Inspection on 19/04/06 for Oaklands

This inspection was carried out on 19th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Oaklands 08/08/07

Oaklands 29/08/06

Oaklands 21/12/05

Oaklands 04/08/05

Oaklands 14/09/04

Oaklands 15/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Oaklands Shaw Road Royton Oldham OL2 6DA Lead Inspector Michelle Haller Unannounced Inspection 19th April 2006 10:00 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 DS0000005513.V289799.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oaklands Address Shaw Road Royton Oldham OL2 6DA 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) 0161 627 1142 0161 627 1142 Oaklands Rest Home Limited Amanda Dack Care Home 18 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (10), Sensory Impairment over 65 years of age (2) Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 18 service users to include: *up to 10 service users in the category OP (Old age not falling within any other category). *up to 8 service users in the category DE(E) (Dementia over 65 years of age). *up to 2 service users in the category SI(E) (Sensory impairment over 65 years of age). *up to 1 service user in the category MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 21st December 2005 2. Date of last inspection Brief Description of the Service: Oaklands Rest Home is a privately owned care home with 18 registered places for people over 65 years of age and whose needs fall within the following categories: dementia; physical disability; mental disorder and old age. The building, which is a detached property, is situated on the main Shaw Road in the Royton area of Oldham. It is approximately two miles from the town centre and is in easy reach of public transport and community facilities. Accommodation comprises of three single en-suite bedrooms, three single and six double bedrooms with shared en-suite toilet facilities. Lounge/dining facilities are provided in three adjoining areas, which comprise two lounge areas and a dining area, the latter being situated to the rear of the building and next to the kitchen. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of five hours. The home was not aware that an inspection was to take place. This was a key inspection, which means that all the key care standards as identified by the CSCI were inspected. The inspection process included the examination of five service-user assessments and care plans, examination of other documents concerned with the care of service users and the running of the home, including the staff roster, staff files, the homes policy’s and procedures, medication records, the accident book and other records and reports. An observation of the interactions between staff and service users was also undertaken. Over the course of the inspection a four service users, one relative, two members of staff and a District Nurse were interviewed. A tour of the communal, public and private areas of the building was also undertaken. What the service does well: What has improved since the last inspection? The detail of assessments and the instructions written in care plans continues to improve. An activities programme has been developed. The manager has continued with a system supervision and appraisal for staff concerning the work they do. Training opportunities for staff has increased. A quality assurance system is being developed for the home. The safety checks carried out in the home have increased and the recording of problems improved. The records kept in respect of service users personal finances have improved. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 6 It must be noted that these improvements were due to the professional input of the registered manager, however she has recently resigned from her position in the home. 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. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 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 DS0000005513.V289799.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a site visit to the home. Oaklands provides adequate information to enable potential service to make an informed choice about moving into the home. The home ensures that service users have their health needs realised through completion of comprehensive need assessments prior to, or soon after, becoming resident in the home. EVIDENCE: The home’s service user guide was examined, this document contained information about staff qualifications and experience, the philosophy of care provision, a brief description of the home and it’s facilities, visiting arrangements and a copy of the homes complaints procedure. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 9 Five service user files were examined, those chosen were the newest admission, the most frail person and someone receiving input from the district nurse, someone who had resided in the home for a long period and another suggested by the manager. Four of the five service user files examined contained signed contract detailing the terms of residency. During discussion the manager also stated that service users and their representatives were encouraged to visit the home prior to admission. Detailed assessments were seen in all care files and these included information about the psychological well-being, food preferences, health and social needs and expectations of the service users. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a site visit to the home. The health care needs of service users are well-documented and known to staff, which ensures that such needs are met. Medication in the home is not always stored in safely and in accordance with the homes medication policies and procedures and is a potential risk to service users. The environment makes it difficult for staff to promote the dignity of service users. EVIDENCE: Five care plans were examined and instructions about meeting health needs were clearly identified. Records and daily reports for service users confirmed that all routine and specialist health care including pressure area care is provided. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 11 Results and prescriptions confirmed that health care checks including opticians, dentist, influenza injection, podiatry as well as out patient appointments, nursing care and other specialist input is arranged as required by the service user or in accordance with relevant guidelines. A district nurse attending the home was interviewed and, though keen to say that she was not a frequent visitor to the home and that everything is to hand when she provides any treatment. It was also observed that staff followed instructions the vast majority of the times. Four service users were interviewed and all were satisfied with the standard of health care provided in the home. The relative also confirmed this positive assessment. Service user comments included: ‘Yes staff are alright.’ The staff interaction with service users was also observed and monitored, it was noted that for the most part staff supported these service users in accordance with the instructions written in the care plans. The medication round was observed and for the most part was completed in accordance with the guidelines; staff were interviewed and were clear about the correct procedure even though this may not always be followed. The manager indicated that further training and supervision is necessary in relation to the distribution of medication-however staff sought the consent of service users before giving medication, and it was noted that appropriate support was offered to ensure medication was successfully administered. The Medication policy was also examined and it was highlighted to the manager that, there are no references to service users who want to manage their own medication. As on previous inspections there are no privacy screens or curtains in shared bedrooms, furthermore it was noted that a male and female service users were sharing a common ‘en-suit’ area, with no consideration given in respect of privacy for either person. In addition it was possible for the service users to enter each others bedrooms unimpeded, this issue was discussed with the manager. Infection control is carried out in the home, however the manager must be always mindful of the dignity and rights of all the service users when it is necessary to consider isolation or barrier ‘nursing’ in accordance to accepted guidelines. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using the available evidence including a site visit to the home. The range of activities in the home provided in the remains poor, however an increase in the frequency and range of activities is apparent, and so opportunities for service users to participate in meaningful activities has improved very slightly. Visiting time in the home is flexible and in line with the needs of service users ensuring that they maintain good contact with family friends. The nutritional value of meals provided in the home is in keeping with current guidelines, however, the choice offered to those on special diets is variable. EVIDENCE: The activities calendar was examined and activities included arts and crafts, board, ball, music and picture games, sing-a-longs, pamper days, beetle drives and themed movie nights. It was also observed in the daily reports that staff assessed whether individual service users participated in or enjoyed the activities offered. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 13 Staff who were interviewed acknowledged that they had noted an improvement in dexterity, number skills and concentration for those service users who joined in with activities on a regular basis, and so felt encouraged to provide more variety. It as also evident from daily reports that activities had not taken place the previous week, the manager stated that this was due to lack of staff. Five service users were questioned about activities. Four were happy with the increased activities although all noted that they would welcome the opportunity to go on excursions away from the home, and one service user was very dissatisfied with the range of activities, stating that the home was ‘too quite, with not enough to do or chances to get out’. No organised activities took place on the day of this inspection. Fund raising has taken place so that activities equipment and resources can be purchased. Residents meetings are not yet established, however service users and the relative who were interviewed confirmed that, their ideas were taken into consideration, although not necessarily acted on, by the staff and manager on an individual basis. Concern in respect of activities arises from the fact that the provision is inconsistent and does not cater for the less able living in the home. Furthermore activities do not happen in accordance with the calendar and this causes disappointment to those who are expecting this input. Excursions, outings and entertainers have not been arranged and activities are cancelled due to lack of staff. Observation of interactions in the home was undertaken; those observed included the service users whose care plans were examined. From these observations it was possible to conclude that service users relate well to each other and staff, comments from service users included “A lot of them like a laugh” and “Lovely staff, it’s a shame when they leave.” The relatives’ observations included “I’ve never any problems with staff-they keep us informed of everything”. On the day of inspection Oaklands cook was off duty and so care staff were preparing all meals. The lunchtime meal was steak and kidney pie, or sausage casserole, mushy peas or beans and mashed potatoes. Pudding was ice cream or homemade rice pudding. It was noted that service users made favourable comments about the food and particularly enjoyed the pudding. Menus were examined and demonstrated a variety of meals including stews meat pies, the diabetic choice continues to appear limited as the choice tends to be yoghurt or ice-cream for dessert. Fresh fruit has been introduced. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 14 The store cupboards were examined and found to be adequately stocked. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using the available evidence including a site visit to the home. The homes complaints procedure is robust, clearly written and staff and service users understand who they can go to and that they are entitled to voice any complaints and be listened to if they have any concerns. The guidelines concerning the protection of vulnerable adults have not changed, and do not promote the actions that further adult protection; furthermore, staff demonstrated a simplistic understanding of adult protection, and accredited training in this area has not taken place and service user protection from abuse is not maximised. EVIDENCE: The complaints procedure was examined and assessed as satisfactory and allowed service users and their relatives to be confident that complaints would be taken seriously and acted upon. Complaints were recorded and a note made of the outcome and actions taken. Service users confirmed that they were confident the staff or manager would treat any concerns seriously. Discussions about adult protection issues with both service users and staff indicated that they had some knowledge and integrity to reduce the occurrence, or deal with obvious abuse. It was made clear through further questioning, however, that staff lacked knowledge relating to more subtle types of abuse, furthermore they did not understand the protocol to be followed concerning protection, prevention and reporting. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 16 The manager stated that staff training in respect of Adult Protection was a priority and negotiation in respect of this to be a priority. This lack of training has been commented on in the last 2 inspection reports and now has been an ongoing issue since October 2005. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is poor. This judgement has been made using the available evidence including a site visit to the home. Significant areas concerning the environment of this home fails to provide service users with a comfortable clean and homely environment. The home provides sufficient bathing and toileting facilities to meet the needs of service users however a lack of maintenance means that the equipment and facilties are not always pleasant to use. All the bedrooms can be furnished in a flexible manner, however, a significant number are poorly furnished, do not provide adequate privacy, furthermore failure of the call system in some rooms means that the safety of the service user is compromised. Some areas of the home were dirty and unhygienic. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 18 EVIDENCE: In the process of this inspection a tour of the private and communal areas in the home was undertaken and the findings were very much in keeping with those of the previous inspection on the 21st December 2005. The hallway carpet outside the office is frayed and presents a trip hazard. The furniture in the communal areas is domestic in appearance and there is sufficient lighting to enable service users to read if they so wish, however the sofa and chairs in the lounge areas are worn and stained. The majority of bed bases examined are stained and dirty and carpets in at least two bedrooms are stained and smell of urine despite evidence of frequent cleaning. Furthermore the flooring in some of the en-suite and bathroom areas are cracked and in poor condition. As on previous inspections maintenance work and refurbishment has not taken place and so the bath lift chair remained stained and unpleasant to use and the commodes were rusty, with the plastic coating disintegrated and missing lids. The majority of the bedroom furniture provided by the home is in poor repair and broken furniture repaired with visible screws furthermore many chest of draw units had chipped and broken surfaces. On this inspection it was also noted that a number of the call bells were not operational, this was discussed with the manager who presented evidence that the matter had been recorded and discussion taken place with the owners. The laundry area remains unsatisfactory; walls cannot be cleaned and are covered in cobwebs and dust. The area is also damp and on this inspection there were puddles of water on the floor near the drier. It was observed that laundry baskets were now in use and dirty clothes stored correctly, however, the dampness makes the laundry unsuitable for storing clothes. The washing machine offers a programme to disinfect soiled bedding and other items. Staff have been provided with an alcohol spray to clean their hands between dealing with service users, and it was observed that protective clothing was used when moving between the kitchen and other areas. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 19 Equipment such as slide sheets, turning stands, and other moving and handling equipment noted. Service users were also observed mobilising independently using Zimmer frame and walking sticks. Discussion with staff verified that they were aware of the actions they needed to take to reduce the risk of cross infection, however, it was observed that some protective clothing such as aprons were unavailable. This was discussed with the manager and it was noted that although not fully satisfactory, staff had been encouraged to improvise. A request for an action plan that addressed the poor state of repair of furniture and fittings in the home has been made by the Commission for Social Care Inspection, and the breadth of the work and expected timescales for completion are currently being negotiated with the registered individual. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a site visit to the home. Staff are not always employed in sufficient numbers to meet the social needs of the service users. A training calendar is being developed and staff training has commenced and service users are beginning to benefit from a trained staff team. The home’s recruitment practice is adequate ensuring that for the most part staff are suitably vetted and affords appropriate protection to service users. EVIDENCE: On the day on inspection there were 16 people living at Oaklands and these were being supported by the manager, 1 senior carer, three care assistants, one domestic staff and one person preparing meals. The duty roster was examined and it was noted that at times members of staff were commencing work at 15:00 and worked through to 08:00 the following morning. Although staff had signed wavers agreeing to this it was highlighted that staff could not be at their best working such long hours. Furthermore there is insufficient staff to provide adequate holiday cover, resulting in the curtailment of social activities, this was particularly evident over the Easter period. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 21 Staff training has commenced, and certification identified that a number of staff had commenced or were competing the National Vocational Qualification (NVQ) 2 in care award, staff confirmed that moving and handling, food hygiene and first aid training had also been provided. The manager is in discussion with Oldham social services training unit to access courses concerning adult protection, Dementia Care and other topics relevant to the home. The manager has also highlighted that Care of substances hazardous to health (CoShh) and additional medication administration training is required by staff. Prior to the inspection staff had informed CSCI that they had been made to pay towards health and safety training, this was discussed with the manager who took additional advise. During the inspection she stated that staff were to be reimbursed these payments. The files and records for four staff members were examined. Each contained, completed application forms, Criminal record bureaux (CRB) checks, evidence of induction and supervision and training and development. Only two files contained two references, with other two containing only one in each. The vetting process for the most recent recruits was satisfactory, with all the correct records in place. At the time of inspection new recruits were on duty, therefore those interviewed were longstanding care staff. Staff volunteered that they felt the home was for the most part well run, and the service users well looked after. They acknowledged that training had increased and service users enjoyed the activities that had been introduced. Both felt, however, that regular staff meetings would help to develop and maintain a more positive working relationship between staff that work different shifts. Discussion with the manager indicated that there had been some staff disquiet over the payment for courses and other changes in the home but she felt that these issues had being resolved. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a site visit to the home. The manager is suitably qualified, experienced and professional in approach. There is no evidence, however, that the registered individual fulfils their responsibility to provide service users and staff with the opportunity to discuss with him the management and services provided in the home. A rudimentary quality assurance system, which needs to be further developed to ensure that professionals, and relatives can influence how the home is run, has been introduced. The arrangements for managing service users finances were adequate on the day of inspection. There are some health and safety arrangements in place but they need to improve in this area to ensure the environment is safe. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 23 EVIDENCE: The manager has successfully completed a Fit Person interview with the Commission for Social Care Inspection (CSCI) and had previously achieved the National Vocational Qualification level four-management award; furthermore the manager has developed positive relationships with staff from other statutory agencies. Discussion with the manager indicated that she continues to keep up to date with new developments in care and has recently completed courses includes updated moving and handling, medication training and First Aid. Records kept on staff files demonstrated that supervision and appraisal has been introduced and continues for staff. A quality assurance monitoring system has been introduced; all service users have been given a questionnaire, completed independently, with their representative or with the assistance of the manager. The questionnaire provides service users with the opportunity to comment on, how they feel about living in Oaklands, whether they feel their needs were being met, what changes they may like, whether the food plentiful and to their taste, was there enough staff to help with care and support, whether there were sufficient activities, were visitors made welcome, their satisfaction with the laundry and the general care provided by the home. It was noted that key-workers were not involved in the process of quality assurance and the manager acknowledged that this system did not yet include the relatives, health professional or staff. A development plan for the home has been written, but this does not address all the requirements concerning the repair of the furniture, fixtures and fittings, provision of activities in the home and training issues. Discussion with the manager confirmed that the local authority procurement unit is satisfied with a computerised system for managing service users accounts. All money is paid to the service users directly or their relatives and a small allowance returned and managed by the home. The accident log was examined and nothing untoward was noted. A fire safety risk assessment has been completed by the local Fire office and recommendation made, paper work indicated that fire safety equipment, including the alarms and emergency lighting had been checked in accordance with current guidelines. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 24 Records demonstrated that electrical wiring had also been surveyed in accordance with the appropriate regulations. Conversely, regular maintenance and safety checks of the passenger lift; bath hoist and other equipment and services could not be confirmed, furthermore it was evident that 9 call bells required mending and this had not been attended to. There was no evidence that the owners had completed the statutory visits to provide additional support to the manager, care staff or service users. Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 1 2 2 3 1 2 2 1 STAFFING Standard No Score 27 2 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 3 3 2 Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14 & 15 Requirement The registered person must demonstrate that service users and their representatives are involved in the assessment, care planning and review process. The registered person must ensure that all medication in the home is securely stored. Previous timescale 01/03/06 not met. The registered person must ensure that privacy screens are provided in all shared bedrooms. (Previous timescale 01/03/06 not met. The registered person must consult with service users and provide a programme of activities that they want. (Previous timescale 1/11/05 not met). The registered person must ensure that staff receives adult protection training. (Previous timescale 1/10/05 and 01/03/06). Timescale for action 01/06/06 2. OP9 13(2) 01/06/06 3. OP10 12(4) 01/06/06 4. OP12 16(n) 01/06/06 5. OP18 13(6) 01/06/06 Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 27 6. OP24 23 7. OP26 23 8. OP30 18 9. OP33 26 10. OP33 24 11. OP38 13 (4) a 12. OP27 18 The registered person must initiate a programme of refurbishment, maintenance and improved storage provision, a copy of which must be sent to the Commission for Social care Inspection. (Previous timescale 01/10/05 and 01/03/06 not met). The registered person must ensure that all areas of the home are clean and fit their intended use by replacing stained beds, stained carpets and cracked flooring in ensuite areas. The registered person must ensure that staff receives sufficient training to enable them to meet the needs of service users including Adult Protection; First Aid and Dementia Care. The registered provider must undertake regular visits to the premises and carryout the actions detailed under this regulation. The registered person must develop a system for monitoring the quality of the service that incorporates the opinion not only of service users, but also their representatives, health professionals and others involved in the home. The registered person must ensure that all equipment such as lifts, nurse call bells and hoists are regularly checked, deemed safe and operational by appropriately qualified individuals. The registered person must ensure that staff are available in sufficient numbers to meet the social and educational needs of service users at all times. 01/06/06 01/06/06 01/06/06 01/06/06 01/11/06 01/06/06 01/06/06 Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 28 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 DS0000005513.V289799.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oaklands DS0000005513.V289799.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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