Inspection on 07/06/07 for Oaklands North Care Home

This inspection was carried out on 7th June 2007.

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 North Care Home 13/07/10

Oaklands North Care Home 23/10/09

Oaklands North Care Home 08/05/08

Oaklands North Care Home 09/01/06

Oaklands North Care Home 10/04/05

Oaklands North Care Home 08/07/04

Oaklands North Care Home 14/04/04

Oaklands North Care Home 22/01/04

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

CARE HOMES FOR OLDER PEOPLE Oaklands North Care Home North Road Whaley Thorns Langwith Derbyshire NG20 9BN Lead Inspector Bridgette Hill Unannounced Inspection 7th June 2007 09:15 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 North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaklands North Care Home Address North Road Whaley Thorns Langwith Derbyshire NG20 9BN 01623 744412 01623 748759 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) www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Miss Josephine Farren Care Home 40 Category(ies) of Dementia (20), Mental disorder, excluding registration, with number learning disability or dementia (20) of places Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Southern Cross Care Homes No.2 Limited may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder - Code MD, MD over the age of 55 years and over. Dementia - Code DE 60 years and over. Mental disorder - Code MD, age 55 years and over. 2. Dementia - Code DE, age 60 years and over. The maximum number of service users who can be accommodated is 40. 9th January 2006 Date of last inspection Brief Description of the Service: The Oakland’s North Care Home is a purpose built 40 bedded home set on the outskirts of the village of Whaley Thorns. Residents’ rooms are situated on two floors, each with its own lounge and dining areas. The home is registered to provide nursing care for service users with dementia 20places and mental disorder 20 places. The ground floor is dedicated to caring for service users with dementia with the first floor housing service users with mental health needs. The home is within walking distance of the few local shops and GP surgery. The range of fees charged at the home are £331.60 - £706.74 per week with extra charges made for Chiropody, toiletries and newspapers. This information is taken from documents in the home during the visit. Some information including the Statement of purpose, Service User Guide and most recent inspection report were available in the entrance hall of the home. It was observed that these would only be accessible to visitors as this was outside of the key pad controlled door which provided security for the service users. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which focused on assessing compliance to previously listed requirements and on assessing all key standards. As part of the inspection a sample of service users care files and a range of documents were examined. During the visit opportunity was taken to have discussions with management, staff and service users. Some service users did not have the capacity to express themselves due to having dementia. The person in charge at this visit was the Manager Josephine Farren. What the service does well: What has improved since the last inspection? What they could do better: The care plans in place were not always person centred and individualised. General descriptions of care needs were given or descriptions of conditions and Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 6 not details of how this affected the service user and the care needs resulting from this. The majority of pre recruitment checks were in place however some staff had commenced employment with just a pova first having been received. Not all staff working in this capacity were working on a supervised basis. There was not a skill based induction programme for staff to ensure staff were sufficiently skilled and knowledge of how to care for service users. The recording of service users monies was found to be poor with infrequent updating of records with no clear audit trail in place. Records and balances of monies did not correlate and personal allowance cheques were not being promptly cashed and put into service users monies. This is an outstanding requirement as previously this has been identified as an area which needed improvement to ensure there is protection for service users monies. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 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 North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure service users needs were assessed and recorded prior to admission being agreed therefore ensuring that service users needs could be met. EVIDENCE: The manager said that unless admissions were on an emergency basis all service users would be assessed prior to admission being agreed. It was stated that where possible service users would visit the home but sometimes if this was not possible family visited the home to help them make a decision regarding placement. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 9 Assessment forms were available to record the findings of the assessment. This included a form which was designed for assessment of service users with dementia. Where emergency admissions were accepted the Manager said that additional information would be sought from care managers prior to agreeing to accept service users. The file of a recently admitted service user was examined. This indicated that the service user had been assessed prior to admission by the Manager of the home. The records were informative and contained all relevant information regarding the care needs of the service user. A file available in the home indicated that there were Terms and conditions of residency contracts available and these had been issued to service users. These included the fees and gave information to service users on what was included in the fees. The home does not provide intermediate care as defined by National Minimum Standard 6. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place to described assessed needs however these were generally written and had scope for improved personalisation to ensure all service users needs are met at all times. EVIDENCE: A sample of three service users files were examined at this visit. The care plans viewed were variable in the quality of content. Some had service users documented preferences and routines recorded. Other care plans were found to generally written for example for hygiene needs – ‘complete assistance required’. Other examples were that conditions were recorded as an identified problem but the care plan did not indicate how this affected the service user and what were the assessed needs of this. One care plan reviewed gave details of a medical condition but did not detail any first aid treatment that may be required as a result. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 11 A good range of risk assessment tools as well as individualised risk assessments were in place in files. These were updated regularly on a monthly basis. According to staff are plans reviews were included as part of the ongoing records. In the sample examined these could not be found. Ongoing records were recorded for each shift staff worked. Entries were found to be repetitive in content and gave little information about the service user as an individual. Examples were ‘assisted with needs’, ‘hygiene needs met’. The storage and administration of medicines was examined at this visit. There were no service users who self-administered medicines. Generally medication administration records were well completed and included recording of variable dosages. Medications were recorded in on receipt although a full audit trail of medicines was not possible due to there not being any disposal records to indicate what had been placed in the returns bin. Some records for returns were available but staff said these did not include the returns bin. Some inconsistent practice was evident regarding the recording of when topical preparations were opened. Some service users spoken had a good knowledge of their medications and were clear about when and who administered these. Some medications were administered by Community nursing staff. Service users at the home were registered with a local GP within walking distance of the home. It was reported from staff that there had been frequent changes of locum GP’s recently but this has been outside the control of the Provider and it was hoped that the more recent changes would improve this. Where GP’s had visited service users this was recorded within their care records. There were regular chiropodist, optician and dental services used by the home if service users wished to access these. Staff spoken demonstrated a good knowledge of service users and how they reacted to different situations. Staff were observed as communicating to service users when approaching them to deliver care. One significant period of time was observed when no staff were in the main communal area. Part of the care plan was dedicated to record if service users wished to be resuscitated. Some of these had been completed and signed by relatives Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 12 without records of any discussions or inclusion of GP’s. No dates of signing were evident and no review date recorded. It was not clear if service users had been consulted or had the capacity to be involved in this process or how the decisions had been reached. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Positive choices and appropriate stimulating activities were offered to service users. EVIDENCE: An activities coordinator is employed by the home for 20 hours per week but it was evident that other staff also became involved in the provision of activities. The Manager said there were plans to increase the number of hours. There was an activities plan on each floor of the home of what was planned for the week. Staff were actively involved in fundraising money for the service users Wish fund. An example of new activities introduced included a sewing group facilitated by laundry staff. This started by service users doing minor repairs but has progressed to recreational sewing. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 14 Care records examined indicated that service users did participate in different activities some as individuals for example a walk in the garden and local areas with staff and as a group for example bingo, biscuit decorating, memory stimulating activities or crafts. The care plans viewed did not however document individual assessed recreation/leisure needs of the service users or how these were to be met. It was apparent from the entries however that activities were meeting the needs of service users and reflected their preferences. Staff spoken to demonstrated a good knowledge of what service users liked as well as what they didn’t like. Occasional external entertainers visit the home. A hairdresser also visits and a dedicated hairdressing salon is available. The local Brownies and guides had also visited the home and were going to be involved in the garden renovations. Some service users attended local clubs on a regular basis. This included a Friendship Club, the Darby and Joan club and Tea dances. One service user said they did not like the bingo at the community groups but attended anyway. A recent trip out had also been arranged to celebrate VE day celebrations. For the majority of the visit age appropriate music was played in the home. It was observed that during the afternoon the television in the lounge had children’s programmes on which one service user said they did not particularly want on. This was discussed with the manager who said that another service user did particularly enjoy these programmes and attempts were made to give service users choices at different times. One service user had a regular communion offered to them at the home as was their choice. Other service users said they went to a local church on occasions. Religious persuasion of service users was known and recorded on the care planning documents. There were no visitors in the home during the visit to speak to. Some service users did not have any relatives. Others had regular visits from family and friends. Staff spoken gave examples of where relatives had been consulted regarding service users likes and the choices they offered. Records in care plans were in place to record any communication with relatives. Some observation was made of the serving of the lunchtime meal which was the main hot meal of the day. Two choices were routinely prepared by the cook and a choice offered to service users at the point of serving. Service users spoken to said the food served was good and they enjoyed it. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 15 Observations of staff assisting service users to eat indicated that they sat and helped service users individually and wore aprons. Some service users were seen using plate guards and had special cups to help them eat and drink independently. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that there are appropriate procedures to be followed should any complaints or allegations be raised regarding the care of service users. EVIDENCE: One complaint had been recorded in the homes complaints book over the past 12 months. This had been regarded as a safeguarding adults concern and dealt with through locally agreed procedures. Some questionnaires in the home which had been supplied by the Commission for Social Care Inspection indicated that nearly half of service users did not know who to raise concerns with. The complaints procedure was included in the Service User Guide in the entrance hallway and on a notice board in the reception area. The Manager said they held regular surgery times which were advertised on a notice on the office door but these were rarely attended and that generally relatives used an informal approach if they wished to speak to staff. The Manager said they had an ‘open door’ policy if anyone had any concerns. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 17 Since the last inspection there have been two safeguarding adults referrals. As a result of these some recommendations have been made and staff training instigated. Discussions with the Manager also confirmed that some monitoring practices of service users have been implemented. Training records indicated that all apart from recently appointed staff had completed safeguarding adults trainin g. This meets a previous requirement. One of the homes staff had completed a course to enable them to trainers others in safeguarding adults. New staff were said by the manager to be given an overview on an individual basis during the induction on safeguarding adults. The policy and procedure on safeguarding adults was available and referred to locally agreed procedures. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was found to be clean and well maintained with positive regard given on the ground floor with respect to tailoring it to the needs of the service users with dementia. EVIDENCE: The ground floor was dedicated to accommodating service users with dementia and this had been reflected in the décor and other aspects. Rummage boxes with interesting items had been sited on corridors along with textiles and other items which could be touched and handled. Doors had been painted in different colours with doorknockers and imitation letterboxes. Names were on all doors and collages of items relating to the purposes of the room were situated near to rooms for example a collage of sponges, toothbrushes and bathroom items was placed near to bathroom doors to aid orientation. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 19 The first floor had an activities room which was in the process of being developed but was also currently used for crafts. Plans had been drawn up to develop the garden and the Manager received confirmation during the visit that a grant had been secured for this. Service users spoken to said they would like to do some gardening and were disappointed that a green house had not yet been erected, this has been outstanding for some time. During the visit an opportunity was taken to speak to the maintenance person who is employed full time at the home. They said a system was in place which they checked each day for any jobs which needed doing. Routine checks were completed to ensure equipment was fully functioning such as wheelchairs, window restrictors and bed rails. A booklet was available which recorded all the above checks and other aspects such as water temperature checks. These were all found to be in good order. Whilst window restrictors were fitted on all upstairs windows it was aid by staff that orders had been placed to fit them on ground floor windows to improve security. The home was found to be clean and tidy in all areas. Staff were observed to wear gloves and aprons when engaging in care related tasks and these were available in bathroom areas. Staff were observed to Hoover up promptly when it was needed. A valid contract was in place to ensure waste was removed from the homes premises. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a group of staff who receive training in order that they are able to meet service users needs. Deficits in recruitment procedures have the potential to place service users at risk. EVIDENCE: The occupancy of the home on the day of the visit was 28 service users. 17 service users had dementia care needs, 11 had mental health care needs. The home provides nursing care but also accommodated 5 service users who required personal care only. Typically there was 6 staff on duty for day shifts always including 1 nurse but mainly 2. At nights there was 1 nurse and 2 care staff. In addition to this the Manager worked on a supernumerary basis. Service users spoken to spoke warmly of some staff and one knew who their key worker was. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 21 Additional staff employed included an administrator, handyman and an activities coordinator. The home has a number of regular bank staff who cover any gaps to ensure the home is staffed. There is considered to be a low number of nurses who are qualified in mental health nursing with two out of five nursing staff (including the manager) holding these. Some staff training had been organised to address this and most staff had attended a range of in house training to improve their knowledge on a range of topics related to mental health. A vacancy currently exists for a Deputy Manager and the Manager said that this had been advertised as a Mental health nurse post. There were currently 18 staff employed at the home. Of these 7 had achieved at least NVQ (National Vocational Qualification) level 2 in care qualifications. One further staff member was enrolled on a course and had begun this with plans stated that further staff would be enrolled. This does not yet meet the required 50 of care staff who are needed to be NVQ (National Vocational Qualification) trained. Two staff files were viewed in full and one discussed to explore how recruitment standards were being met. It was evident from files and discussions that 3 staff had commenced in post without full Criminal Records Bureau clearance, only pova first checks had yet been returned. These staff were working as part of the homes staffing numbers but reportedly under supervision although rota’s indicated that this was not always the case. Application forms and references were in place. Interview notes were recorded. Proofs of identity and photographs of staff were on file. Job descriptions were available for the various posts staff were employed in. Since the last inspection there was a significant improvement in the provision and recording of staff training. An overview including statistics and percentages of what staff training courses had been attended was in place and reviewed monthly. The range of training offered included moving and handling , Basic Food Hygiene for the majority of staff, pressure care, Protection of vulnerable adults, infection control, fire safety and medications. The staff group of the home included staff who were qualified moving and handling and Protection of vulnerable adults trainers. Generally all the training was up to date apart from some staff who were relatively new in post. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 22 The induction process for new staff was examined. An induction checklist was in place but this was not supported by a skill based induction package as is required. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place for monitoring the quality of the service provided to service users. The system for safekeeping service users monies is not being robustly implemented and does not adequately ensure financial protection for service users. EVIDENCE: Since the last inspection a new manager is in post who has been formally registered as a ‘fit person’ to undertake the role by the Commission for Social Care Inspection. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 24 The new Manager is in the process of completing the Registered Managers Award and has an anticipated completion date of September 2007. A range of audit tools were in place and were being completed to monitor the quality of the service. Documented monthly visits made on the Providers behalf were available in the home. These recorded that staff and service users were spoken with but did not record any content of the qualitative aspects discussed. Two surveys were available from visiting professionals although these were not dated. One commented about waiting a long time for the door to be answered. In the entrance hall the valid public liability certificate was displayed. Records for establishing financial liability were not requested. Some monies were stored safely in the home on service users behalf. A sample of records indicated that whilst storage arrangements were acceptable the records were not being updated on a regular basis. The outcome of this was that the balances recorded did not correlate with monies available. Some purchases and withdrawals had been made but not documented. Personal allowances paid to the service users had been paid by cheque from the provider in a timely manner but staff at the home were not cashing these regularly. Some records had not been updated for 3-4 months which did not provide protection for service users that their monies were being managed well at all times. No service users monies were held in bank accounts not in their name. The Service User Guide described the practice to be implemented regarding service users monies but this was not being adhered to and service users had significant amounts of money which were not being managed according to the homes policy and procedures. A range of documents were examined relating to the servicing of installations and equipment in the home. These were found to have been completed and were all in date. Accidents were recorded and audits completed on a monthly basis. The general trend over the past four months was of a reduction in the number of recorded accidents. Care records that where service users had had an accident relatives were informed of this. Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 25 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 3 Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement Care plans must be sufficiently detailed to ensure service users individual needs are recorded and met by staff Records must be kept of medications for disposal to ensure an audit trail is possible Decisions regarding resuscitation must be clearly documented and reviewed and adhere to lawful, good practice and ethical practice Care plans must record assessed social and leisure needs and how these are to be met Where staff are working with a pova first check in place but no full Criminal Records Bureau check supervisory arrangements must be in place and documented for all shifts to ensure vulnerable adults are not placed at risk A skills based induction package must be implemented for each new staff member DS0000058022.V338057.R01.S.doc Timescale for action 30/08/07 2 3 OP9 OP11 13 12 31/07/07 30/09/07 4 OP12 16 30/08/07 5 OP29 19 30/06/07 6 OP30 18 30/09/07 Oaklands North Care Home Version 5.2 Page 27 7 OP35 16 Schedule 4 A system for the storage of valuables and monies must be in place that: Provides accountability for transactions Is fully auditable Is able to be maintained accurately at all times Previous timescale 30/05/06 30/06/07 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 Refer to Standard OP28 OP35 Good Practice Recommendations The Provider should aim to achieve at least 50 of care staff hold at least NVQ level 2 in care Financial transactions made on service users behalf should include 2 signatures Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oaklands North Care Home DS0000058022.V338057.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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