13th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Oaklands 03/01/06

Oaklands 26/07/05

Oaklands 08/12/04

Oaklands 01/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Oaklands Lower Common Road West Wellow Romsey Hampshire SO51 6BT Lead Inspector Tracey Horne Unannounced Inspection 13th April 2007 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 Oaklands DS0000011639.V331679.R03.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. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaklands Address Lower Common Road West Wellow Romsey Hampshire SO51 6BT 01794 322005 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) admin@oaklandscarehome.co.uk Delicourt Ltd Mr Robert Tyson Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (45), Old age, not falling within any other category (45) Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: This residential home is registered to provide personal care and accommodation to 45 residents who are over 65 years in age and are in the category of Old Age. They may also have dementia or mental health problems. The home is privately owned by Delicourt Limited. This organisation owns a number of residential and nursing homes in the county. Mr Robert Tyson is the registered manager. Accommodation is provided in a large house that has been extensively extended to provide thirty five single and five shared bedrooms located on the ground and first floors, thirty of which have en suite facilities. Two passenger lifts enable residents to access both floors. Communal space is provided in four lounges, a chapel/quiet room and a large dining room. The home has a large patio area and garden to the rear of the property with car parking space at the front and is situated in a quiet residential road in a rural area between Romsey and Salisbury. The home is close to local shops, amenities and public transport. The Mr Tyson confirmed the fees for the home range from £327.00 to £440.00 per week. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards (NMS) and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 13th April 2007 between 09.30 and 15.30, during which the inspector (Mrs Tracey Horne) had the opportunity to look around the home, view records and procedures and talk to Mr Tyson and the deputy manager. Observations were made regarding the interaction between residents and staff. The people living in the home prefer to be referred to as residents, therefore the rest of this report will reflect this. The inspector received a pre inspection questionnaire (PIQ) from Mr Tyson prior to this visit, which provided further evidence of how the service is meeting the Key National Minimum Standards. The Commission for Social Care Inspection (CSCI) sent feedback forms to the home prior to this site visit, six residents forms were completed and returned, nine members of staff and seven relatives returned their comment card to the CSCI prior to this site visit. The inspector contacted one care manager to obtain their views of the home. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. What the service does well: Residents stated they liked living at the home and it has a relaxed atmosphere. The home is good at assessing if it can meet the needs of residents before they come to the home and one relative stated in their survey to the CSCI that their relative was able to live in one of the respite flats which worked very well for a few years, by the time her relative needed more care they were already familiar with their surroundings within the home which helped a great deal.’ Residents stated that the activities provided by the home meet their needs, one resident commented that the home has a ‘Good social front.’ Residents, relatives and staff stated they were aware of how to complain, and were confident Mr Tyson would act appropriately to deal with any issues raised. Staff stated that they were supported and encouraged to obtain qualifications. The majority of staff have been recruited from overseas and the home are supporting them by arranging additional training in English. 77 of staff have achieved a National Vocational Qualification (NVQ) level 2 or above. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 6 One resident stated they feel safe and comfortable at the home and their opinions are sought. Residents feel they have a good rapport with Mr Tyson and he runs the home in their best interests. What has improved since the last inspection? 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. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 7 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 Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 8 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have the information needed to choose the home that will meet their needs and have their needs assessed and a contract that clearly states the service they will receive. EVIDENCE: Feedback from residents and relatives stated that they had received information from the home, which enabled them to decide that they wanted to visit the home to view the facilities and environment. The inspector looked at the three most recent pre admission assessment records. Mr Tyson had visited the prospective resident to complete the home’s pre admission assessment before a place was offered at the home and said this usually occurs in the residents home or whilst they are in hospital and may coinsides with a care manager assessment. This was to ensure the home could meet their individual needs before the placement being offered. The resident’s family were involved and provided further information. Mr Tyson said Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 9 prospective residents and their families/ representatives are welcome to look around the home to see if the home would meet the individual’s needs. The pre admission assessments included a moving and handling assessment, medical history, allergies, history and risk of falls, equipment needed, personal care needs, personal preferences, medication and any anxieties etc. Once Mr Tyson is satisfied that the home can meet their needs, the home send a letter offering the prospective resident a place. The letter confirms which bedroom the resident will have. The resident’s contract states the fees that the home will charge them and all contracts seen had been signed by the resident or their representative in most cases. Mr Tyson said home provides single accommodation, for one person to receive respite care for a short period of time before they return to their home, or they are admitted into a permanent room if the resident wants to and is assessed as needing residential care. One relative stated in their survey to the CSCI that their relative was receiving respite care at the home which worked very well for a few years, by the time their relative needed more care they were already familiar with their surroundings. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive health and personal cares based on their individual needs and are treated with dignity and respect whilst their privacy is maintained. EVIDENCE: The inspector looked at four residents’ care plans. The plans contained the information gathered during the pre admission assessment but were vague in some places, for example one residents foot care plan was blank but records showed that the resident had seen the chiropodist recently. Another plan stated in the skin care section that the resident is prone to dry skin, there was no information of how this is to be treated, despite daily notes stating cream has been applied. Daily records were brief and did not include information such as: what the resident had done during the day or how they were feeling/interaction etc, records stated ‘good appetite’ and ‘all care given’. One record stated a resident was ‘very agitated this morning and verbal’. There was a risk assessment for mental health but it did not include information to show how behaviours may be triggered, or guidelines for staff to follow to safeguard themselves and others, it stated to monitor medication and Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 11 check daily report, which did not have enough information to monitor trends of behaviours. Mr Tyson acknowledged that records and care plans need to be more detailed but as staff and residents stated that the care and support given is as they wish, and staff stated that they have the information needed to provide the care and support to individual residents, this was not made a requirement on this occasion. Staff stated they review the care plans with the resident on a monthly basis, or as needs change. Records seen confirmed this. Residents stated in their feedback to the CSCI that the care given was exactly as they wished it to be. All care plans have been signed and dated by the resident or their representative and by staff. Mr Tyson confirmed that advice would be sought from the appropriate person, mainly by the resident’s general practitioner (GP) if staff have any concerns regarding residents health care needs. Records showed residents had accessed a diabetes nurse, community psychiatrist and chiropodist. The PIQ stated residents could also access the district nurse, Pharmacy, occupational and physiotherapists, dietician, speech therapist, dentist, audiologist, optician, incontinence adviser and memory nurse. One care manager stated in their survey to the CSCI that: ‘the home are very good at providing care for people with Dementia, and are good at contacting others for help and advice if needed (ie the GP’s to obtain psychiatric input.)’ Mr Tyson confirmed that at the time of the inspection one resident self administered their medication risk assessments were in place for this activity and included sharps needle stick injury risk. Mr Tyson said the medication ordered is checks as it is received into the home and he carried out regular audits (the last one was completed 2nd April 2007) and a pharmacist inspection was carried out six months ago. The home uses the ‘Medicine Administration Record Sheets (MARS) system for recording the administration of medication. Each resident’s record also has a recent photograph. Medication that is in need of disposal is returned to the local pharmacy and a record is kept by the home that is signed on receipt by the pharmacist. Staff confirmed that two staff administer medication (one being a senior carer) and they receive training in the safe handling and administration of medicines, Mr Tyson confirmed the local college and pharmacist ‘Lloyds’ supplies training. The inspector observed the staff interacting with the residents and found them attentive, caring, respectful and they have a good understanding of each individual’s needs. Throughout the visit, staff were seen to knock on doors and wait before entering rooms and they spoke to residents in their preferred manner, as stated in their care plans, and were friendly but respectful. Staff said they are aware of the importance of dignity and respect, one staff stated, ‘I treat people as I wish to be treated’. Staff induction records showed that privacy and dignity and the provision of personal care are covered during the induction process, and the response from Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 12 residents indicated that the carers treat them with dignity and respect and that they are trustworthy. Records showed signed statements from staff to uphold individuals confidentiality, to respect choices and individuality, privacy and dignity One carer sated in their survey to the CSCI that: ‘The whole holistic approach to care in this home is encouraged by the management and carried out by the carers, kitchen & domestic staff with pride.’ Two residents stated that: ’care staff are always respectful of us’ and ‘Staff are always polite to clients & have a caring approach.’ Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise control over their lives, participate in social activities, receive visits from friends and relatives as they wish and enjoy a choice of meals served in a relaxed atmosphere. EVIDENCE: Residents felt they are able to exercise choice by participating in social activities if they wish, one resident stated that ‘the home have a good social front.’ Resident’s preferences are identified during the assessment process, and this information is included in the individual’s care plan, therefore staff are aware of what residents like doing, but records do not always reflect this. Mr Tyson said that one senior carer has additional responsibilities as the home’s activities coordinator to arrange various activities, during the inspection residents were chatting with staff (there was a carer in each of the communal areas with residents) and in the afternoon the majority of residents attended a disco in the dining room. Residents could be heard singing along to the music playing. The pre inspection questionnaire states the following facilities/activities are available to residents inside the home/premises: Computer, theatre shows, bingo, pet therapy, story telling, music movement, Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 14 reminiscent, choir, music show, library, disco, art and craft, instrumental, garden party, therapy, BBQ, summer fetes, slide shows and quizzes. The following is accessed in the wider community: ‘happy go lucky’ club, blind club, age concern companies, church services and dinner club. All residents stated the activities matched their needs, and that staff respected their wishes to spend time on their own if they wanted to. Mr Tyson said that the home provide care for people from ethnic minority group and cater well for their cultural needs by ensuring their dietary needs are catered for. The home has an open visiting policy, this was evidenced by records of visitors to the home and confirmed by residents and relatives who stated they visit the home at different times of the day on a regular basis and are always welcomed. The home employs one head cook and one assistant. The head cook said everything he cooks and prepares is fresh, nothing is pre cooked. On the day of the inspection refreshments were offered throughout the day for residents, the lunch consisted of two choices for each starter, main course dessert, followed by tea or coffee. Homemade cakes and tea were available mid afternoon. Supper consisted of another hot meal if residents wanted it, one resident said ‘I usually ask for soup and sandwiches’ another resident said All residents stated in their CSCI surveys that the meals were always very good. Mr Tyson said that the majority of residents prefer to eat in the dining room to socialise with one another. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a good understanding of Adult Protection issues but certain procedures need to be improved to fully protect residents from potential abuse. EVIDENCE: Residents spoken with said that they were very aware of the complaints procedure, even though they have not had to use it. They said they would go straight to Mr Tyson if they had a concern or complaint and were confident that Mr Tyson would take their concerns seriously. Residents confirmed that the staff are very good and listen to them, no one has felt the need to complain, only compliment. Staff stated in their CSCI surveys that they were aware of the home’s complaint procedure which includes the address for the Commission and that all complaints will be dealt within 28 days. The complaints procedure included the name of a CSCI inspector, after discussion with Mr Tyson he agreed the name would be removed so the appropriate person from CSCI can deal with any complaints. The complaint log was available which included sufficient detail to monitor complaints successfully, Mr Tyson confirmed one complaints had been received since the date of the last inspection and records showed this was responded to and dealt with appropriately. Records showed Mr Tyson completes monthly Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 16 audits of complaints and adult protection issued to monitor trends and progress. All staff who responded to the CSCI survey stated that they were aware of the correct procedures to follow if a disclosure of abuse was reported to them, and they had received formal training in abuse awareness, certificates confirmed this. The home has procedures for staff to follow should abuse be suspected, including Hampshire County Council’s Protection of Vulnerable Adults and Whistle Blowing. All of the staff records seen did not show that the appropriate level of CRB had been completed prior to the carer commencing their role. This issue is raised later in this report as a requirement. Mr Tyson said that he had referred an adult protection issue to Romsey social services regarding incidents that had occurred involving two residents. The home acted on the advise given by social services and a care manager made weekly visits to the home this has resulted in no further incidents. Records were available to show the process Mr Tyson had followed and of the outcomes of meetings. Mr Tyson confirmed that policies and procedures are reviewed and available for staff to access regarding complaints and protection, staff confirmed this. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment continues to be improved to provide residents with a warm and comfortable home. There are good infection control procedures at the home to safeguard the welfare of residents EVIDENCE: The home was warm and very welcoming, at the time of the visit the home looked extremely clean. The home has a maintenance programme to refurbish the remaining rooms to provide en suite accommodation; a porch will be added to the front door, air conditioning will be added to the conservatory and the residents will be involved in the construction of a ‘sensory garden. One resident said the home is always clean, Mr Tyson explained the home employ domestic staff who take great pride in their work to ensure the home is always clean and that staff ensure that Oaklands has a ‘homely’ feel by Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 18 ensuring the communal areas look inviting, for example the dining room tables were laid very nicely for lunch, and the library area had comfortable chairs with ample lighting to enable people to read if they wish. Accommodation is provided over two floors. Access to the first floor is by two passenger lifts, and four flights of stairs. There was ample communal space for residents and their visitors to use, the majority of which overlooks the well maintained gardens and a small patio courtyard garden (the home have plans to include a moving sensory garden). Resident’s bedrooms looked very comfortable and contained many personal items such as pictures, furniture and ornaments. Two residents stated in their replies to the CSCI survey ‘it’s very comfortable, the staff ensure it is cleaned every day, my bedding and towels are changed once a week’ and ‘What more could I ask for, I have everything I need’. ‘My room is decorated to my taste, and I have a fabulous view of the garden.’ Keys are provided for residents who wish to lock their doors, residents stated they feel safe and secure in the home and the grounds. The communal areas in the home let in plenty of natural light which residents stated makes them feel as if they are outdoors. Residents were observed to walk freely around the home independently or with the assistance of staff or various walking aids. The home has an internal laundry that is well equipped. Infection control procedures were in place. Staff were observed to follow these guidance, equipment such as gloves and aprons were available, so too was antibacterial hand gel for staff and visitors to use. Staff stated in their CSCI surveys that they had received infection control training. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff receive mandatory and specialist training and are supported to obtain NVQ level 2 or above. Staff are skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. Recruitment practices need improving to ensure resident’s safety. EVIDENCE: Residents stated there are always enough staff on duty who know how they like to be cared for, staff stated in their CSCI surveys that they felt there are enough staff on duty on each shift. Mr Tyson confirmed their is always at least one senior carer, (this does not include Mr Tyson or deputy manager) on shift. One member of staff wrote in the survey she returned to the CSCI, ‘we get the time to be able to ensure high standards are maintained, and more importantly have the time to spend with residents, I have worked in many homes, this is definitely much better, the owner is of the opinion that more staff are better, it works for me, I do not have to rush about, it’s a lovely relaxed home to work in.’ It was evident from practices and interactions observed that staff had developed a good relationship between themselves and residents. Comment from residents included that staff were very kind and always helpful and that they were a “good team”. One resident praised the domestic staff for their hard work in keeping their bedrooms clean and tidy. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 20 Staff said they receive regular formal supervision by their line manager, this gives them the opportunity to discuss any training needs they may have. Staff wrote in their surveys to the CSCI that they receive very comprehensive handovers of information at the beginning of each shift. Mr Tyson confirmed in the pre inspection questionnaire that 77 of the twenty three care staff employed at the home have received an NVQ 2 and above. The staff confirmed in their surveys to the CSCI that they undertake training regularly in the necessary health and safety subjects such as fire safety, first aid, moving and handling, health and safety, infection control and food hygiene. Other training courses attended by staff include abuse training, social care, induction, maintaining safety at work, understanding the organisation & my role as a worker, understanding principles of care, effective communication and English. The staff stated in their CSCI surveys that the recruitment process within the home is thorough. The inspector was able to see four different staff records and found that they were detailed with the necessary checks taken to ensure staff are fit to work at the home. Other records seen on file include signed contract of employments, job descriptions and criminal record bureau and protection of vulnerable adults register. The staff wrote in their CSCI surveys that they feel the induction programme run by the home was useful and detailed. The files seen held records of the individual staff induction training covering the key areas with the signatures of the staff member and trainer. Mr Tyson confirmed that the home’s induction programme meets the recently amended Skill For Care standards for induction. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Mr Tyson is experienced and competent to run the home. Management and administration of the home is based on openness and respect. An effective quality assurance system is in place. The home is not involved in monitoring or handling residents’ money. Residents’ health, safety and welfare are well promoted by the home with systems that ensure everyone is protected within the home. EVIDENCE: Mr Tyson was registered with the CSCI in 1993 and has been registered manager of the home ever since. Both Mr Tyson and the deputy manager have the Registered Managers Award (RMA) and NVQ level 4 qualifications. Mr Tyson says she is committed to quality assurance and continuing development of the service. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 22 There is a strong ethos of being open and transparent in all areas of running of the home, residents felt they were involved in the development of the home, and were confident in Mr Tyson’s ability. Staff stated in their surveys, and observations showed there are clear lines of accountability within the home. Also the management approach of the home creates an open, positive and inclusive atmosphere. The staff felt they were included in the day-to-day decision making within the home, stating that changes and or issues are discussed and actions agreed at regular staff meetings that are minuted. Residents stated that they felt able to give their views, which they feel are valued, on the quality of care provided at the home to Mr Tyson and feel involved in issues affecting the home. Residents stated that all staff are very approachable, always make themselves available and readily help with any problems. They also had nothing but positive comments to say about staff which included – “They really care”, “They don’t rush you” and “Staff like a laugh”. A robust quality assurance and monitoring system based on seeking the views of residents, relatives and professional is in place. The inspector read the findings taken from the most recent survey about the food the home provides, residents commented on their satisfaction with food, and Mr Tyson said any suggestions were listened to, the current menu reflects this. Resident said if they are not happy with something, all they need to do is tell someone, and it will be seen to. Mr Tyson said that unannounced visit by the service manager [Regulation 26 visits] occur on a regular basis, records of these visits were available. Mr Tyson said resident’s family or financial appointees safeguard residents money, rather than the home, two residents confirmed this. No unsafe practices were observed during the inspection. Certificates were available for required checks of systems and equipment. Risk assessments where necessary have been completed. Staff have received training in health and safety, first aid, fire safety, care of substances hazardous to health and moving and handling. The fire drill records showed that all staff had attended two fire drills in the last year as well as fire training every six months. Mr Tyson explained the recording system for fires safety maintenance, training, evacuation and visual checks. The visual checks of all fire safety equipment has been recorded and undertaken at appropriate intervals and weekly fire alarm tests are carried out to ensure the safety of the residents. Regular risk assessments are undertaken and recorded to ensure that the safety within the home room by room. These were sampled and found to be satisfactory. The home has a satisfactory reference file for the Control of Substances Hazardous to Health (COSHH) information leaflets for each chemical being used in the home. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 23 The home has a policy, procedures and information on health and safety. A sample of policies and procedures were seen that are reviewed regularly. There is an ongoing system in place that ensures that all appliances are serviced, records and certificates seen indicated that the systems such as the electrics and specialist equipment including bath aides received regular servicing and maintenance. The employer’s insurance liability certificate was displayed and current. Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 x x 3 Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oaklands DS0000011639.V331679.R03.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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