Inspection on 24/11/06 for Oaklands

This inspection was carried out on 24th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oaklands 06/03/08

Oaklands 29/12/05

Oaklands 18/08/05

Oaklands 09/12/04

Oaklands 21/09/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Oaklands 5 The Green Theale Reading Berkshire RG7 5DR Lead Inspector Stewart Mynott Unannounced Inspection 24th November 2006 11:00 Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaklands Address 5 The Green Theale Reading Berkshire RG7 5DR 0118 930 5288 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) londonroad@tiscali.co.uk Milbury Care Services Limited Mrs Theresa Ann Bieny Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th December 2005 Brief Description of the Service: Milbury Care Services Ltd is a private company that is registered to provide care and accommodation for up to six adults who have a learning or communication difficulty. The accommodation is provided in Oaklands, a large, older-style detached house that is situated on the outskirts of Theale village. The home is within walking distance of local shops, churches, pubs and cafés. There are bus and rail services from the village to the towns of Reading and Newbury. A private drive at the front of the house provides parking space for several cars and there is a large garden to the rear of the property. Each of the Service Users has an individual bedroom in addition to use of the shared accommodation of the property. The fees in respect of this service, taken from the pre inspection questionnaire, are £958.54 per week. These are correct at the time of this inspection. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over a four-day period between the 1st and 24th November 2006, with an unannounced visit to the establishment occurring on the 22nd November 2006 lasting for 5 hours. During the site visit a full tour of the premises was facilitated. Over 50 of the visit was spent with all the service users, who were present at different times during the day, as well as the staff on duty observing the everyday life at the home. All service users except one have difficulty communicating verbally and views about their experiences were gained indirectly through observations and interactions with staff. Discussions also took place with all staff on duty including the registered manager. Some of the service users and the home’s records were examined to support observations made during the day. The inspection also included reference to documents completed and supplied by the home to include a pre inspection questionnaire and staff training records. What the service does well: What has improved since the last inspection? At previous inspections requirements had been made in relation to improving some aspects of the environment to include, the upgrade or removal of the outside wooden structure, housing the laundry and provision of additional recreation space for service users’ enjoyment. During the inspection the manager confirmed the final plans. The existing outbuilding will be removed and a prefabricated building erected to house an upgraded laundry area with Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 6 appropriate equipment to deal with the current needs of the service users. In addition this building will house the office, which is currently located inside the main house. This will therefore create an additional recreational space separate to the lounge/dining room within the home for service users’ use. This is a positive step forward. 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 DS0000011150.V318565.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. There is a clear and detailed admission policy available within the home that details the assessment process for prospective service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager confirmed that there have been no new admissions to the home since 1994. The current service user group is stable and unlikely to change in the near future. There is an admission policy available within the home, which is thorough and detailed, and limited details of this are also contained within the Statement of Purpose. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. Service users have a good range of appropriate activities to participate in. Staff have a good relationship with service users’ families and provide support as needed. The menu and food provided at the home are appropriate and reflective of a family home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service users’ care plans were case tracked to include a diversity of the individual needs of service users living at the home. Each service user had an individual plan which provides a clear overview about the essential care and support needs with reference to more in depth care plans, support guidelines and risk assessments. Two of these overviews contained pictures to illustrate the information provided. Care plans for each individual examined provided further in depth information for each element of their identified needs to include personal care and activities in their daily lives. Care plans seen clearly stated the support required with an emphasis on promoting service users to be as independent as possible. One service user’s care needs have changed since the last inspection and care plans had been monitored and reviewed to ensure Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 10 their needs would continue to be met. All care plans had been kept under regular review and updated information was provided as necessary. Most service users do not communicate verbally. Further work in addition to comprehensive care plans, includes a communication book devised by the home manager. This clearly states how to communicate and interpretation of non-verbal actions and was viewed as good practise. The staff spoken to understand each service user’s needs and were able to explain communication methods in detail. During the inspection it was clear that service users are able to exercise choice, make decisions and were engaged by the staff team for all activities of daily living. Care records also demonstrated support needed to make appropriate decisions. Three service users’ risk assessments were viewed and contained a variety of assessments to support independence wherever possible in all areas of their daily life. Each service user benefits from possible risk being identified and strategies put in place to assist independence. All risk assessments had been kept under review. Staff spoken to were clear about the use and understanding of each service user’s risk assessments. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. Service users are fully supported to have an enjoyable and fulfilling lifestyle, which includes suitable activities and opportunities to follow leisure pursuits. The daily life in the home is relaxed and inclusive with service users’ support needs taking priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are supported to engage in a variety of planned social activities. The home has a weekly pictorial planner providing details of regular structured activities to include attendance at day centres and organised clubs. During the inspection service users attended day centre sessions and one service user was supported by a staff member to go shopping for items they needed, to include lunch out. From information provided in the pre inspection questionnaire, care records and staff discussion, service users have a good range of social activities provided to include use of local facilities within the community, more specialist resources and various in house activities. Evidence was viewed that the provision of leisure and structured activities had been kept under review to Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 12 ensure each individual continues to have an appropriate and relevant programme based on need and observed preferences. Staff described that four service users had been on holiday to Butlins earlier this year. Two service users who prefer not to spend longer periods away from home benefited from planned day trips. A number of photos of these activities were on display at the home. Staff advised that they assist service users to maintain contact with their relatives, to include assistance with transport as necessary. One relative via a returned survey confirmed that the staff team always keep them up to date with current events and are made to feel welcome when visiting the home. The registered manager described the planned event for one service user who has a significant birthday in the near future. Staff have arranged a party and disco nearby and have invited friends and family to celebrate. The daily routine of the home was observed to be relaxed with service users having unrestricted access to the communal areas as well as spending time in private in their rooms. Staff were observed to interact well with service users with emphasis on the individual’s routines and support requirements. Staff were observed as inclusive, friendly and professional. Service users were enabled to assist with housekeeping tasks with staff support within their individual abilities. The manager confirmed that menus are planned on a weekly basis. A sample of menus for the past four weeks was examined and demonstrated a variety of different meals. The registered manager advised that the home has reviewed its menu to ensure a reliance on fresh foods instead of frozen or “convenience” foods. The menus also detailed the staff responsible for the preparation of each meal during the week. Staff spoken to advised that service users are encouraged to be involved during shopping at the supermarket and local shops. Service users at the home are unable to prepare meals and drinks for themselves, however during the inspection it was evident that they are involved and encouraged to assist within their abilities, for example, to assist in making a drink of their choice and observe meals being prepared. During the inspection a support worker prepared the lunch for four service users who were at home. Lunchtime was observed to be relaxed with service users appearing to enjoy their meal, with assistance and encouragement provided in line with information contained in care plans. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. Service users’ personal support and healthcare needs are met and supported by the staff team. The medication procedures at the home are safe, however the registered manager must review the procedures for recording the administration of service users’ medication to include the reason for non-administration of prescribed medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Through observation, discussion with the staff on duty and individual records it was confirmed that service users receive a good level of personal support from the staff team. They confirmed that timings for going to bed, rising, meals and other activities are flexible in accordance with service users’ preferences. One service user requires additional equipment to assist them with moving around the home. Equipment particular to the individual need was seen to be in place and staff were able to clearly explain how this was used. Staff confirmed that personal care is provided in line with individual guidelines in private. Daily records viewed for four service users provided further evidence of a good level of personal support. The registered manager described the current arrangements to monitor individual service users’ health. Records viewed for three service users, Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 14 confirmed access to local NHS care facilities to include a record of GP and hospital appointments, and access to the dentist and optician. One service user also has regular access to more specialist care to include occupational and speech therapy. The home keeps a record of ongoing health issues and evidence of annual reviews to include medication was also documented. The registered manager explained how service users’ medication is managed within the home. There are appropriate systems for the ordering, collection, administration and disposal of medicines. Records relating to the administration of medicines for four service users were examined and completed clearly with no evident gaps over the past two weeks except in two cases. In exploration of these gaps with the registered manager the medication was not required for legitimate reasons. It is required that when this occurs that an appropriate entry is made into the records to indicate the reason for non-administration rather than leaving the records blank. There are individual guidelines in place for the use of “as and when required” medicines. There is an up to date staff signature sheet to enable staff initials to be easily identified. The pre inspection questionnaire indicated that currently there are six staff responsible for administering medication. Training records viewed indicated that all staff have received the relevant training to be able to undertake this function. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Service users’ well being and their representative’s views will be listened to and acted upon. Service users are protected from abuse by the home’s robust polices and procedures, that are fully understood by the staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a clear complaints procedure available within the home and also a pictorial format contained in the Service Users Guide providing information about how to complain if unhappy with any element of the service provided. From observations and staff confirmation, service users would be unable to formally make a complaint and would require support from the staff team to do so. The manager and responses from relatives surveys confirmed that they are aware of the complaints procedures should the need arise. There have been no recorded complaints since the last inspection and the CSCI have not received any concerns or complaints regarding this service. The home has an appropriate policy and procedure in place in relation to the protection of vulnerable adults. This provides clear information about how to recognise and report any suspicions of abuse. Information provided from training records evidenced that staff have attended training in this area, and all new staff since the last inspection attended training as part of their ongoing induction. Staff spoken to during the inspection clearly demonstrated their understanding of the policy and procedure in place. Senior staff spoken to described a safe and accountable system of safeguarding service users’ financial interests to include the procedures for handling service users’ personal monies. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30 Quality in this outcome area is good. Service users live in a clean, comfortable and homely environment. Positive developments to upgrade the laundry facilities and provide further recreation space for service users were confirmed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At previous inspections requirements had been made in relation to improving some aspects of the environment to include, the upgrade or removal of the outside wooden structure, housing the laundry and provision of additional recreation space for service users’ enjoyment. Since the previous inspection correspondence was received from the Providers to address these deficiencies. During the inspection the manager confirmed the final plans, which will be completed during January of next year, further evidenced in paperwork and purchase orders seen. The existing outbuilding will be removed and a prefabricated building erected to house an upgraded laundry area with hand washing and appropriate equipment to deal with the current needs of the service users. In addition this building will house the office, which is currently located inside the main house. This will therefore create an additional Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 17 recreational space separate to the lounge/dining room within the home for service users’ use. This is a positive step forward. During the tour with the registered manager the main communal space was viewed. The lounge/diner had been redecorated and new flooring and furniture provided since the last inspection. It was noted that there were more ornaments and plants at this inspection, which greatly added to a homely atmosphere. The manager and staff advised that they had continued to work with a service user who prior to this inspection did not tolerate additional items in the communal areas. Service users were seen to use and enjoy the communal area within the home. Senior staff spoken to were enthusiastic about the plans to redevelop the office into an additional recreational space for service users and described some of the plans and equipment required to maximise service users’ enjoyment. Two service users’ bedrooms were viewed during the tour. Both had appropriate flooring provided to meet the personal needs of those service users. One room had been redecorated since the last inspection involving the service user in the design and colour. Both bedrooms viewed were individual, appropriate to the service user need and clean. During the tour further positive changes were noted in the home to include, the refurbishment of the downstairs toilet and the removal of a step in the hallway near the back door to aid the movement of a service user who now uses a wheelchair. The systems in place to ensure the home remains clean and hygienic were discussed with the staff team and were viewed as appropriate and ensured good cross infection control. During the tour the home was viewed to be clean, tidy and odour free. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. Service users benefit from a staff team that is competent, appropriately trained and available in sufficient numbers to meet their assessed needs. The registered manager follows good practice for recruitment of new staff, which is protective of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the staff on duty were observed to interact positively and comfortably supporting service users either at home and when leaving or arriving from planned daily activities. All staff spoken to were able to clearly demonstrate their understanding of service users’ specific conditions and support needs and demonstrate the necessary skills to communicate effectively. Senior staff and the registered manager confirmed that the home is currently almost fully staffed and there has been no reliance on agency staff for a long while. Rotas examined for the past five weeks indicate a stable staffing level, which usually provides three staff members during the day and two members from mid evening. There is one night staff with a staff member sleeping in to provide additional support if needed. Due to the increased needs of one of the service users an additional thirty-five staffing hours are provided each week. The staff at the home confirmed that these are used flexibly in accordance with Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 19 the service user’s particular support needs. The registered manager works flexibly and is sometimes included in the above staffing levels when needed. The monthly team meetings and minutes for the past four meetings indicated a good attendance with a focus on service users’ issues. Records seen indicate that there are 14 staff employed, excluding the registered manager. Five staff have achieved at least NVQ 2 or an equivalent and four further staff members are working towards this qualification. The registered manager currently takes the lead role with support from the senior team for recruiting staff in line with the policies contained in the home. There is a coordinated approach with the regional office to aid the recruitment of staff. One recent staff file was examined and found to contain all the necessary pre employment checks obtained before they commenced employment to include evidence of Criminal Records Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) First checks. The registered manager is clearly competent and ensures the fitness of new staff to work. This was evidenced through interview notes and additional notes when checking the validity of references and other information. The registered manager currently organises the training programme within the home since the senior support worker responsible for this area left employment earlier this year. Information provided in the pre inspection questionnaire demonstrates a good range of both mandatory training and more specialist topics having been provided for the staff team. During the site visit individual training records and copies of certificates for six staff were viewed to cross check with the information already provided revealing that staff have received regular refresher training. Records indicating training has been booked in advance according to individual staff needs were also seen. Staff spoken to felt that the training opportunities were a strength of the provider. Arrangements for new staff commencing employment since the last inspection revealed that they have completed an appropriate induction as evidenced in completed induction booklets. The registered manager confirmed that the latest member of staff would be commencing the LDAF in the near future. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. The registered manager is competent and qualified to run the home. The management style is open and staff and service users are included in decision-making. There are good systems to monitor the quality of the service provided at the home, which the registered manager uses to measure the home against its aims. There are good arrangements and well-maintained records that evidence that the heath, safety and welfare of service users and staff are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for over three years and has completed the registered managers award. Training records viewed and discussions with the manager demonstrate a commitment to continued learning and updating knowledge. All staff spoken to, including senior support workers, were positive about the registered manager confirming that the home is managed in an open, inclusive and transparent manner. Oaklands DS0000011150.V318565.R01.S.doc Version 5.2 Page 21 The registered manager described the processes of quality assurance and the monitoring of systems within the home, which has remained the same since the last inspection. On an annual basis the registered manager sends out questionnaires to seek the views from service users’ representatives including professionals involved with each service user. A sample of these questionnaires that had recently been returned for this year were viewed to evidence this process. The manager had completed an action plan for the next year and had identified a wide range of projects and continued development to the service. Regulation 26 visits occur on a regular basis and are thorough focussing on service users and the quality of services provided. Information with regards to monitoring and maintaining the health and safety of service users and staff was provided in the pre inspection questionnaire. From this information the home regularly ensures equipment is serviced and the necessary checks are completed to monitor the systems involved in protecting the health, safety and welfare of service users and staff. A limited range of records was viewed to cross check the information provided in the pre inspection questionnaire and these were up to date and well maintained without exception. Records viewed included fire safety records, COSHH assessments, maintenance of equipment and food hygiene records. Staff observed and spoken to had a good understanding of these systems and were fully aware of their responsibility to assist in the monitoring and recording to maintain safe systems. Oaklands DS0000011150.V318565.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 2 3 3 3 X X 3 X Oaklands DS0000011150.V318565.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 YA20 Regulation 13(2) Requirement The registered manager must review the procedures for recording the administration of service users’ medication to include the reason for nonadministration of prescribed medication. Timescale for action 31/12/06 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 DS0000011150.V318565.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000011150.V318565.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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