Inspection on 01/07/09 for Oakleigh Retirement Home

This inspection was carried out on 1st July 2009.

CQC found this care home to be providing an Adequate service.

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 Retirement Home 09/07/08

Oakleigh Retirement Home 11/07/07

Oakleigh Retirement Home 10/07/06

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Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Oakleigh Retirement Home Oakleigh Road Clayton Bradford BD14 6NP Lead Inspector Liz Cuddington Key Unannounced Inspection 1st July 2009 11:15 DS0000066814.V376691.R02.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakleigh Retirement Home Address Oakleigh Road Clayton Bradford BD14 6NP 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) 01274 880330 01274 817825 Bel Air Care Limited Care Home 31 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (31), Physical disability (1), of places Physical disability over 65 years of age (4) Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th July 2008 Brief Description of the Service: Oakleigh is registered to provide personal care for up to 31 people, a small number of whom may be diagnosed with a physical disability or dementia. The home is situated in the Clayton area of Bradford, approximately 3 miles from the city centre. There are bus routes to Halifax and Bradford. There are good community facilities in Clayton village including banks, shops, a post office, hairdressers and pubs. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The weekly fees the home charges are between £360.00 and £417.00. this does not include personal expenses such as hairdressing and chiropody. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Oakleigh. The visit to the home was carried out over one day by one inspector. The last key inspection was in July 2008. In May 2009 we also carried out a random inspection of the home, to follow up areas of concern that had been raised with us. These concerns were mainly about the staffing levels in the home and whether staff should combine their care duties with working in the kitchen during the same shift. We required the home’s owner to review this and increase the numbers of staff on duty. The report of that visit is available on request. The methods used to gather information included conversations with the people living at the home, their relatives, healthcare professionals and the staff, as well as looking at care plans and examining other records. We received the homes self-assessment questionnaire before the inspection visit, which gave us a lot of useful information about the home and helped us plan the visit. What the service does well: The home is managed and run in the best interests of the people who live there. The people who live at Oakleigh said they are very happy and the home has a warm and welcoming atmosphere. People said they enjoy living there and said the staff do what people want in the way people prefer. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 6 The pre-admission assessments make sure the home can meet people’s needs. The staff understand the needs and preferences of all the people who live at the home. People’s health is looked after and the staff have the skills and experience they need to do this. Everyone said that staff listen to them, and act on what they say. Visitors said they are always welcomed. There is good and friendly interaction between the people who live at the home and the staff. There seemed to be enough staff on duty to make sure they have time to spend with people in conversation as well as supporting people to take part in individual and group activities. The homes recruitment procedures are thorough, making sure that staff are safe to work with the people who live at the home. All the staff said they enjoy working at Oakleigh and felt they were well supported by the acting manager. They all said the training is good and helps them to do their job well. The majority of staff have achieved a National Vocational Qualification (NVQ) at level 2 or 3. The complaints and adult protection systems work well and people said they know and understand what to do if they have a concern. The home is clean and fairly well maintained and everyone we spoke to said the home is always kept fresh and clean. What has improved since the last inspection? Since the last inspection the care plans have been improved, making them more straightforward and easy to use. They contain up to date information about the individual, including risk assessments where needed, clearly showing how staff are to provide the persons care and support. The care plans are now being reviewed regularly, to make sure they are up to date and reflect the persons current care and support needs. The newly appointed deputy manager has been asked to take on the role of activities co-ordinator as part of her new duties. The deputy manager plans and leads the activities, along with the care staff, and people take part or not as they wish. This has meant that the range of activities has improved. The menus have been changed by the acting manager, to include the wishes of the people who live at the home, giving people a greater choice and to meet any special dietary needs. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 7 Improvements are being made to the decor and furnishings within the building, including new armchairs and carpet in the large lounge. This will make the house a more attractive place for people to live. The assisted bath in the downstairs bathroom has been moved, so that people who need to use a hoist to transfer in and out of the bath can now use it. This has also made space for the new ‘walk-in’ shower. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 8 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 9 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 Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 does not apply People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before they are admitted to the home, to make sure their needs can be met. EVIDENCE: People said that they were given enough information about the home before deciding to move in, and they had also received a contract. Where possible the home encourages people and their families to visit the home and talk to the people who already live at the home, their relatives and the staff. The home invites them to come and spend time at the home, share a meal and maybe take part in the days activities. This means that the home Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 11 can get to know the persons needs and the individual has the information he or she needs to make a decision. Before moving into Oakleigh, peoples needs are assessed to make sure that the home is able to meet their needs. This assessment, as well as Social Services needs assessments when available, forms the basis for the individual plan of care and support. Recently a service was offered to people in the belief that the home could meet all their needs. When it was discovered that the home could not, the owner remedied the situation by making changes to the facilities in the home. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal and healthcare needs are met. People are not fully protected by the medication administration systems. Staff treat people with respect, care and consideration at all times. EVIDENCE: From observation and discussions with staff and people living at the home, it was clear that the staff are aware of each person’s needs and preferences. The staff make sure they provide the help people need in the way they prefer. Five care and support plans were looked at, to make sure that people’s health and personal care needs are being met in the way the person prefers. The Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 13 plans have been improved since our last visit and clearly show each area of the individual’s care needs. They all contain enough information to guide staff in how to care for and support each person. The plans include risk assessments and management plans where someone is at risk of falling, developing a pressure sore, becoming malnourished or any other area the staff feel may put the individual at any risk. Health care visits and treatments are recorded in detail and everyone who commented said they always receive the healthcare they need. In one person’s plan we saw evidence that the District Nurse had been contacted as soon as the staff noticed that they needed treatment. Not all of the plans include a personal history of the individual. If the person, or their relatives, are willing to disclose information about themselves a life history can give staff a basis for understanding the individual better and help them to provide more person centred care. The care plans are reviewed regularly but they need to show that, where possible, the individuals and their families are involved in developing and reviewing their plans. The medicines are kept safe and secure and the Medicines Administration Record (MAR) charts are securely stored. Most of the medicines are supplied by the pharmacy in a monitored dosage system, but some remain in the original packaging. The MAR charts, which must show clearly the quantities of medicines received and in stock for each person, were examined. The medicines supplied in the monitored dosage system appeared to be recorded accurately. The medicine trolley was locked when it was unattended and the members of staff who administered the medication signed the MAR chart after offering each dose. We checked some of the medicines that are supplied in their original packaging, to make sure the numbers that have been signed as administered tallied with the amounts received and the quantities remaining. Not all of the medicines we checked were accurate and staff had not signed the MAR charts on every occasion that a dose of medicine was offered. Staff are still taking sachets of the laxative, Movicol, from the individually prescribed boxes and putting them altogether in the medication trolley. All medicines must be administered directly from the packaging in which they were dispensed, in accordance with guidance from The Royal Pharmaceutical Society. This is to make certain that people receive the medicines that are prescribed for them, in accordance with their doctor’s instructions. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 14 This practice was happening when we inspected the home in 2008 and they were required then to start administering directly from each person’s own supply. We saw one member of staff put someone’s medicines into a pot, signing the MAR chart at the same time, and then they handed the medicines to another staff member to take to the person. When staff take medicines from their packaging and sign the chart, they must also administer the medicine to the person themselves. Otherwise the second staff member is administering medicine which they have not prepared or signed for; this is potentially unsafe and is not following The Royal Pharmaceutical Society guidance. After last year’s inspection visit, we made a requirement that a ‘brought forward’ system was to be introduced in order to make sure that an accurate audit of all the medicines in stock for each person can be carried out. This has not been done, making it difficult to check that the quantities in stock and the amounts administered tallied with the amounts that have been dispensed. Some medicines, especially those that are only taken ‘as required’, must have the correct administration instructions recorded on the MAR chart. This had not happened for some of these medicines, as well as for one person’s cream which was being applied four times a day, although the instructions on the MAR chart said to apply three times a day. During the visit, all the staff were seen to treat people with respect and maintain their dignity. The people who commented said that they receive the care they need and are supported to maintain their independence for as long as they are able. People’s relatives confirmed this. Everyone said the staff listen and act on what they say. People said that the staff are very kind and look after them well. One healthcare professional said that there are staff available to assist whenever they visit. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take part in a range of activities. People are offered a good choice of meals to make sure their dietary needs and preferences are met. EVIDENCE: The home does not employ an activities co-ordinator, but the newly appointed deputy manager has been asked to take on this role as part of her new duties. The deputy manager plans and leads the activities, along with the care staff, and people take part or not as they wish. One person said they enjoy the games. Entertainers visit the home occasionally and special days through the year are celebrated and relatives are invited to join in. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 16 Outings to a famous fish and chip shop had been arranged as well as trips to the local pub, the park or just for a walk in the area near the home. Group activities such as singing sessions and armchair exercises are offered, as well as games of cards and dominoes, along with one to one activities such as reading the newspaper and nail care. Notes are made of the activities people have enjoyed, who took part and the staff who were involved. This will help the deputy manager plan future activities that people will enjoy. Some peoples care plans include life histories, which help staff get to know people better and also plan activities that they will enjoy. Some people said there are sufficient activities and others said there are not enough. This is an area that the deputy manager and staff are starting to develop further, in order to improve the daily life of the people who live at Oakleigh. One relative said that the activities have improved during the last few months. The menus have been changed by the acting manager, to include the wishes of the people who live at the home, giving people a greater choice and to meet any special dietary needs. There are always alternatives available if people do not want the choices on the menu. On the day of our visit the main course at lunchtime was either roast chicken or shepherds pie with vegetables. One of the dessert choices was fresh melon which people said was lovely. People who eat a soft diet are offered their meals with, for example, the meat, gravy and vegetables pureed all together forming a ‘soup’. One person said she is quite happy with this, but it was not clear whether other people had agreed to have their meals presented like this or if they would prefer the meat and vegetables to be presented separately. Staff were seen to assist people who needed help in a calm and discreet manner, following the persons own pace. As well as a cooked meal at lunchtime, there is a choice of hot and cold dishes at teatime. People are asked what they would like at suppertime and this is prepared for them. Since the conservatory dining room has been refurbished, more people are being encouraged to have their meals there rather than in their armchairs at a small table. This makes mealtimes more sociable and gives people who do not move around a lot, a change of scene and different people to talk to. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 17 People said that they enjoy the meals; one person said The meals are lovely. Another person told us that if they do not want the choices on the menu the cook will prepare something they can enjoy. People are offered hot and cold drinks and snacks throughout the day. The people who live at Oakleigh said they can do what they want, when they want. This confirmed our observations that the staff support people to live their life in the way they choose. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have not all received suitable adult protection training. The adult protection policies and procedures, which make sure that people at the home are safe, are in place. EVIDENCE: Any complaints or concerns are recorded in a complaints file. The actions taken and the outcomes are recorded. Staff said they know what to do if anyone has concerns. The relatives said the home responds appropriately to any concerns. People said they know what to do if they have a concern or complaint. Newly employed staff are made aware of the homes whistle blowing policies and procedures, to be used if they suspect abuse or see examples of poor Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 19 practice. We were told that all of the care staff will take adult protection training this year. All the appropriate policies and procedures are in place to guide staff. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable and work is in progress to improve the environment. EVIDENCE: The home is clean and fairly well maintained and everyone we spoke to said the home is always kept fresh and clean. The rooms are comfortably furnished and have a welcoming feel. There are sufficient, accessible toilets on both floors of the house. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 21 A programme of refurbishment has been started which is making the house a more comfortable and attractive place for people to live. New armchairs and carpets have been purchased for the main lounge, the conservatory dining room has been re-painted and new blinds have been ordered as well as new table linen. New carpets have also been fitted in the hallway. The bedrooms are gradually being re-decorated and new bedding and carpets are being purchased to go with the new décor. One of the bathrooms, which is currently used as a hairdressing room, is still in a poor state and is in need of improvement. The assisted bath in the downstairs bathroom has been moved, so that people who need to use a hoist to transfer in and out of the bath can now use it. This has also made space for the new ‘walk-in’ shower. Protective gloves, aprons and antiseptic hand rub are available for staff to use when necessary, to support the homes infection control measures. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet peoples needs. People are protected by thorough recruitment procedures, which ensure that staff are suitable to work with people who live at the home. Suitable training is provided to make sure staff have the skills and knowledge they require to be able to meet peoples needs. EVIDENCE: When we did the random inspection in May 2009, we were concerned that there were not enough staff on duty to meet people’s needs. We checked the staffing levels at this visit and the staff rotas, and peoples comments, confirmed our observations that there are currently enough staff on duty to meet peoples care, social and leisure needs. There are three care staff on duty during the day and evening and two waking night staff. This number seems to be sufficient to provide care and support for the sixteen people who were living at Oakleigh when we visited. The home’s owner said the staff numbers would increase as occupancy levels rise. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 23 The management confirmed that staffing levels are adjusted to meet peoples needs. People said there are always or usually enough staff around and our observations confirmed this. All new staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks are obtained and no new staff begin work until these checks have been completed satisfactorily. There is training available for staff. The home keeps records of staff training, which also shows when updates are needed. Some staff have recently attended training courses on fire safety and health and safety and we were told that the remaining staff will be taking the training later in the year. The owner of the home also said that staff will be taking dementia care and Mental Capacity Act training this year. Further training will be arranged by the home’s new manager. All new staff complete induction training which meets the Skills for Care criteria. This gives them good basic training to help them do their job effectively, and provides a sound basis for taking a National Vocational Qualification (NVQ) course. Fourteen of the eighteen care assistants have achieved an NVQ in care at level 2 or 3. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although there was not a permanent manager in post when we visited, the home was being managed in the best interests of the people who live there. EVIDENCE: The registered manager left at the end of March 2009. Since then another manager from within the organisation has been managing the home. This manager is still managing her own home, as well as Oakleigh. The registered provider is providing additional management support for Oakleigh. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 25 When we visited we were told that the home had just started advertising for a new manager. It is important that a new manager is appointed as soon as possible, in order to make sure there is a full-time manager in post who is solely responsible for managing Oakleigh. The records and the staff confirmed that staff are not currently having one to one supervision meetings with their line manager. The home’s owner said the new manager would be expected to start this. Supervision meetings should be held regularly, as they support staff to plan their personal and professional development and give them the opportunity to discuss any areas of concern in a confidential setting. The staff said that on the whole they are well supported and they work well together as a team. The staff said they are kept up to date with any changes through written records and verbal communication. Peoples personal information is stored securely when it is not being used. Where the home helps people to manage their personal finances, accurate records are kept of all transactions and all monies are securely stored. The homes policies and procedures are kept up to date, to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. These measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. The home has a range of quality assurance systems in place, to help determine the quality of service the home offers. These include surveys for the people who live at the home and their relatives. Regular meetings for people who live at Oakleigh and their relatives, as well as staff meetings, have been taking place and good notes kept of what has been discussed. Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 26 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 3 8 3 9 1 10 3 11 X 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 2 3 3 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 1 X 3 Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 27 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 OP9 Regulation 13(2) Requirement In order to keep an accurate record of all the medicines that are supplied in their original packaging, a ‘brought forward’ system for recording the amounts carried forward and in stock must be introduced. This has been brought forward from the last key inspection when it was required to be completed by 31/08/08. For the safety of everyone, all medicines must be administered to people from the prescription dispensed in their name, in accordance with the Royal Pharmaceutical Society guidance. This has been brought forward from the last key inspection when it was required to be completed by 31/07/08. 3. OP18 18 All staff must have adult protection training, to make sure they all understand fully how to DS0000066814.V376691.R02.S.doc Timescale for action 31/08/09 2. OP9 13(2) 31/08/09 30/11/09 Oakleigh Retirement Home Version 5.2 Page 28 protect the people who live at the home. 4. OP36 18 Individual staff supervision meetings must be held regularly. This is to support staff to plan their personal and professional development and give them the opportunity to discuss any areas of concern in a confidential setting. 30/09/09 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 OP7 Good Practice Recommendations To confirm that people, or their representatives, have agreed to their care plan people need to sign the plan wherever possible. The bathroom that is currently used as a hairdressing room needs to be refurbished, to make it hygienic and more attractive for the people who use it. A manager needs to be appointed and registered with us, with minimal delay, in order to make sure there is a fulltime manager in post who is solely responsible for managing Oakleigh. 2. OP26 3. OP31 Oakleigh Retirement Home DS0000066814.V376691.R02.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission Yorkshire & Humberside Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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