Inspection on 11/11/05 for Oaklands Care Centre

This inspection was carried out on 11th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Care Centre 13/05/09

Oaklands Care Centre 16/06/08

Oaklands Care Centre 26/07/07

Oaklands Care Centre 20/09/06

Oaklands Care Centre 24/02/06

Oaklands Care Centre 10/02/05

Oaklands Care Centre 08/09/04

Oaklands Care Centre 29/10/03

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

CARE HOMES FOR OLDER PEOPLE Oaklands Care Centre 4 Oakland Road Moseley Birmingham West Midlands B13 9DN Lead Inspector Alison Ridge Unannounced Inspection 11th November 2005 02:30 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 Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 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 Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oaklands Care Centre Address 4 Oakland Road Moseley Birmingham West Midlands B13 9DN 0121 449 6662 0121 449 3097 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) Exceler Healthcare Services Limited Mrs Rachel Christine Daley Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the Manager successfully undertakes the Registered Managers Award or equivalent by April 2005. 10th February 2005. Date of last inspection Brief Description of the Service: Oakland’s Care Centre provides 24 hour nursing care for older adults. The home has been adapted and extended from an existing property and is situated on a quiet road not far from Moseley village. There is a range of community facilities to be found nearby, and a number of bus routes are within a fairly short walk of the home. There is off road car parking to the front of the property. Bedrooms are a mixture of shared and single rooms; spread over three floors of the premises. There are no en suite facilities provided by the home. There are lounges situated on two of the three floors of the home and there is a pleasant enclosed garden area for residents to access. The home has a passenger lift to all floors, a nurse call system and some aids and adaptations to assist residents with limited mobility. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The main part of this inspection was undertaken over the afternoon and evening of one day. A visit was made to the home by the CSCI pharmacy inspector two weeks after the main inspection. Information used in this report was collected by talking with the people who live in the home, and some relatives and staff. The inspector watched the care and support offered during the afternoon, during a meal, and when service users were getting ready for bed. The care documents of three people were tracked. Records about care, staffing, and health and safety were also assessed. The inspector walked around the home, and looked in some bedrooms, bathrooms and all the communal areas. The inspector extends her thanks to everyone who assisted with the inspection. What the service does well: All the people the inspector spoke with reported that generally Oakland’s is a good place to live and work. The inspector looked at seven quality audit forms the manager had distributed to the people that live in the home. Six of these further supported that Oakland’s is a good place to live. The inspector tracked three peoples care. Staff had developed care documents with the person, and they were very individualised, and showed that the person had been consulted and informed about the content. The staff had included information about the person’s life before they came into the home. During the visit the inspector observed lots of positive contact and conversation between staff and the people living in the home. This included staff that sat and chatted to people, played dominoes with them, and supported them sensitively with personal care. Staff worked hard to protect people’s dignity and reassure them when they were lifted with a hoist. One person informed the inspector she had been very nervous about moving into a care home, but said that, “Staff know what they are doing, and that reassured me” Staff retention and recruitment is good. The home has a regular staff team, and the use of temporary staffing is minimal. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 6 The food looked and smelt nice. The kitchen had a wide range of food available. The cook and people who live in the home commented this is usually of good quality, and that there is plenty of food. The communal areas, and most bedrooms were reasonably decorated. The dining rooms were attractively laid for tea, with napkins, condiments and a copy of the menu available. The medicine management within the home is good. The home has systems installed to ensure the service users are administered the medicines prescribed. What has improved since the last inspection? What they could do better: Upon arrival at Oakland’s an unpleasant odour was evident. This was present in the ground and first floor communal areas. The home must get better at removing or managing this. The bathrooms and toilets were not welcoming. Some of these were dirty, and others required upgrading and redecorating. The record of water temperatures showed water to be very cool from these outlets, and the inspector could not evidence showering or bathing would be a pleasant experience. Care records need to better describe the person’s day, and not just clinical needs or events. The manager must ensure peoples cultural needs are better met. Two people commented that the West Indian Food was good but they would like to choose a dish from their own culture every day. The menu did not cater well for people of Asian descent, or who choose to eat a vegetarian diet. One person described the food as, ”The worst part of living here”. The allocation of staff within the home must be reviewed. The inspector noted two key times when people were not supervised or supported which could have placed them at risk. The manager must ensure staff are in the right place at the right time. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 7 Specific care needs including diabetes, exercises (as prescribed by physiotherapy), and eating and drinking must be planned better, to ensure staff are provided with clear information and effective monitoring can be undertaken. Entries by staff in the care notes must improve to ensure all healthcare appointments are recorded and that the person’s day is reflected in the daily notes. 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 Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 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 Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 All potential service users are assessed prior to moving in to the home. EVIDENCE: The plans of three service users were assessed. It was apparent that a full preadmission assessment had been undertaken prior to the person’s admission to the home. It was not evident that the person or their relative had been able to visit the home prior to moving in. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 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, 10 Service users needs and wishes are generally well planned and delivered. Some specific shortfalls in this area were observed, that could result in service users needs being unmet. Staff work hard to ensure service users dignity and privacy is maintained. The home demonstrated some good practice for medicine management. EVIDENCE: The inspector spent time sitting with service users and observing the support they received and were offered. Staff generally worked in a very sensitive way to support service users, and to protect their dignity. The inspector did observe a number of service users for whom personal care had not been undertaken to a high standard, resulting in food being left on their hands and mouths, clothes being soiled, and male service users who had not been supported to shave. In most of the rooms the inspector visited, evidence that the service user had an individual supply of toiletries was evident. In one room no toiletries, hairbrush or toothbrush were available, and it is required these be provided for all service users. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 11 The home uses a communal supply of towels and flannels. It is recommended that ways to enable service users to utilise their own supply be explored. The three-service user plans tracked contained details about their healthcare needs. Generally the inspector found these to be adequate to provide staff with clear information on how to meet the need. For two people tracked a physiotherapist had prescribed specific exercises to help maintain or regain strength. It was not apparent in the daily notes that these were being undertaken, or that staff were tracking if the service user had undertaken these. One person tracked was eating a soft diet and thickened fluids. No clear guidance on how food and drinks were to be prepared was available, and no risk assessment regarding choking or dysphasia had been developed. One service user with diabetes was tracked. The plan of care did not evidence how often blood sugars should be tested, or what a normal blood glucose range for that person would be. Service users had manual handling assessments, which had been kept under review. It was required these be further developed to provide specific guidance to staff on the type of hoist, and size of sling to be utilised. Examples of entries in some of the care plans and risk assessments that need to be made more specific were shared with the care manager. Phrases such as “ assist to” or “support to” without clear guidance on “how” should be avoided. It was generally evident that staff seek assistance from the multi-disciplinary team or GP when required. It was required that one service user be referred to the GP re a possible eye infection. Staff must ensure they enter all appointments onto the service users records. Examples of appointments the care manager knew had been attended, but which had not been recorded were evident. One person tracked had seen the optician and been prescribed new glasses. It was not evident that these had been received. Medication audits demonstrated that medicines are administered as prescribed. The home has a contract with a clinical waste company for the removal of medicines that are no longer prescribed or needed. All return medicines are fully documented. The refrigerator temperature was too cold at the time of inspection. And this was to be addressed by the care manager. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 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, 15 The home offers a variety of in house and community activities that some service users are satisfied with and which others would like to see increase. Friends and family are encouraged to visit the home and made to feel welcome. Most service users are offered a varied and wholesome diet. Provision for people who prefer Asian and Afro-Caribbean meals must improve. EVIDENCE: Previous inspections have identified that more activities and opportunities for engagement need to be provided. The inspector found some progress in this, and discussion with one service user identified he was very happy with the level and range of activities provided. On display was an advert informing service user’s of a firework display on the following Saturday night, and a social event prior to Christmas. Other service users reported they would like the opportunity to get out more. It is positive that the home does provide some opportunity for service users to access the community. The care manager reported a number of church groups visit the home, and support service users to attend events at the church, or undertake services in the home. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 13 Some of the relatives reported that few planned activities are observed in the home. The inspector was pleased to observe a number of ad-hoc games and interaction with service users during the inspection. The main source of entertainment appears to be the television. In all communal lounges these were on. It is recommended that this be reviewed, and alternative stimulation such as music, or chat be explored. In some lounges the picture size and picture quality was poor. If service users are to watch this, the facility needs to improve. The inspector observed the greatest need for improvement regarding activities is for service users with higher dependency. Activities planned and offered would not be accessible or of interest to them. The inspector spoke with four family members. They all reported being made to feel welcome in the home, and supported to visit their relative. Entries in the care notes further evidenced family contact being undertaken. The inspector observed several opportunities for service users to take control of their life during the inspection. It was pleasing to find all service users in their room had been supplied with a call bell, and that this was within easy reach. Choices were made at meal times, and for service users able to vocalise, choices were made regarding when to get up and go to bed. Evidence of service users involvement in their care plan and its review were also evident. The menu for the current week was assessed. The home operates a four-week rolling menu. The food stock was of good quality, and the service users reported food was generally of a good quality and “plentiful”. The meal on the day of inspection was attractive, and smelt nice. The inspector tracked opportunities to eat food other than of traditional English origin. Some Afro-Caribbean foods were served. Two service users reported these were very good, and wished they could have this type of food more often. The needs of one Asian service user were tracked. He reported, “The food is the worst part of living here”. It was evident form reviews that this had been raised previously, but not to his satisfaction. It is required that this be explored, and arrangements made to ensure the service users cultural needs in this area are met. The inspector observed one service user ask for a drink. Staff promptly arranged this. The service user commented, ”It’s good service here!” Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 14 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 The home has an open culture in which people feel able to raise concerns. Records of concerns, and how they have been dealt with must improve. EVIDENCE: The inspector was informed during the inspection of two concerns raised by service users. Neither had been recorded as a complaint. The manager must ensure service users concerns are formally recorded, and evidence of the action taken to address the issue made. Relatives the inspector spoke with reported that the home had a very open culture, and they would feel able to raise any concern or complaints they had. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 15 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, 23, 24, 25, 26 The premises of Oaklands require bathrooms to be developed, and attention to cleanliness and warmth to ensure service users safety and comfort. Staff support service users to add homely touches to some communal areas and their rooms. EVIDENCE: The Oakland’s Care Centre is a large building over three floors. Communal space is provided on two of these. The home has two large lounges and two dining rooms, and a smaller “quiet” lounge. The temperature in the home was very warm. Service users, staff and relatives commented on this. Thermometers within the home recorded the temperature at between 25-26°c. This has previously been raised as a concern and must be addressed. The dining tables on both floors had been attractively set. They were laid with napkins, condiments and a copy of the day’s menu. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 16 The standard of décor in most bedrooms and the communal lounge/dining areas was adequate. The inspector found all toilets and bathrooms inspected to require upgrading. The number of toilets and bathrooms provided was ample to ensure service users are always within close reach of this facility. Not all toilets and bathrooms had been serviced with soap or hand towels. These must be available at all times. Bathrooms and shower rooms must provide space or facility to hang service users clothes, toiletries and towel while showering. The inspector looked in six bedrooms. These were generally comfortable and decorated to a reasonable standard. Some rooms had been very personalised, to the taste of the service user. Service users and relatives reported that rooms were kept clean, warm and comfortable. The cleanliness of the home was generally good. The staff must remove or effectively manage the offensive odour in the home. Specific areas were noted to be dirty, such as some toilets, some bathrooms, and areas where food had been deposited on the wall close to dining tables, or service users chairs. Attention to these details needs to improve. It has previously been required by the Environmental Health Department, and CSCI that the kitchen units be upgraded. This work remains outstanding, although the care manager reported it was scheduled to be undertaken. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 17 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, 29 The allocation of staff within the home does not always ensure service users needs are met. Or that they are protected from hazards. The recruitment practice is generally robust and does ensure service users are supported by staff suitable to undertake care work. Staff attititude towards service users positive and friendly. EVIDENCE: The inspector found the allocation of staff within the home to require review. During teatime on the ground floor, staff were engaged serving food and drinks, but no support or supervision was provided to service users eating. Later on the first floor the inspector found a trolley of hot drinks in the lounge, with service users moving unsupervised around this room. Staff were supporting another service user. This situation put service users at risk of harm. No staff were located on the second floor at that time. Relatives comments about staff were very positive, that they were “Approachable” and that there was, ”Always someone around”. Service users comments about staff were positive and included, ”They are very kind” and ”They know what they are doing” and several service users complimented one of the nurses regarding meeting their healthcare needs. The recruitment records of three staff were assessed. These were generally good. The inspector identified one reference that had raised concern about a Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 18 staffs practice in a previous post. How this had been explored to ensure the problem would not be repeated was not evident. One staff only had only provided one reference. The inspector would expect this be risk assessed and the possible implications of this explored prior to an offer of employment being made. The manager has compiled a training matrix that evidences the training undertaken by staff. The matrix identified some staff are over due for mandatory training including manual handling and fire safety. This must be planned and undertaken. Staff training was not fully assessed. It was pleasing to hear that fifteen care staff are enrolled on to the NVQ level 2. Six staff had already achieved NVQ level two or three. The staff are enrolled on a distance learning infection control course. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 19 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, 36, 37, 38 The management of the home is stable, and is focussed on meeting the needs of the people who live in the home. Evidence that all health and safety testing is undertaken at the required intervals must be provided to ensure service users and staff live and work in a safe environment. EVIDENCE: The inspector was pleased to evidence a stable management team at the home, with the home manager and care manager both having been in post for over three years. The manager is registered with the CSCI. A condition of registration that she achieves NVQ level 4 by April 2005 has been breached. The inspector found the home to be generally well organised and run. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 20 Records of staff supervision did not show staff are regularly supervised, and this should increase. The inspector identified in one appraisal areas where the staff member needed to improve to meet the expected standard. It was surprising to find the goals set did not reflect this developmental need, and it is recommended this be reviewed. Systems of record keeping appeared to be logical and in good order. Most records required could be located, and were up to date. Records for service users were held securely and showed sign of monthly review. It was positive to see that service users were undertaking audits regarding their satisfaction with the home. The inspector read seven of these. Generally feedback was very positive. It was not evident what action had been undertaken to address areas of concern, and to improve the situation for one person who reported to be very unhappy with many aspects of the service. This must be undertaken. In house tests and servicing of the fire alarms, emergency lighting and fire fighting equipment had been undertaken. It is required that all call points be tested in turn. (Call point four not tested since before 28/4/05) Fire drills had been undertaken. The inspector noted these were not with adequate frequency to meet the homes own fire risk assessment (Three monthly) The fire risk assessments were all overdue for review. It is required these be reviewed six monthly, or sooner in the event of an incident. West Midlands Fire Service inspected the home in March 2005. It was not evident all their requirements had been addressed. Some gas equipment and fittings had serviced as required. Evidence that the catering and laundry equipment had been tested was not available. The lifts and hoist had been serviced as required. Evidence that remedial work identified had been undertaken was not available. Tests of the electrical hardwiring appeared to be overdue (Due October 2005) and it is required this be undertaken. Evidence of legionella risk assessment and screening was not available. The record of accidents identified a large number of accidents that had not been reported to the CSCI under Regulation 37.It is required this be addressed. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 21 All workplace risk assessments were due for review. The inspector did not find the control measures in place to be adequate. An example of this is a risk assessment for electricity. The two control measures are Portable appliance tests and electrical hard wiring tests. This fails to recognise and assess the full risks regarding use of electricity in the home. One staff member was observed to wear the same protective clothing for all the service users he supported. Staff should only wear this when required, and ensure it is changed between service users. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 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 X 3 X 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 1 18 X 2 3 1 X X 2 2 1 STAFFING Standard No Score 27 2 28 1 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 1 X 1 Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 23 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. Standard Regulation Requirement Evidence the potential service users have been offered trial visits to the home must be available. Personal care must be undertaken to an acceptable standard Personal items to undertake personal hygiene must be available for all service users. Evidence that required therapies are being provided must be available. Service users with dysphasia must have an eating and drinking plan and choking risk assessment. A full plan of care must be provided for all service users with diabetes. Care plans must detail the specific actions to be undertaken, and equipment required. Timescale for action 01/01/06 1 OP5 12(2) 14(1)(c) 2 OP7 12(1)(a) 12(1)(a) 13(3) 12(1)(a) 13(1)(b) 16/12/05 3 OP7 16/12/05 4 OP8 16/12/05 5 OP8 12(1)(a) 13(4)(c) 16/12/05 6 OP8 12(1)(a) 13(4)(c) 16/12/05 7 OP8 12(1)(a) 13(4)(c) 01/02/06 Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 24 8 OP8 12(1a) 13(1b) 17(3a) All health care appointments and follow up must be evidenced in the service users plan. Staff must improve the stimulation and engagement for service users with higher dependence levels. Food to meet service users cultural needs must be provided. Concerns raised by service users must be recorded as a complaint and evidence of the action taken to resolve the concern recorded Unmet from the previous inspection. 16/12/05 9 OP12 16(2 m-n) 01/02/06 10 OP15 16(2)(i) 16/12/05 11 OP16 22 09/01/06 12 OP19 23(2)(b) The Registered Person shall ensure that the storage units and cupboards in the in the kitchen are repaired/replaced. Toilets and bathrooms in the home must be improved. Hygienic means to wash and dry hands must be available at all communal sinks. Unmet from the previous inspection. 01/02/06 13 OP21 23(2)(b) (j) 13(3) 01/03/06 14 OP21 12/12/05 15 OP25 23(2)(p) The Registered Person shall ensure that the air temperatures 12/12/05 in the first floor lounge are maintained at around 21 degrees centigrade at all times. Staff practice must promote good infection control to include 12/12/05 changing gloves and aprons after supporting each service user. Effective odour management must be achieved. Specific cleaning must be 16/12/05 16 OP26 13(3) 17 OP26 16(2)(k) Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 25 undertaken as required. 18(1)(a) 13(4)(c) The allocation of staff within the home must be reviewed to ensure service users are not left unsupervised or without support. Unmet from the previous inspection. 19 OP28 18(1)(c) The Registered Person shall ensure that a minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005. Evidence how concerns raised in the recruitment process are addressed and resolved must be available. Written evidence that risks have been considered for employing people with one reference must be available in the staff file. 01/06/06 18 OP27 12/12/05 20 OP29 13(4)c 13(6) 19(1)a 13(4c) 16/12/05 21 OP29 13(6)19(1 a) 16/12/05 22 OP31 23 OP33 24 OP36 25 OP38 Unmet from the previous inspection. The Registered Manager is 9(2)(b)(i) required to obtain a recognised management qualification by 2005. Evidence of how information gathered in the Quality 24(1)(b) questionnaire is used must be provided. All staff must receive adequate 18(2) levels of supervision. (Six times per year) Unmet from the previous inspection. The Registered Person shall: Forward to the CSCI the homes 13(4)(a-c) Legionella Risk Assessment and evidence of actions taken by the home to negate any risks identified; 23(4) All fire alarm call points must be tested in turn. DS0000024872.V265823.R01.S.doc 01/06/06 01/02/06 01/02/06 16/12/05 26 OP38 05/12/05 Page 26 Oaklands Care Centre Version 5.0 All risk assessments must be subject to review. 27 OP38 13(4)(a-c) Control measures in risk assessments must be further developed to fully reflect the assessed risk. 13(4) All requirements made by West Midlands Fire Service must be addressed. Evidence that a Landlords Gas safety test has been undertaken on appliances in the laundry and kitchen must be provided to the CSCI. Evidence that remedial work identified at the lift service in May 2005 has been undertaken must be forwarded to the CSCI. The Electrical hard wiring must be tested every five years (Due October 2005) All accidents and incidents must be reported to the CSCI without undue delay. 01/01/06 28 OP38 01/01/06 29 OP38 13(4)(c) 23(2)(c) 16/12/05 30 OP38 13(4)(c) 23(4)(c) 16/12/05 31 OP38 13(4)(c) 23(4) (c) 01/01/06 32 OP38 37 05/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP12 OP12 Good Practice Recommendations It is recommended that a personal supply of towels and washcloths be provided for each service user. It is recommended that the programme of activities continue to be developed and increased. It is recommended that stimulation other than TV be DS0000024872.V265823.R01.S.doc Version 5.0 Page 27 Oaklands Care Centre 4 OP36 explored, and that the quality of the TV picture be improved where poor. It is recommended that deficits in performance or knowledge identified in appraisal be subject to goal setting/monitoring. Oaklands Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Care Centre DS0000024872.V265823.R01.S.doc Version 5.0 Page 29 - 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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