Inspection on 23/03/07 for Oaklands

This inspection was carried out on 23rd March 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 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 27/03/06

Oaklands 03/06/05

Oaklands 02/12/04

Oaklands 14/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Oaklands 14 Pinfold Lane Methley Leeds West Yorkshire LS26 9AB Lead Inspector Stevie Allerton Key Unannounced Inspection 23rd March 2007 10:30 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 DS0000001487.V325607.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaklands Address 14 Pinfold Lane Methley Leeds West Yorkshire LS26 9AB 01977 515451 (01977) 667644 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) Oaklands Residential Home Limited Mrs Kathleen Foley Care Home 21 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (21) of places Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th March 2006 Brief Description of the Service: Oaklands Residential Home provides care for 21 older people, with up to 4 people with Dementia. The day-to-day care is supervised by the owner/manager, who is a registered nurse; however, the home provides personal care only and is not able to care for people with long term nursing needs. The home has a contract with the local authority to provide some transitional beds, for people leaving hospital that are not yet ready to return home. The older part of the house has been extended in recent years and provides 21 single bedrooms, all of which now have en-suite facilities. The house stands in private landscaped gardens and is situated close to the local amenities in the village of Methley, part way between Leeds and Castleford; many of the service users and their families are from the local area, hence the home has a lot of visitors on a daily basis. Current fees are £359 - £410 per week. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector over the course of a day, starting at 10.30am and finishing at 6.30pm. The Registered Manager was present throughout the day; the Deputy Manager and other staff team members also assisted the inspector. Survey forms were sent out to a sample of residents prior to the visit and 10 were returned. Before the visit, information about the home since the last inspection was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI, including reports from other agencies, such as the Fire Officer. This information was used to plan this inspection visit. The inspector case tracked four residents. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspector assessed all twenty-two key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. The inspector spent time with residents and spoke to relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Visitors were also spoken to during the course of the day. The inspector would like to thank everyone who took the time to talk and express their views. What the service does well: People feel that they are provided with a good level of information about the home prior to admission. There is prompt attention to making sure that residents’ health needs are met, both for routine matters and in response to rapid changes in health and well being. The Manager is able to give some in-house training in the management of medical conditions. There is an atmosphere in which residents and relatives feel comfortable about saying if they are not happy with something. There is general confidence that the Manager or Deputy will resolve any concerns raised. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 6 The owners continuously look at ways to improve facilities for the residents and have just completed a major refurbishment and internal alterations. Attention to general repairs and maintenance is good and there is a high standard of cleanliness throughout. The owners believe in investing in their staff team. Staff are motivated to achieve nationally recognised qualifications and are rewarded and recognised for the benefits they bring to better care for the residents. Residents and relatives made the following comments: “The home is well run and staff are caring”, “The owner is hands on and is there a lot of the time”, “When we first went to look round we were made very welcome and all our questions were answered”. What has improved since the last inspection? What they could do better: Improvements could be made in the recording of medication; due to some signatures being omitted it was not clear whether or not medication had been given as prescribed. Complaints recording could also be improved, so that any investigation and outcomes of investigations are clearly recorded, along with action taken to resolve the difficulty. General risk assessments need to be cross-referenced with specialist ones, such as fire, so that staff are aware of potential risks, no matter which document they pick up. A bathroom would benefit from refurbishment, as it is showing signs of wear and tear. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 7 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 DS0000001487.V325607.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with a good level of information about the home, so that they can make an informed decision about going to live there. New residents and/or their relatives are issued with written contracts that outline the services to be provided. The addition of the transitional beds provides a good alternative to remaining in hospital for long periods, allowing a period of recuperation before returning home. EVIDENCE: Assessment details were seen in the case file of a newly admitted resident, including a copy of the referring agency’s core assessment & care plan. The home now has a contract with the local authority for “transitional beds”, i.e. providing a short-term (2 – 4 wks) stay between hospital and returning home. There is 1 bed being used so far, but vacant beds could be used as well. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 10 One person was currently being cared for under this arrangement. There are no separate facilities in the home for people admitted for transitional care. The staff have had some additional training in specific medical conditions that these service users may have, and already promote mobility, continence and self-care for the permanent residents. The Manager said that there had been some successful returns to home for people using these places so far. Service user comment cards confirmed that contracts had been received and that people felt they had a good level of information prior to coming to live at the home. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has a written care plan that is easy to understand and which includes all areas of their life, including health, personal and social care needs. Residents have full access to all primary health care services, staff ensuring that those who are well enough attend appointments, or getting services in for those who are frail or ill. Residents are treated with respect, with good attention to maintaining their privacy and dignity. With some minor omissions in recording, medication is well managed. EVIDENCE: Four residents with differing needs were case tracked. Records are all held in one place and accessible to staff. There was evidence that residents and their families are involved in their own care plans; relatives are asked if they would like to read and sign the written plans. The Manager and staff discussed how changing needs are assessed and reviewed, sometimes on a daily basis. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 12 On arrival at the home, the Manager was just going out, escorting a resident for a blood test at a local clinic. Regular notifications are sent regarding admissions to hospital, if health needs are identified as needing medical attention. On the day of the visit a 999 call was made for a lady experiencing chest pains and breathlessness, who was subsequently admitted for observation. Observations were made of staff as they went about their daily routines in the communal areas, supporting residents with attention to privacy and dignity. The Manager felt that staff had responded well to the new challenges posed by taking people in to the transitional beds, for example, caring for someone with a urostomy. The Manager has the skills to provide in-house training and showed staff how to deal with the urostomy bags. The care plan for this person also detailed the involvement of the stoma nurse, District Nurses and GPs, with an emphasis on pain management. Residents who are at risk of pressure damage can be quickly supplied with pressure relieving mattresses and cushions through the District Nurses; these were seen in place where appropriate. A complementary therapist also visits some of the residents, providing aromatherapy and Reiki for those who would like this. The Manager went through the medication system, the obtaining of prescriptions, storage of drugs, administration and recording. A couple of omissions were noted on the drugs recording sheets, where staff had not signed that drugs had either been given, or put a reason why they had not been given. Service user comment cards & discussions on the day produced the following comments: “I’d recommend this place to anybody. I’m satisfied and settled here”, “The staff work round my Mum’s condition very well”, “My husband has always had medical support quickly, or the district nurse if needed”. Oaklands DS0000001487.V325607.R01.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. Staff make efforts to put on a varied programme of activities and try to find things to interest people. Family and friends are welcomed and good relationships exist between them and the staff. There is flexibility in the daily routines and residents feel they can make choices. Meals are of good quality, nutritious and to the liking of the residents. EVIDENCE: Care plans provided records of social activities that each person takes part in. A programme of activities for the month is displayed in the main hallway and in the dining room. Arts & Crafts were scheduled for the day of the inspection visit, which took place in the dining room after lunch. A group of four residents with a staff member were completing the painting and decoration of some Easter baskets they had made. Some individuals have been having a try with the computer, mainly playing games such as solitaire so far. The garden continues to be a source of enjoyment for many people. Friends and relatives say they feel welcomed in Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 14 to the home by all the staff. “When I visit there is always an excellent atmosphere, with the staff making both visitors and residents welcome”. The meals are freshly home cooked, which the residents appreciate. The provider’s husband grows vegetables and soft fruit in his allotment, some of which is used in the home. “The meals are varied and attractively presented”, “There is always a choice of two main courses. I’ve never found reason to complain about the quality of the food”. The inspector ate lunch with the residents in the dining room. The meal was of good quality, well presented and appetising. Staff assist residents with discretion, maintaining their dignity. One person spoken to had just got back from a walk, which he does independently most days. He said he felt happy and settled and felt he had enough to do to pass the time. Other comments made: “Apart from parlour games and arts and crafts, they also arrange occasional pub lunches, visits to the theatre and shopping trips”. Oaklands DS0000001487.V325607.R01.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 relatives are comfortable about raising concerns and know who in the home to speak to about these. Staff are receiving training in Adult Protection, which will equip them to provide good support if any incident of this type is reported. The recording of complaints and how they have been dealt with could be improved, so that other staff, if asked about the progress of a complaint, can access the relevant information. EVIDENCE: Complaints outcomes have not all been recorded; the Manager said that only one complaint had been recorded and was stored within the resident’s file. Discussion took place as to how best to record any concerns/complaints raised, along with the outcomes of the investigations, so that other staff were aware of what action was being taken. No complaints have been made to CSCI. Adult Protection training has taken place for key staff and is to continue for all staff. Everyone that responded in a comment card said they felt confident about raising concerns and knew who to tell if they had any complaints. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 16 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, 21, 23 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The providers have continued to upgrade residents’ personal space as well as make improvements to fire safety standards. The accommodation provides very good facilities, with all 21 bedrooms en-suite. One bathroom on the first floor would benefit from upgrading, along with the bath hoist, to further improve the facilities. Bedrooms are personalised and decorated and furnished well. The ongoing programme of maintenance and re-decoration ensures that no areas of the home are allowed to fall into disrepair. The home is kept to a very high standard of cleanliness throughout. EVIDENCE: Since the last inspection, internal alterations have been completed and the home now provides en-suite facilities in every bedroom. Upstairs, a corridor layout has been changed to remove 3 steps. All windows in the original part of Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 17 the house have been replaced with double glazed windows and many of the carpets have been replaced. There is an ongoing programme of redecoration. The electrical wiring was checked and a 5 yr safety certificate issued in February 2007. Other maintenance certificates were seen, including the lift certificates and hoist maintenance records. The Fire Officer’s visit at the completion of the building work identified some improvements that need to be made, to bring existing fire safety measures up to the most recent standards: some of the store cupboard doors need smoke seals, an extra fire door is needed upstairs (this was being done the following week) and a magnetic hold-back for the new door was also needed. All of these tasks are in progress. The former staffing ”station” in the main hallway has had to move, following advice from the Fire Officer. This has been relocated into the “green room”, where staff can still be in a position to observe and be on hand for the residents. The handyman is very much appreciated by everyone in the home. Staff find him approachable and willing to do everything from hanging pictures in residents’ rooms to decorating or maintaining the garden. Protective equipment for staff was seen to be freely available in bathrooms and WCs. One bathroom is now showing signs of wear and tear and the staff feel that a more up to date hoist would be advantageous. The housekeeper spoke with pride about her role. She has a regular schedule for thoroughly cleaning each of the bedrooms in rotation. She has her NVQ (National Vocational Qualification) in housekeeping and has also been included in other training, such as Dementia. Service user comment cards include the following observations: “When we first went to look round we were immediately struck by how fresh everything was. I have been in a few homes that smelt of urine and old age. There is never a hint of this at Oaklands”, “It never smells of urine, which must take some doing. All toilets are kept very clean”. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 18 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 excellent. This judgement has been made using available evidence including a visit to this service. Recruitment of staff is in line with best practice, which protects residents. The extensive induction period makes sure that staff are skilled and confident before they are fully part of the rota. The home’s ethos of trying to create a diverse workforce is reflected in the current staff team, which contains people of various ages, cultural and ethnic backgrounds and gender. The staff team are highly motivated to involve themselves in training and the provider recognises the value of their achievements. To have over 50 of the staff team with a nationally recognised qualification is to be commended. The training provided is geared to the client group being cared for and promotes the delivery of person-centred services. EVIDENCE: The rotas show that there are sufficient staff on duty to meet the needs of current service users. There are four male staff, one on night duty, but they always work with a female staff member. Four care staff are designated Seniors; along with the Deputy they act as shift leaders. Certain staff are designated to administer medication. All care staff have current First Aid certificates. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 19 The home has more than 50 of its’ care staff qualified to NVQ level 2, and five are currently working towards level 3. The home uses Joseph Priestley College for care training and believes in rewarding the staff for certificates achieved in their own time. All have done the Continence Management and Dementia training and a few have done a course in Palliative Care (even the cook and the housekeeper did the Dementia course). Currently there is a group doing Nutrition and another doing First Aid updates. Moving & Handling training, Fire Safety, Infection Control and Adult Protection have all been done during the course of this year, along with NVQ. The Manager, Deputy and Senior care staff meet together once a month. The Deputy and one of the Seniors did the Adult Protection course and presented it to the senior meeting this month; they will start next month with presenting it to small groups of staff. Staff meeting minutes were seen. The first document in the policy file is Equal Opportunities, which contains a statement about creating a diverse workforce. Recruitment files were seen for the two newest members of the team. These contained evidence that all of the required background checks are carried out. There has been an unusually high turnover of staff in the last 12 months; some long-standing staff moved on, but a significant amount of turnover was due to new starters not staying long and posts having to be re-recruited for. New staff generally have a month’s induction period, during which time they are supernumerary. Induction books were seen. The Manager is the designated Moving & Handling trainer for the home and has recently been on refresher training for this. Service user comment cards and discussion with residents & relatives produced the following comments: “I find all the staff to be kind and considerate and they always find the time to help”, “The staff are always ready to listen and help with any problems”, “I think the staff are well trained and have a good, friendly attitude”. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 20 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, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and residents feel satisfied with the service they receive. The Manager regularly surveys people to identify any weak areas in the service and tries to make improvements. Residents say they feel they can have a say in what happens in their home. Records are generally kept in good order, which protects residents and contributes to the smooth running of the home. A couple of omissions were noted, which the Manager said would be rectified. There is good attention to health and safety matters, making for a safe working environment for staff, as well as good living conditions for residents. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home is managed by the owner, who is suitably qualified, competent and experienced. She is held in high regard by staff, residents and their families. She works in the home “hands on” where needed. The results of the last quality survey were seen, displayed along with other information about the home in residents’ bedrooms. Comments and suggestions made about areas that could be improved were matched by those on the comment cards returned to CSCI. Health and Safety records were seen, including COSHH data and risk assessments. Fire safety records showed that regular alarm testing and fire drills take place. The home has a fire risk assessment undertaken by an external consultant; this is comprehensive and includes an audit of every room. This noted the risk from an oxygen cylinder in one of the residents’ rooms. However, this had not been included in the general risk assessment for that resident in her care plan. Records seen included: care plans, risk assessments, medication, menus, food safety records, fire safety records, maintenance records, staff files and training records. All were readily available. The Manager does not handle personal finances for residents. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 22 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 3 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 17 X 18 3 3 X 3 X 4 X X 4 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 17(1)(a) Schedule 3 Requirement Improvements must be made in the recording of medication; due to some signatures being omitted it was not clear whether or not medication had been given as prescribed. Complaints recording must be improved, so that any investigation and outcomes of investigations are clearly recorded, along with action taken to resolve the difficulty. General risk assessments need to be cross-referenced with specialist ones, such as fire, so that staff are aware of potential risks, no matter which document they pick up. Timescale for action 01/06/07 2 OP16 17(2) Schedule 4 01/06/07 3 OP38 13(4) 01/09/07 Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 24 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 Refer to Standard OP21 Good Practice Recommendations A bathroom would benefit from refurbishment, as it is showing signs of wear and tear. Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 25 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 Oaklands DS0000001487.V325607.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!