Inspection on 22/11/05 for Oakleigh Care Centre

This inspection was carried out on 22nd November 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

Oakleigh Care Centre 12/12/06

Oakleigh Care Centre 23/06/05

Oakleigh Care Centre 10/02/05

Oakleigh Care Centre 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Oakleigh Care Centre Oakleigh 89 Benhill Avenue Sutton Surrey SM1 4DJ Lead Inspector David Pennells Unannounced Inspection 22nd November 2005 14:00 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 Oakleigh Care Centre DS0000038487.V269154.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. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oakleigh Care Centre Address Oakleigh 89 Benhill Avenue Sutton Surrey SM1 4DJ 020 8770 4919 020 8642 2192 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) London Borough of Sutton Mrs Pauline Jean Emmerson Care Home 35 Category(ies) of Dementia - over 65 years of age (35) registration, with number of places Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Oakleigh Care Centre is registered for 35 places, 5 of which are used for respite care. 23/06/05 Date of last inspection Brief Description of the Service: Oakleigh Care Centre provides residential care for up to 35 older people with a dementia (or similar condition) diagnosis; it is owned, run and managed by the London Borough of Sutton. The home was built in 1972 – to a design familiar in that period and is now divided into six units with their own lounges, kitchens, dining rooms, toilets and bathrooms. Overall, the home has 29 smaller single rooms and 6 larger rooms (which were previously double rooms but are now in single occupancy). Thirty beds are spread across five units providing permanent residential care, and five ‘respite care’ beds occupy a separate, but not isolated, sixth unit. Permanent service users are encouraged to have items of their own furniture and personal possessions with them in their rooms. Lounges are small and ‘cosy’ and all have the ubiquitous TV and other furnishings. Dining areas are also quite intimate, with ‘kitchenettes’ – allowing a domestic, home cooked approach to food provision. A wide variety of assisted bathing facilities - and a shower - are available for personal hygiene, and the home is kept clean and odour-free. A separate room is provided for service users to use the telephone. Movement around the home is open - though staff members encourage service users to relate to one area where familiar faces of both service users and staff are present. On the ground floor, there is access to two secure garden areas, to the front and rear. Visitors are always welcomed. There is also a day centre on the same site, and the care centre manager is responsible for both services. Some service users – especially those using the Respite Unit – use the day care facility during the day. The home also provides carer support in addition to the residential and day care. The home has its own transport, which is used for the benefit of all service users. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was conducted across an afternoon and early evening. The inspector was able to meet many service users, staff and management. At present, the ‘acting’ manager - Carol Daniel - is running the home, in the absence of the registered manager. An Action Plan has been implemented to address issues arising from two wide-ranging investigations carried out at the home looking at concerns raised by service user’s relatives. This wide-ranging Action Plan addresses communication, documentation, premises issues, staffing issues (including training, support and monitoring, roles and responsibilities), risk assessments – both of individual service users and also premises audits, policies and procedures, workload distribution, job descriptions and computer system usage. It is clear that the registered provider is committed to implementing this plan within the shortest possible timescale - the majority having been addressed already, or at least being implemented - bringing direct benefit to the home and its daily conduct, almost immediately. The inspector is optimistic that issues previously raised will be properly addressed over time. The inspector arrived in time to attend the morning-to-afternoon shift handover session, followed by having a chat with the acting manager, prior to touring the building - and auditing records - as he toured the home. Feedback was then given to the acting manager and her line manager who was present at the home, prior to departing in the early evening. The inspector is grateful to the service users, the staff and the management for their assistance and hospitality during the visit. What the service does well: Relative’s opinions have previously (June ’05) stated that they are well satisfied with the care and attention their loved ones receive; even relatives who did have concerns about the home are happy for their loved one to remain in the home. Service users, themselves, again appeared relaxed, free form anxiety and seemed to enjoy their lifestyles – this noted from the inspector just observing the ‘flow of life’ at the home. The daily routines and engagement of service users and staff was warm and mutually appreciative. Relative or carer involvement in reviews is solid; the inspector was at the home on a day when two reviews had been booked - with close relatives / Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 6 friends being in evidence and involved in these important meetings. The observed handover between shifts also evidenced enhanced communication – the staff ensuring that all service users were covered - allowing a ‘global’ overview of service users to staff, as well as the focused handing on information directly to the carer that would be ‘on the unit’ for that afternoon. The home now benefits from all its bedrooms being single occupancy – the six old ‘doubles’ are now used for people who have high dependency needs where, perhaps, bulky equipment is required to provide appropriate or safe assistance. This move to single occupancy bedrooms has clear positive implications for the privacy and dignity of each individual resident at the home. The home has been assessed for compliance with the Disability Discrimination Act and the main front, and side entrance (into Primrose Unit), have been fitted with ramps and rail bars – and the front door has an automatic sensorcontrolled door opener. What has improved since the last inspection? What they could do better: Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 7 Other documentation – various assessment and information forms were noted, when the inspector reviewed some records relating to new service users, to have been completed for some but not all newcomers. Consistency of approach now has to be the home’s mantra for the future. The passenger lift is due, hopefully, to be refurbished soon; the Commission supports this work, which will make the lift car more accessible, safer and a pleasanter environment. The maintenance of the fire alarm panel was also discussed and a concern expressed by the maintenance engineer - who stated that the fire alarm panel should be replaced ‘a.s.a.p.’ - is to be urgently addressed / resolved. On the record keeping front, the need for formal records of the registered provider’s representative visits to the home is – it is understood, in process – however such visits must be recorded and copied to the Commission. A requirement concerning the Fire Drill recording, which should be more thoroughly focussed with details of what happened and outcomes – particularly learning points and which should be cascaded to those who were not present at the drill itself, is reiterated. 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. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Service users now receive an adequate care plan package provided within the house - including respite care users – based on full assessment information obtained, or demanded from other professionals, by the home. The Home does not provide intermediate care; therefore standard 6 does not apply in this inspection. EVIDENCE: The acting manager was able to demonstrate that appropriate access to the Borough’s social services database enabled better access to information concerning individuals referred to the home; this is especially vital with regard to service users coming to Oakleigh on a ‘respite care’ basis. The home is also being, quite rightly, more assertive in accessing up-to-date information from care management – refusing to accept out-of-date assessments. This allows a more focused assessment of need initially and then leads on to the senior staff visiting a service user at home prior to admission. Intermediate care is not provided at Oakleigh. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10. Service users can rely on initial assessment bringing together a care plan that focuses on the individual’s needs, satisfactions and aspirations – though attention to ensuring the consistency of other information gathering and recording is necessary – and should be monitored by senior staff using a checklist of ‘contents’ for such significant files. Service users can be confident that their general health care needs will be met through the home providing regular access to medical and paramedical services. Service users are assisted with their medication by staff trained to administer the medication. The home has a structure and policy / procedures which clearly protects the service users and ensures their protection in this regard. Service users can be confident that their dignity will be protected through the ethos and practices generally at the home, including the conduct of the staff. The issue of privacy is also held in generally high estimation, the removal of ‘double rooms’ being an indicator of the promotion of respect for the individual. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 11 EVIDENCE: The above statements reflect the outcomes of this inspection visit and also the view of the inspector concerning other areas covered in the previous inspection – which he feels have been consistently maintained. Each service user is allocated a named member of care staff as a Keyworker. Carers are designated to Units throughout the home on a long-term basis, thus allowing the development of familiarity and relationships between service users and service users generally have their needs mapped out in a plan of care. A new risk assessment process has been introduced – which is now completed – along with the care plan, prior to an admission to the home. Various assessment and information forms were noted, when reviewing some records relating to new service users, to have been completed for some - but not all newcomers. Documents such as the ‘pen picture’, Barthel (‘activities of daily living’) Assessment, and familiarisation sheets were inconsistent. Consistency of approach now has to be the home’s absolute ‘mantra’ for the future – ensuring that parallel information (where useful or appropriate) is held for each individual person. Medication administration for one unit was scrutinised and found consistently administered, with only one or two accidental minor ‘glitches’. The inspector was happy to observe on this inspection visit that the public telephone room was uncluttered and allowed comfortable access to the phone and for calls to be made. Such rooms are all too easily commandeered as storage space of other items – the home is now being vigilant in this regard. Oakleigh Care Centre DS0000038487.V269154.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): none inspected at this visit. Service users can expect to enjoy a lifestyle which matches their expectations and cultural / social background, through the provision of a varied and appropriate programme of activity and social engagement. Service users may maintain contact with their relatives, friends and colleagues through the positive ‘open house’ approach that the home has to encouraging visitors to engage with the home and their individual loved ones. Service users can expect a good level of nutritious and well-presented food suited to their needs, and served in a pleasant and homely environment. EVIDENCE: The previous inspection report evidenced the above statements; all four standards were considered ‘met’. There has been little change in the elements contributing to the above, and the inspector confidently reiterates the paragraphs for readers’ information. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 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 the following standard(s): 18. Relatives and service users can be confident that expressions of complaint will be taken seriously and fully addressed through the home’s – and the Borough’s - comments and complaints procedure. Service users can confidently expect that the service they receive is based on an ethos of adult protection, seeking to protect the dignity and rights of each vulnerable individual. EVIDENCE: Some of these standards were not inspected this time; the home has a clear and rigorous complaints procedure, which - through the experience of this last year’s issues - is evidently implemented. The above statements are taken from the last inspection report. One recommendation was checked under this heading. The recommendation – set under standard 18 - that the locally created Oakleigh disclaimer document (requiring a signature of a service user and a witness stating: I understand that Oakleigh will not be responsible etc…”) which has a dubious provenance, and uncertain legal validity / appropriateness – be withdrawn, had not been carried out. New, signed copies of the paper were found on more than one service user’s file, despite the manager assuring the inspector that this document had been withdrawn. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 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 the following standard(s): 20, 21, 22 & 26. Service users can rely upon the home being clean and well maintained to a safe and comfortable level, with adequate facilities to meet their individual needs - and to promote their health and safety – through adequate, ongoing, input from the home’s staff and other professionals. EVIDENCE: Both the indoor environment and the external areas have been assessed for compliance with the Disability Discrimination Act and the main front, and side, entrances (into Primrose Unit) have been fitted with ramps and rail bars – and the front door now has an automatic door opener. Bathrooms are provided with a variety of hoisting and assisting mechanisms, seeking to make a bathtime an enjoyable experience. A previous visit’s recommendation - that bathroom areas be cupboarded to enable the storage both out of sight, and more hygienically, items that are not appropriate to a service users bathing experience is still outstanding. Many bathrooms continue to appear as storage cupboards / clinic rooms - and anything but a ‘familiar’ bathroom where one might relax and have a ‘good soak’. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 15 One concern is raised by the inspector with regard to the temperature of hot water provided for baths; the regular water temperature testing showed that some hot water taps were running at between 36 to 38 degrees Celsius. This, to the inspector, is a decidedly chilly reading – especially in these winter months - and it is recommended that valves be monitored for the water temperature in both directions – and adjusted ‘up’ appropriately (within the safe parameters - i.e. not above 43 degrees) when necessary. A new call bell system has been installed and commissioned; digital keypads have been installed on the stairwell doors; this is in response to an accident that had shown up a previous deficit. Staff members are now more effectively able to communicate with each other using a ‘mobile phone’ system. The home is also in the process of piloting individual sensor alarms with some ‘high-risk assessed’ service users – seeking to ensure that unusual movement, especially at nighttimes, is appropriately responded to – thus reducing the risk of falls. Such individual monitoring must be carefully care planned and a statement of the rights of the individual should also form part of a protocol regarding such concentrated monitoring. The home has ensured all appropriate measures are provided (at a high level) to challenge any issues of cross-infection – and the home was clean and odour-free on the days of the inspection visit. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 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 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): none were specifically inspected this time. The staffing input at the home is provided in numbers and skills-mix to a level that generally meets the assessed and recorded needs of service users. Staff members are sufficiently trained - both in local and vocational disciplines - to ensure that the service users are in safe and competent hands at all times. The registered provider supports the home through its recruitment and employment procedures and practices to ensure that equal opportunities are promoted and that service users are protected from potentially abusive staff. EVIDENCE: Staffing issues at the last inspection were all scored at a satisfactory level and therefore have not been inspected at this visit. The above statements applied to the last visit’s analysis; there was nothing noted by the inspector to suggest that any elements had significantly changed. The Borough has – and provides to the home - a solid ‘human resources department’ and an excellent ‘staff training’ element which continues, this year, with a strong focus on the independent reviews’ Action Plans - ensuring that staff training is pertinent to the well being of service users. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 17 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): 33 & 38. The management and ethos of the home serves the best interests of service users; the home’s philosophy of care & staff members’ approach is appropriate and sensitive; there is clearly a strong concern for service users’ wellbeing. The home benefits from strong support from line management – ensuring that issues are addressed and staff members are supported to provide the best service. The home is also subjected to unannounced visits to independently examine the conduct of the home; it would benefit the home to have written reports to evidence this support - and the Commission to see the evidence of this regular scrutiny. Service users can be confident that their financial interests will be safeguarded by the home’s appropriate management and accounting / financial procedures. Staff members receive appropriate supervision from their seniors and recently developed and ongoing attention to this process will ensure a ‘tighter’ focus on this important area of staff practice development – for the overall benefit of service users. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 18 The registered provider is currently updating all their volumes of policies and procedures at this moment – thus ensuring the best most current practice is adopted over the ensuing months based on this new documentation. The registered provider positively promotes the health & safety of both service users and staff - through regular maintenance and checks of facilities, though concerns about the passenger lift and fire alarm panel require swift action and greater written detail for in-house fire drills detail would benefit the whole home. EVIDENCE: The above statements also cover standards not inspected at this visit – but covered in June 2005, and in those cases, stated in the last inspection report. The inspector was not - and did not become - aware of any issues that would have altered these statements in the interim or subsequently on this visit. A detailed report concerning the passenger lift was undertaken in September 2005. The resulting report identifies a significant number (some admittedly small) of items requiring attention. The intention when the work is undertaken to refurbish the passenger car - which is still fit for purpose; the Commission supports this work, which will make the lift car more accessible, safer and a pleasanter environment. It is now important that the Council addresses the issue with due speed to ensure the best and safest travelling for service users and all at Oakleigh. The maintenance of the fire alarm panel was also discussed and a concern by the maintenance engineer visiting in September 2005 - who stated that the fire alarm panel should be replaced ‘asap’ - is to be urgently addressed / resolved. Fire Drill records were noted still to have little detail about the drill itself or any learning points accrued from the experience; the home must strive to be kept in sufficient detail to ensure that the actual drill is described; with leaning points noted and subsequently cascaded to those staff members who were no present at the drill. The ‘Regulation 26’ visits by a representative of the person-in-control of the home – copies of reports of which should be sent to the Commission - had commenced but there was still a deficit of any reports being regularly sent to the commission. The Interim Service Manager has been visiting the home on a very regular basis (evidenced by her presence on the day of the visit) - and she is acutely aware of the conduct of the home. The formalisation of these visit records – being undertaken by another representative of the organisation - must now be consolidated and regularly submitted to the CSCI. Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X 3 3 3 X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 1 Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 20 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 All pertinent documentation relating to a service user must be amassed at the point of admission, or immediately thereafter, and senior staff must ensure that any such additional surrounding information gathered is monitored by senior staff using a checklist of ‘contents’ for such files thus providing the most adequate and full information for staff to access (Ref: Standards 7 & 12). Whilst acknowledging that steps have been taken to establish a process - regular, monthly, unannounced visits to inspect the conduct of the home - by a representative of the registered provider - must be undertaken, recorded, and a copy of this audit sent to the Commission. Timescale of 15/09/05 not met. Fire Drill records must be kept in sufficient detail to ensure that the actual drill is described; with leaning points noted and DS0000038487.V269154.R01.S.doc Timescale for action 31/12/05 2. OP33 26 30/12/05 3. OP38 23(4) (d) 29/11/05 Oakleigh Care Centre Version 5.0 Page 21 subsequently cascaded to those staff members who were no present at the drill. Timescale of 15/09/05 not met. 4. OP38 23(2) A recent survey has indicated that the passenger lift requires works – the report showing 55 specific items (some very small) for attention, including especially - the levelling of the car at respective floors. Steps must be taken to ensure this advice for works is heeded as soon as practicable (38). The fire alarm panel must be replaced with due speed – in line with the written comments made by the Fire Alarm Maintenance Company on 05/09/05 (38). 28/02/06 5. OP38 23(4) 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP18 Good Practice Recommendations That the Oakleigh disclaimer document requiring a signature of a service user and a witness stating: I understand that Oakleigh will not be responsible etc... has a dubious provenance and should be checked out for legal validity and appropriateness. Although the manager assured the inspector that this document had been withdrawn, some signed copies were found on new service user’s files. That bathroom areas be cupboarded - to store both out of sight, and more hygienically, items that are not appropriate to a service users bathing experience. Many bathrooms continue to appear as storage cupboards DS0000038487.V269154.R01.S.doc Version 5.0 Page 22 2. OP21 Oakleigh Care Centre and anything but a ‘familiar’ bathroom. 3. OP19 The temperatures of bathroom hot water supplies should be monitored to ensure that the thermostatic valves provide adequately safe - but warm/hot water. Valves can be adjusted upwards if they are providing ‘cool’ water. The piloting of individual sensor alarms with some ‘highrisk assessed’ service users, especially at nighttimes, must be carefully care-planned - and a statement of the rights of the individual should also form part of a devised protocol regarding such ‘concentrated’ 1:1 monitoring. The specification of regular lift maintenance works subsequent to its upgrading must be made clear - and monitored - to ensure this work is regularly and correctly undertaken, thus ensuring the lift’s optimum performance. 4. OP22` 5. OP38 Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Oakleigh Care Centre DS0000038487.V269154.R01.S.doc Version 5.0 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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