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Inspection on 23/06/05 for Oaklands Care Home Limited

Also see our care home review for Oaklands Care Home Limited for more information

This inspection was carried out on 23rd June 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Overall, Oaklands continues to offer a good basis of care, in spite of some omissions in record keeping and policy making. Whilst there has been some recruitment to the staff group, the home is fortunate to have a core of senior care staff who offer a supportive and caring staff group. Oaklands was reflected as being part of the local community. Situated as it is on the edge of the town centre, visitors and relatives in the area are easily able to access the home. The majority of the resident group are people who have resided in Brightlingsea for many years. Both visitors and residents interviewed at this inspection spoke of staff and management support and involvement in the care provided. All were complimentary of both staff and management practices in the home.

What has improved since the last inspection?

In the last two years, extensive decoration and maintenance has been undertaken both internally and externally. The decoration and maintenance of the home is ongoing, with planned completion of the installation of radiator covers throughout the home. This follows the installation of pre-set valves on all hot water outlets accessed by residents in the home.Oaklands Care Home LimitedVersion 1.30 I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.docPage 6Basic training opportunities offered in the home have increased and improved since the last inspection. Staff were said to have attended courses on lifting, manually handling, infection control, the management of diabetics, pressure area management, fall prevention and continence and catheter care. All of these have been accessed through the Tendring Specialist Nurse (Care Homes). Training records were not fully reviewed at this inspection.

What the care home could do better:

Both the Statement of Purpose and the Service Users` Guide continue to require attention. Whilst it is acknowledged that some minor changes and amendments had been made to these documents in the last year, a major review of these documents is required to ensure that they fully reflect the care service offered and meet regulatory requirements. Staff recruitment processes and administration continue to require attention. This was highlighted by the omissions found in the documentation held for two overseas staff. Immediate action in this regard is required and this has been highlighted within a separate letter. The basic training programme is seen as requiring continued improvement. With the recruitment of new care staff this is heightened. Care planning, risk assessment and risk management strategies require further attention. Whilst it is acknowledged that senior care staff have a good understanding of the care needs of the residents, new care staff will need to rely on these care plans and in their current condition they are do not detail sufficiently the care needs and plan of care of each individual resident. In addition, further work on the policies and procedures in the home is required. This is with particular regard to the home`s complaints procedure and the adult protection procedure. From speaking to residents and visitors the need to expand and develop social activities within and outside the home was highlighted. Current staffing levels will need to be reviewed, using a specific assessment tool (such as the Residential Forum guidance) and increased to reflect the needs of service users. Consideration should also be given to reflect the current practice of care staff undertaking domestic duties, such as cooking and laundry and cleaning tasks, over the weekend. A staffing level review has been highlighted as a requirement in previous inspection reports, this is therefore a matter of concern to the CSCI.

CARE HOMES FOR OLDER PEOPLE Oaklands Care Home Limited 34 A/B Church Road Brightlingsea Essex CO7 0JF Lead Inspector Pauline Dean Final Unannounced 23rd June 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 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 Version 1.30 I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Page 3 SERVICE INFORMATION Name of service Oaklands Care Home Limited Address 34 A/B Church Road Brightlingsea Essex CO7 0JF 01206 305622 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Lalita Devee Cahoolessur 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 Version 1.30 I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age (not to exceed 14 persons) 2. One named person, over the age of 65 years, who requires care by reason of dementia 3. The total number of service users to be accommodated in the home must not exceed 14 persons Date of last inspection 6th January 2005 Brief Description of the Service: Oaklands is a care home which is registered for fourteen older people. The category of dementia, for one specific service user only, is included in the home’s conditions of registration. The home is in the town of Brightlingsea, in 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 a 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 Version 1.30 I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc 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 June 2005. This was the first inspection of the inspection year 2005 to 2006. Throughout the day there was discussion with the registered manager and care staff. Five service users and three relatives, visiting the home, were interviewed. A tour of the premises was conducted during this inspection and both service user and staff records were sampled and inspected at this inspection, along with a number of policies and procedures. Twenty-two of the thirty-eight standards were inspected; of these thirteen were not met. In addition requirements were carried over from the last inspection. The inspector was disappointed to find that in spite of some progress, over 50 of the care standards inspected were not fully met. What the service does well: What has improved since the last inspection? In the last two years, extensive decoration and maintenance has been undertaken both internally and externally. The decoration and maintenance of the home is ongoing, with planned completion of the installation of radiator covers throughout the home. This follows the installation of pre-set valves on all hot water outlets accessed by residents in the home. Oaklands Care Home Limited Version 1.30 I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Page 6 Basic training opportunities offered in the home have increased and improved since the last inspection. Staff were said to have attended courses on lifting, manually handling, infection control, the management of diabetics, pressure area management, fall prevention and continence and catheter care. All of these have been accessed through the Tendring Specialist Nurse (Care Homes). Training records were not fully reviewed at this inspection. 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 Version 1.30 I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc 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 Standards Statutory Requirements Identified During the Inspection Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 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 standard(s) 1, 2, 3, 5 and 6. Currently prospective residents and their relatives do not have clear detailed information to make an informed choice as to whether they wish to be admitted to the care home. Written contracts/statement of terms and conditions sampled were not complete and the pre-admission assessment completed was not sufficient to ensure that residents are assured that their needs will be met. Intermediate care is not offered at Oaklands. EVIDENCE: Both the Statement of Purpose and the Service Users’ Guide continue to require attention. Whilst some minor alterations had been undertaken since the announced inspection of June 2004, major amendments are required to ensure that these documents fully detail the change of Commission i.e. National Care Standards Commission to the Commission for Social Care Inspection (CSCI) and the change to the registration to a limited company. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 9 Detailed individual guidance and guidance produced by CSCI has been sent to Mrs Cahoolessur under separate letter with the expectation that the final drafts of these documents are submitted by 8th July 2005. Resident’s contracts/statement of terms and conditions were sampled and three were inspected. Two of those sampled met requirements with the third requiring attention around the detail of the money paid. The initial pre-admission assessment comprises of two record sheets – a care plan record sheet and a nursing assessment. Whilst the entries sampled detailed particular aspects of care, some omissions were also found, namely history of falls, medication usage, social interests, hobbies, religious and cultural needs and personal safety and risk. Mrs Cahoolessur was advised of the need to review the current documentation used to ensure that it fully meets requirements. All three relatives spoken to confirmed that they and their relative had been involved in the admission process. As possible, visits were arranged to view the accommodation on offer prior to admission and all had moved in on a trail basis. Oakland’s does not offer intermediate care. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 and 11. Care planning documents did not fully detail all health, personal and social care needs and records did not evidence that all aspects of care required. Oaklands established senior care staff have a good understanding of residents’ individual needs. Staff treated residents with respect, actively supporting residents to maintain control of their care and health care needs as appropriate. Arrangements for the storage and administration of service users’ medications, other than in relation to the management of a controlled medication. EVIDENCE: Three care plan files were sampled and inspected. Whilst they were found in a variety of formats, they were found to meet requirements. Monthly reviews were noted and all aspects of care ranging from health to social care, are considered. Whilst it is understood that there is some involvement of relatives in the care planning process, the need to involve residents and their relatives (should they wish) in drawing up the care plan should be considered. This was initially considered at this inspection, but it will be explored in full at future inspections. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 11 All five residents spoken to were positive with regard to the management and arrangements for their personal and health care needs. A local GP surgery is used, with several of the residents being able to remain with their GP on admission to Oaklands. Medication administration and storage was sampled and inspected. The majority of medication was administered from blister pack storage. Records and practice were well maintained. Clarification is required regarding one medicine, for whilst it was acknowledged by the home’s management that it was a controlled drug it was not being treated as such. The need to manage and maintain controlled drugs detailed in the National Minimum Standards – Standard 9, required by legislation, was highlighted as a requirement. Guidance in the form of policies and procedures for managing the care of the dying and procedures in the event of a death, are to be found in the home. Mrs Cahoolessur spoke of the ways in which both residents and staff are supported at these times. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 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 standard(s) 12, 13 and 15. The daily routine in the home was flexible, with residents being encouraged to maintain contact with family and friends. Three relatives visiting the home on the day of inspection confirmed this. Whilst residents spoke of regular contacts in the community, the lack of activities and stimulation in the home was highlighted as a shortfall. Oaklands offered a varied, planned menu with thought given to individual dietary requirements. EVIDENCE: Three residents highlighted the lack of planned regular social activity sessions. They spoke of regular musical afternoons, but spoke of missing short outings, such as into the town of Brightlingsea for shopping and to see the sea. From sampling care planning assessment records it was not possible to ascertain what preferences they had with regard to social activities. This has been highlighted as a shortfall earlier in this report. The three relatives visiting the home said that they were made very welcome when visiting their relative. Residents confirmed that they were able to receive visitors in private and they could choose whom they wished to see or not. A four-week rotation menu is in place, with two to three choices at lunch and teatime. Nutrition records are kept to evidence that the diet offered to resident is wholesome and nutritious. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 13 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 standard(s) 16 and 18. The home’s complaints procedure is made available to residents and their families to enable them to progress complaints as they wish. An adult protection procedure is in place to ensure that residents are protected from abuse. Both of theses procedures require development. EVIDENCE: As at the last inspection, Oaklands had a complaints procedure which overall met requirements. There is however a need to review and revise this document to ensure that all references to the National Care Standards Commission (NCSC) are removed and the Commission for Social Care Inspection (CSCI) is added. Since the last inspection, copies of the local authority guidance on adult protection have been obtained. An immediate revision and review of the home’s adult protection is required. As this is an outstanding requirement from the last two inspections, a copy of the revised adult protection procedure is required to be sent to the Commission within one month of this report. When asked two residents said that should they have any complaints they would take it to the manager and all three relatives spoke of following similar action. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 14 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 standard(s) 19, 22, 24, 25 and 26. The home provides a safe, well-maintained environment that is accessible to residents, 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. There was however, an outstanding requirement from the last two inspections, namely the flooring in the ground floor bathroom still requires attention, for it continues to be raised up, presenting as a safety hazard. A second Oxford Midi mobile hoist has been purchased, thus enabling the home to have one on the first floor and one on the ground floor. Mrs Cahoolessur showed the inspector a variety of lifting and handling aids for use in the home. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 15 Bedsides were seen on at least two beds. From discussion with Mrs Cahoolessur the inspector understands that the installation of bed rails have been raised with relatives. A relative spoken to at this inspection confirmed this. Risk assessments however, do not appear to have been implemented and no consideration has been given to alternative measures. An immediate review of current arrangements is required, with consideration given to alternatives. A suitably qualified person such as a qualified occupational therapist should be requested to undertake an assessment of the premises and facilities. Pre-set valves were said to be fitted and hot water temperature records showed water temperatures being around 43 degrees C. Hot water temperatures were not sampled on this occasion. Radiator covers have been fitted on the majority of radiators, with the final covers to be fitted in the hallway and communal areas. Mrs Cahoolessur acknowledged that detailed risk assessments need to be completed to prioritise the installation of the remaining covers. This is outstanding from the last inspection. Other records relating to the environment were not inspected at this inspection. All bedroom accommodation at Oaklands is single. As at the last inspection an audit of bedroom furniture, fixtures and fittings is still required. Furthermore the outstanding requirement to complete risk assessments regarding the provision of bedroom door keys for residents is still required. Mrs Cahoolessur was advised of the need to action these requirements immediately. Oaklands has an in-house laundry. Care staff undertake laundry tasks during the day and night. The home has two washers and one dryer. Clarification was not sought as to whether the home has services and facilities that comply with the Water Supply (Water Fittings) Regulations 1999, on this inspection. Mrs Cahoolessur does need to ascertain, however, whether the home has such compliance. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. Staffing levels are not appropriate to meet the needs of residents, for little consideration has been given to the provision of social activities in the home. Staff recruitment practices were found to have omissions and shortfalls, which failed to support and protect residents. EVIDENCE: Staff rotas were reviewed and staffing levels were found to be two carers on duty throughout the day and night. Whilst Mrs Cahoolessur said that account had been taken of the Dept. of Health – Residential Forum guidance, this was not reflected in the ratio of staff to residents. Care staff undertake domestic duties such as cooking and laundry and at weekends some cleaning. No account of these duties had been built into the staffing calculations to ensure that resident’s needs are met. Two residents and two relatives highlighted the lack of social activities in the home. Whilst it was recognised that two afternoon musical sessions take place and several residents are taken out on trips by their family, the need to review staffing levels considering this aspect of care, along with domestic duties undertaken, is highlighted as an immediate requirement. Copies of staff rotas and calculations, as completed using the Residential Forum guidance, is requested as part of the inspection report action plan. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 17 Staff recruitment paperwork and practice for two new staff members was sampled and inspected. Both of these staff members were from overseas and the paperwork and practice were found to be not meeting requirements as detailed in the National Minimum Standards – Standard 29. Omissions were found in the application forms completed, references had not been obtained by the care home and references addressed ‘To whom it may concern’ had been accepted. Neither staff member had completed a Criminal Record Bureau enhanced disclosure. Mrs Cahoolessur believed that a copy of a Police Check completed in their home country was sufficient, which is not the case and work permit documentation was incomplete. Following this inspection the original work permit documentation was brought into the Colchester office of CSCI and was seen. Mrs Cahoolessur has been advised of the need to review all staff documentation, taking up references, CRB disclosures and a Protection of Vulnerable Adults (POVA) check immediately. In the meantime the care home must put in place stringent arrangements for the training and supervision of these employees in the interim. Confirmation of action taken and an update is required as part of the inspection action plan. Standard 30 – relating to a staff development and training programme was not inspected in full at this inspection. Some basic training courses were said to have been progressed, such as handling and lifting, manual handling, infection control, diabetics training, management of pressure areas, fall prevention and catheter care. Certificates and records were not inspected. This standard is therefore carried over as a repeat requirement. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 Records held to protect service users were found to be incomplete and not upto-date and therefore did not offer protection, or ensure the effective and efficient running of the business. EVIDENCE: Standards 33, 34, 36 and 38 were not inspected in full at this inspection. They are however carried over as outstanding requirements from the last inspection and are detailed in the Statutory Requirements section to be reviewed at future inspections. As detailed earlier in the report, records required for the protection of service users and for the effective and efficient running of the business, as detailed in Schedule 1 – 4 were not complete, namely the Statement of Purpose, staff recruitment documents and care planning documentation. Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x 2 x 2 2 2 STAFFING Standard No Score 27 1 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 x x x x x x 2 x Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement The registered person must produce and make available to services users an up-to-date Statement of Purpose, with a copy to be sent to the Commission by 08/07/05. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) The registered person must produce and make available to service users a Service Users Guide, with a copy to be sent to the Commission by 08/07/05. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) The registered manager must ensure that no residents move into the home without having all their needs fully assessed as able to to be met by the home. The registered manager must ensuer 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 Timescale for action 08/07/05 2. 1 5 08/07/05 3. 3 14 28/07/05 4. 9 16, 17 28/07/05 Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 21 and storage. 5. 12 The registered person must offer a variety of social activites to suit residents expectations, prefereces and capacities. 22 The registered person must ensure that there is a simple, clear and accessible complaints procedure, making reference to the Commission for Social Care Inspection. 12, 17, The registered manager must 18, 19, 22 review and revise the homes adult protection procedure to ensure that it meets the National Minimum Standards for Care Homes for Older People Standard 19, with a copy of the policy to be sent to the Comission within the timescale for the action plan. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) 16, 23 The registered manager must develop a programme of routine maintenance and renewal of the fabric and decoration of the premises with records kept of work completed. This must include attention to the ground floor bathroom floor covering. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) 23 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. 23 The registered manager must ensure that each service user has accommodation which is I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc 5, 12, 16 28/07/05 6. 16 28/07/05 7. 18 28/07/05 8. 19 28/07/05 9. 22 28/07/05 10. 24 28/07/05 Oaklands Care Home Limited Version 1.30 Page 22 11. 25 23 12. 26 23 13. 27 18 14. 29 19, Schedule 2 furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. (This is a repeat requirement from the last inspection. Previous timescale of 09/08/04 not met.) The registered person must ensure that all radiators are guarded following completion of 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 timescale of 09/08/04 not met.) The registered persons must 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 timescale of 09/08/04 not met.) 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 timescale of 09/08/04 not met.) The registered person must ensure that the home operates a thorough staff recruitment procedure based on equal opportunities and ensuring the 28/07/05 28/07/05 28/07/05 28/07/05 Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 23 15. 30 18, 19 16. 33 24 17. 34 17 18. 36 18, 19 19. 37 4, 7, 9, 17, 19 Schedule 1-4 protection of service users. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) The registered person must 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 not met.) The registered manager must develop effective quality assurance and quality monitoring systems to ensure that the best interests of the service users are met. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) The registered person must develop a business and financial plan for the establishment, which is open to inspection and reviewed annually. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) The registered person must ensure that the employment policies and procedures adopted by the home with regard to supervision arrangements meet National Minimum Standards for Care Homes for Older People – Standard 36. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) The registered manager must review and revise records as discussed and detailed in the Care Homes Regulations 2001, Schedules 1 to 4. (This is a 28/07/05 28/07/05 28/07/05 28/07/05 28/07/05 Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 24 20. 38 16, 17 repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) The registered manager must ensure that so far as is reasonably practicable the health, safety and welfare of service users and staff is safeguarded through the promotion of safe working practices, ensuring basic training opportunities are offered and compliance with health and safety legislation. (This is a repeat requirement from the last two inspections. Previous timescale of 09/08/04 not met.) 28/07/05 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. Refer to Standard 2 Good Practice Recommendations The registered manager should undertake a review of the residents contracts/statement of terms and conditions to ensure that they meet requirements as detailed in the National Minimum Standards - Standard 2.2. (This was a repeat requirement from the last inspection of 06/01/05.) Oaklands Care Home Limited I56_IO5_s55180_Oaklands_v218260_UI210605_Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection 1st Floor Fairfax House Causton Road Colchester, 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. 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