Inspection on 12/12/05 for Oaklands Care Home Limited

This inspection was carried out on 12th December 2005.

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

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

Other inspections for this house

Oaklands Care Home Limited 30/04/07

Oaklands Care Home Limited 30/08/06

Oaklands Care Home Limited 19/04/06

Oaklands Care Home Limited 23/06/05

Oaklands Care Home Limited 06/01/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Oaklands Care Home Limited 34A/B Church Road Brightlingsea Essex CO7 0JF Lead Inspector Pauline Dean Unannounced Inspection 12th December 2005 10:25 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 Home Limited DS0000055180.V269461.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 Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oaklands Care Home Limited Address 34A/B Church Road Brightlingsea Essex CO7 0JF 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) 01206 305622 Oaklands Care Home Limited Mrs Lalita Devee Cahoolessur Care Home 14 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (14) of places Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 14 persons) One named person, over the age of 65 years, who requires care by reason of dementia The total number of service users to be accommodated in the home must not exceed 14 persons 23rd June 2005 Date of last inspection Brief Description of the Service: Oaklands is a care home, registered for fourteen older people. The category of dementia, for one specific service user only, is included in the homes conditions of registration. The home is in the town of Brightlingsea, Essex. The property is situated on the main road into the town and close to all amenities, the seafront and the beach. Mr & Mrs Cahoolessur are the Directors, with Mrs Cahoolessur as the Registered Manager. The home provides fourteen single rooms, with the bedrooms located on the ground floor and the first floor. Access to the first floor is by stairs, a chair lift and a passenger lift. Communal areas are situated on the ground floor and consist of a large lounge and a dining area. The home also has a smaller lounge and a conservatory dining room. Both the kitchen and laundry areas are located on the ground floor in the central area of the property. There is driveway access to the property, with some parking areas and garden areas at the front of the home. Gardens to the rear of the home are large, mainly laid to lawn, with some garden seating. Access is through the conservatory, dining room and some ground floor bedrooms. Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in December 2005. This was the second inspection of the inspection year 2005 – 2006. Throughout the day there was discussion with the Registered Manager, Mrs Lalita Devee Cahoolessur, and senior care staff. All care staff on duty were spoken with during the inspection and service users were spoken with on a tour of the premises. Both care and staff records were sampled and inspected, as were some policies and procedures. Twenty-two of the thirty-eight standards were inspected; of these ten were met, with seven nearly met, four not met and one standard not possible to inspect. All key standards have been considered over the two inspections for the inspection year of 2005 – 2006. It was disappointing to find that ten of the eleven requirements were repeat requirements, five of these from the last two inspections. Over the two inspections, of the inspection year 2005 – 2006, a total of twenty-nine standards were inspected with fifteen of the standards inspected on both occasions. What the service does well: What has improved since the last inspection? After repeated requirements, discussion and consultation both the Statement of Purpose and the Service Users’ Guide have been reviewed and revised and following this inspection copies have been sent to the Commission. They now meet requirements. In addition, the home’s Policy on Adult Protection has undergone further review and this has been sent to the Commission for Social Care Inspection (CSCI) and it now meets requirements. Staff recruitment practices and procedures have also been reviewed and omissions found at the last inspection are now complete. Attention has been given to the maintenance and decoration of the premises since the last inspection. A planned programme of maintenance is now in place and some outstanding work has been completed. Further work is Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 6 required, with the need to implement a risk assessment procedure to highlight risks and the planning and programming of outstanding work. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Clear, detailed information is provided to prospective service users and their relatives to help enable them to make a choice as to whether they wish to be admitted to the home. All service users have agreed written contracts/statement of terms and conditions, which detail the services, facilities and accommodation in the home they have access to. Documentation did not ensure that service users move into the home with having had their needs assessed and being assured that they will be met. EVIDENCE: Following discussion at the inspection, further review and revision was needed to both the Statement of Purpose and the Service Users’ Guide. Prior to writing this report the revised Statement of Purpose and the Service Users’ guide were received and they were found to meet requirements. Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 9 Service users’ contracts were sampled and inspected and these were found to meet requirements. The assessment and admission procedure, and practices for two service users were sampled and inspected and were found to be inadequate. In both cases an initial assessment had only been completed on the day of the admission and not prior to admission. The need to complete a full assessment prior to admission was discussed with Mrs Cahoolessur and the need to fully complete a care management assessment, covering all aspects of the National Minimum Standard (NMS) – Standard 3.3, was highlighted. Oaklands Care Home Limited DS0000055180.V269461.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): 9. Overall, medication administration and storage is well managed, helping to ensure service users’ health care needs are met. The only exception being the record keeping and storage of Controlled Drugs. EVIDENCE: During this inspection medication administration, storage and record keeping was reviewed with a senior member of the care staff. Medication is held in a medication trolley and a wall medication cupboard. Medication administration was sampled and inspected for two service users. Overall, medication administration and record keeping were in good order, with the exception of record keeping and storage of Controlled Drugs for three service users. Whilst clarification and guidance had been sought by the home from the home’s pharmacist, the home was not fully complying with requirements as detailed in the Misuse of Drugs Act 1971 and the Misuse of Drugs (Safe Custody) Regulations 1973. Guidance, as issued by the Royal Pharmaceutical Society of Great Britain – June 2003, entitled ‘The Administration and Control of Medicines in Care Homes and Children’s Services,’ was left with the registered provider. The need to implement the Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 11 installation of a Controlled Drug metal cupboard, as detailed in the Misuse of Drugs (Safe Custody) Regulations 1973 and the National Minimum Standards – Standard 9.5, was discussed with Mrs Cahoolessur and senior care staff, and record keeping must be completed as detailed in the National Minimum Standards – Standard 9.7 & 9.8 in a Controlled Drugs register. Oaklands Care Home Limited DS0000055180.V269461.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 & 14. The daily routine and activites in the home were said to be flexible and optional, but there were no records or plans of activities to support this, thus service users were not able to ensure that the lifestyle experienced in the home matched their expectations and preferences. Service users were said to be able to exercise choice and control over their lives. EVIDENCE: Mrs Cahoolessur said that Oaklands has two morning sessions a week of occupational therapy. These sessions are conducted by a relative of a service user and are centred on music, singsongs, armchair exercise and chatting with service users. Mrs Cahoolessur said that the worker holds records of these activities and the home does not keep records of the activities and of those who took part in the activities. It was also not possible to ascertain what service users’ interests are, for records held in the home did not give this information. The need to develop a mixed activities programme, which is flexible and varied to suit service users’ expectations, preferences and capacities, was highlighted with Mrs Cahoolessur. Current staffing levels do not allow this aspect of care to be currently considered as care staff are involved in both personal care, domestic and laundry duties. Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 13 Records were seen on care planning files of personal possessions brought into the home on admission. Mrs Cahoolessur said that none of the current resident group had the use of external advocates; the majority had family involvement in managing their affairs. Oaklands Care Home Limited DS0000055180.V269461.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 & 18. The home’s complaints procedure is made available to service users and their representatives to help enable them progress complaints as they wish. An Adult Protection Procedure is in place to help ensure that service users are protected from abuse. EVIDENCE: Oaklands has a Complaints Procedure. The registered manager said that there had been no complaints since the last inspection. This procedure met requirements. Following discussion at the inspection, further review and revision was required to the Adult Protection Procedure. Prior to writing this report, the revised procedure was received and it was found to meet requirements. Oaklands Care Home Limited DS0000055180.V269461.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, 22, 24, 25 & 26. The home provides a safe, well-maintained environment that is accessible to service users, homely and meets individual needs. EVIDENCE: A tour of the premises was conducted on the day of inspection and the home was found to be light, bright and clean. Overall, the premises were found to be in good order, with ongoing decoration and maintenance, both internally and externally, noted. A planned maintenance programme is now in place, with records kept of work completed. An outstanding requirement from the last three inspections, namely the flooring in the ground floor bathroom, has now been attended to and new flooring fitted in the bathroom, sun lounge and corridors. Mrs Cahoolessur said that a fire service inspection had taken place recently and the report is awaited. She said that action had been taken regarding the installation of a dishwasher, which had presented as an obstruction and this had been removed. Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 16 As at the last inspection, bedsides were used within the home. Mrs Cahoolessur was reminded of the need to review these arrangements, undertaking detailed risk assessments and arrangements for the management of these bedsides. Whilst it was acknowledged that risk assessments had been completed, these did not fully detail the category of risk and the provision of bedside rail covers. In addition, immediate consideration must be given to an assessment of the premises and facilities by a suitably qualified person, such as a qualified occupational therapist, to ensure that evidence is available that recommended disability equipment is provided and appropriate environmental adaptations are made to meet service users’ needs. These are outstanding requirements from the last inspection. An audit of bedroom furniture, fixtures and fittings is still outstanding from the last inspection. This is a repeat requirement. From sampling records, risk assessments were seen in place regarding the provision of bedroom door keys. These, however, need to be continually reviewed and revised to ensure that they reflect the current situation and practice. Whilst it is acknowledged that the majority of radiators now have fitted radiator covers in place, seven radiators, which are sited in communal areas of the corridors and sun lounge, do not have radiator guards fitted. Mrs Cahoolessur was advised of the need to undertake a comprehensive risk assessment process to identify high-risk areas, to assist with the planned programme of fitting the remaining radiator guards. Hot water temperature record checks are kept, the only exception being that the home had failed to complete a check and record in November 2005. Oaklands has an in-house laundry. Two washers and one dryer are in place. Care staff undertake laundry tasks during the day and night. Mrs Cahoolessur was advised of the need to ascertain whether the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. Oaklands Care Home Limited DS0000055180.V269461.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 & 30. Staffing levels are not appropriate to meet the needs of service users, little consideration has been given to the calculation of staffing hours, using the Residential Forum Guidance, and the provision of social activities and domestic and auxiliary duties undertaken by care staff. Oaklands operates a thorough staff recruitment procedure to help ensure the protection of service users. The staff training programme was found to have omissions and shortfalls that failed to ensure that service users needs are met. EVIDENCE: On arrival at Oaklands, it was evident that staffing levels were low. A carer had failed to come on duty and only Mrs Cahoolessur and one carer were working that day. From inspection of staff rotas and discussion with Mrs Cahoolessur, staffing levels were found to be two carers on duty throughout the day, with two awake night share staff at night. No consideration has been given to the Dept. of Health – Residential Forum guidance and furthermore no thought had been given to care staff undertaking domestic duties such as cooking and laundry and cleaning at weekends. In addition, no account of the provision of social, recreational and cultural activities, other than four hours a week had been built into the staffing calculations. Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 18 A Notice of Immediate Requirement has been left with the home requiring the registered provider to submit copies of staff rotas for the weeks commencing 2nd & 9th January 2006, with calculations of staffing hours detailing care hours, domestic and catering hours. Copies of the calculations, detailing dependency levels of service users, were also requested. Action was required by 28th December 2005. Mrs Cahoolessur responded on 28th December 2005 stating that she was still awaiting a copy of the Residential Forum Guidance and on the 4th January 2006 copies of staff rotas for the above weeks were received by Commission for Social Care Inspection (CSCI). The information provided was incomplete and at the time of writing this report these matters are being pursued by the Commission. Oaklands has not met the requirement of a minimum ratio of having 50 of care staff with National Vocational Qualification (NVQ) level 2 or equivalent by 2005. Three staff recruited in the last year need to complete both induction and foundation training to National Training Organisation (NTO) specifications. Whilst there was some evidence of some in-house induction training, there was no evidence of either an induction or foundation training scheme that meets these requirements. Oaklands Care Home Limited DS0000055180.V269461.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, 35, 37 & 38. The registered manager needs to obtain a management qualification to help ensure that the home meets its stated purpose, aims and objectives. The home has an effective quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the service users. Service users’ financial interests were said to be safeguarded through written records of all transactions. Records held to protect residents were well-maintained, up-to-date and stored safely. The health and safety of residents and staff is protected through the renewal and updating of health and safety certifications. EVIDENCE: Mrs Cahoolessur, a director of Oaklands Care Homes Limited is also the registered manager of the home. She is seen to be in day-to-day control of the home. Whilst it is acknowledged that Mrs Cahoolessur has considerable experience as a hospital nurse, she recognises that she needs to obtain a management and care qualification to a National Vocational Qualification (NVQ) Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 20 level 4 or equivalent. She said that she has approached a local college and is awaiting clarification as to the training on offer. In view of the National Minimum Standard deadline of 2005, Mrs Cahoolessur was advised of the need to pursue this training as a matter of urgency and confirmation of acceptance on an appropriate training course is required by April 2006. Service users, relatives and professionals have completed quality assurance questionnaires. Within the Service Users’ Guide there was reference to the results of the surveys sent to relatives of service users and a brief analysis of the results has been added to this document. At this inspection, the inspector was informed that both the records and monies held for service users were not available in the home. Mrs Cahoolessur said that they were at her home undergoing auditing and accountancy procedures. This standard will be inspected at the next inspection. Records required for the protection of service users and for the efficient and effective running of the care home were inspected and reviewed during this inspection. Records, as detailed in Schedule 1 & 2, were found to be in good order. Schedule 3 records were not inspected in full and of those inspected they were found to be met. Records, as listed in Schedule 4, were sampled and inspected and, of those inspected, they were found to be met. Mrs Cahoolessur helps ensures safe working practices through ongoing basic training courses. In 2005 care staff have undertaken training courses in Infection Control, Pressure Ulcer Care, Continence and Catheter Care, Manual Handling, Diabetes training and Accountability of Medication training. Further training is planned and identified in Fire Safety and Food Hygiene. Health and safety certification was sampled and found to be in good order. Gas safety and maintenance service certification were seen dated 28th October 2005 and Portable Appliance Testing (PAT) certificates were seen dated 25th November 2005. Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 1 X 3 2 2 STAFFING Standard No Score 27 1 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X 3 3 Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Timescale for action The registered manager must 27/01/06 ensure that no service users move into the home without having all their needs fully assessed as able to be met by the home. (This is a repeat requirement from the last inspection. Previous timescale of 28/07/05 not met.) The registered manager must 27/01/06 ensure that there are policies, and staff adhere to procedures, for the receipt, recording, storage, handling, administration and disposal of all medicines. This includes Controlled Drug administration, record keeping and storage. (This is a repeat requirement from the last inspection. Previous timescale of 28/07/05 not met.) The registered person must offer 27/01/06 a variety of social activities to suit service users’ expectations, preferences and capacities. (This is a repeat requirement from the last inspection. Previous timescale of 28/07/05 not met.) DS0000055180.V269461.R01.S.doc Version 5.0 Page 23 Requirement 2. OP9 16, 17 3. OP12 5,12,16 Oaklands Care Home Limited 4. OP22 23 5. OP22 23 6. OP24 23 7. OP25 23 The registered person must demonstrate that an assessment of the premises and facilities has been made by a suitably qualified person, including a qualified occupational therapist, with specialist knowledge of the client group catered for, and provides evidence that the recommended disability equipment has been secured and provided and environmental adaptations are made to meet the needs of service users. Detailed, related risk assessments for bedside rails must be implemented. (This is a repeat requirement from the last inspection. Previous timescale of 28/07/05 not met.) The registered person must demonstrate that an assessment of the premises and facilities, namely the use of bed rails, is undertaken by a suitably qualified person. Detailed, related risk assessments must be implemented. (This is a repeat requirement from the last inspection. Previous timescale of 28/07/05 not met.) The registered manager must ensure that each service user has accommodation, which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. An audit of bedroom accommodation, fixtures and furnishings is required. (This is a repeat requirement from the last two inspections. Previous timescales of 09/08/04 and 28/07/05 were not met.) The registered person must ensure that all radiators are guarded following completion of DS0000055180.V269461.R01.S.doc 27/01/06 27/01/06 27/01/06 27/01/06 Oaklands Care Home Limited Version 5.0 Page 24 8. OP26 23 9. OP27 18 10. OP30 18, 19 detailed risk assessments. Detail of completion of this risk assessment process is required with a planned programme of the implementation of radiator guards. (This is a repeat requirement from the last two inspections. Previous timescales of 09/08/04 and 28/07/05 were not met.) The registered persons must 27/01/06 ensure that services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. (This is a repeat requirement from the last two inspections. Previous timescales of 09/08/04 and 28/07/05 were not met.) 27/01/06 The registered person must ensure that staffing numbers and the skill mix of qualified/unqualified staff are appropriate to the assessed needs of the service users, the size, layout and purpose of the home at all times. Detailed staffing level rotas and Residential Forum guidance calculations are required within the agreed timescale for action. (This is a repeat requirement from the last two inspections. Previous timescales of 09/08/04 and 28/07/05 were not met.) The registered person must 27/01/06 ensure that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce targets, with particular regard to induction and foundation training. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 and 28/07/05 were not met.) Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 25 11. OP31 18, 19 The registered manager must be 30/03/06 qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Confirmation of acceptance on a relevant training course is required by April 2006. 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 OP28 Good Practice Recommendations The registered manager should ensure that a minimum of 50 of members of care staff have a NVQ level 2 or equivalent as soon as possible. The recommended date is the end of December 2005. Oaklands Care Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Home Limited DS0000055180.V269461.R01.S.doc Version 5.0 Page 27 - 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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