Inspection on 21/06/06 for Oakmount

This inspection was carried out on 21st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oakmount 29/04/09

Oakmount 01/05/08

Oakmount 11/07/07

Oakmount 23/03/06

Oakmount 22/09/05

Oakmount 30/03/05

Oakmount 29/12/04

Oakmount 25/03/04

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

CARE HOME ADULTS 18-65 Oakmount 68 -70 Westgate Burnley Lancashire BB11 1RY Lead Inspector Mrs Pat White Key Unannounced Inspection 21st June 2006 09:30 Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 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 Oakmount DS0000044999.V295788.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 Adults 18-65. 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. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakmount Address 68 -70 Westgate Burnley Lancashire BB11 1RY 0795 6592563 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) Emmanuel Tendaiwo Dangare Mrs Eunice Dangare Mrs Susan Burnett Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home will accommodate up to 9 adults up to the age of 65 years who have mental health problems The staffing levels must be maintained at those agreed for registration. Date of last inspection 23rd March 2006 Brief Description of the Service: Oakmount is a care home for 9 adults with a mental illness. The house is of the older type situated close to the town centre. Accommodation consisted of: kitchen; dining room; 2 lounges; a games/smoke lounge; utility room; a communal games room, which also served as a staff sleep - in room; 5 single bedrooms and 2 double bedrooms. There was a staff room and office on the upper floor. There was a small yard and patio at the back of the building. Mr Dangare was the owner of the home; he is a registered mental health nurse and has managed a nursing home for people with mental health problems. Mrs Susan Burnett was the registered manager of Oakmount. She had several years of relevant experience and had gained the Registered Managers Award. The scale of fees was £400 - £600 per week, with additional charges for hairdressing, transport, some leisure activities and magazines and papers. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced “key” inspection, the purpose of which was to decide an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for (Younger) Adults and checking the progress made on the matters that needed improving from the previous inspection. The inspection took about 9 hours and involved: talking to service users, touring the premises, observation of life in the home, looking at service users’ care records and other documents, discussion with a member of staff and discussion with the manager, Mrs Susan Burnett. Comment cards were sent to left at the home for service users and relatives to complete but none had been received at the time this report was written. What the service does well: The support workers worked hard to meet the needs of the service users. Relationships between staff and service users always seem positive, and supportive towards service users. The support workers assisted and encouraged service users to be as independent as possible and to make choices about their routines and lives. The service users were encouraged and assisted to take part in activities. These included going to “Greenspace”, day centres and doing leisure activities. The service users go on holiday together each year and choose where they want to go. Service users were looking forward to a caravan holiday which they said they had chosen. The food was varied, nutritious and tasty and most service users said they enjoyed the food. The service users were well looked after and they had all the necessary medical attention and treatment they needed. One service user said she had been well looked after following two recent operations. Service users’ medication was well managed and safely administered. Mrs Burnett and Mr Dangare had the right experience and qualifications to manage the home. There was a group of support workers who had been Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 6 working in the home for some time and service users were benefiting from a group of staff that they had got to know and trust. Support workers felt that Mrs Burnett and Mr Dangare supported them, and that they were always available to deal with problems. They were both described as “open, approachable and supportive”. Support workers, Mrs Burnett and Mr Dangare met together regularly to organise the running of the home and to support each other. The home was a safe environment for service users and staff. What has improved since the last inspection? Some of the legal requirements made at the last inspection had been met. The written information about the support the service users needed, and the written instructions about what support workers needed to do to assist and encourage them, had been improved and was being reviewed and updated. These included better information about the risks service users faced and how these risks were managed. Some parts of the premises had further improved since the last inspection and an action plan for more improvement had been sent to the Commission as agreed. The stairs and landing carpets and another bedroom carpet had been replaced. The beds were being replaced. The kitchen was still being refurbished and there was a new fridge. The home was free from unpleasant odours. The training courses and qualifications that support workers had completed had improved and this was benefiting both the staff and the service users. The fire safety precautions had improved according to the requirements of a recent fire safety inspection. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The admission procedures, including written information about the home, would assist prospective users to make a decision about whether or not they would want to live at Oakmount and whether or not their needs and aspirations could be met EVIDENCE: The Statement of Purpose and Service User Guide was adequate as a source of information about the home. A copy of The Service user Guide was in service users’ bedrooms. No service users had been admitted for a number of years, so the assessment procedures and admission procedures could not be fully assessed. However the admission procedures as stated by the manager, and in the homes information, would ensure that an assessment was undertaken to determine whether or not the home could meet a prospective service users needs. Also the needs of some of the service users had been reassessed leading to new care plans. Care plans and discussion with manager, a member of staff and service users showed that service users’ needs were being met and that there had been some improvements in terms of behaviour, motivation and level of activity. Three service users spoke positively about life in the home. They stated there was more going on, and they had things to do that they were looking forward to. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 10 Two senior members of staff had attended a mental health course that had enabled them to understand the service users better and to put their knowledge into practice. The service users whose files were looked at had suitable contracts and terms and conditions. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. Some of the service users care plans had improved and contained more useful up to date information particularly about risk and how the risk should be managed. However the complexity of some of the service users’ needs was still not fully reflected in the care plans and more care plans need to be reviewed and updated. Service users were supported in making decisions about their lives and have choices in their everyday lives. EVIDENCE: Three care plans were viewed. Two had been updated according to a previous requirement, and had generally improved, particularly in terms of more current information and how risks were managed. They generally contained enough information about daily activities, routines, support required and risks. There was some information about dietary requirements. There was evidence of reviews every few months but this had not yet led to the updating of some of the care plans. The key worker system was in operation to assist the process of reviewing and writing care plans. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 12 Some of the service users had previously assessed needs associated with learning disability. However there was no reference to such needs on the care plans. Service users were assisted to make choices regarding their routines, and activities throughout the week. Staff could demonstrate why any restrictions on choice had been enforced and some of these were written on the care plan. When restrictions were made these were negotiated with the service users and some were determined by the multi - disciplinary team. There were frequent service users meetings, and one to one meetings with key workers. These were opportunities for service users to discuss choices and preferences. The risk associated with some service users was assessed prior to admission, and risk assessments had been developed in the in house care plans. Since the previous inspection this aspect of the care plans had improved and included more risk management issues. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Service users were encouraged to take part in a wide range of suitable fulfilling activities that promoted personal development and encouraged links with the local community, families and friends. The homes routines and terms and conditions promoted independence and choice. The meals served were in accordance with service users’ preferences, and needs, and the principles of healthy eating. EVIDENCE: Service users were encouraged to take part in fulfilling activities, both educational and leisure. Some service users attended a therapeutic work centre. Another service user had started a part time cleaning job that she had organised herself. Another service user attended a day centre. One service user had completed a cookery course. Service users were encouraged to be part of the local community and this was reflected in the activities and daily routines, such as one service user having a job, and all being encouraged to use the local facilities, for example the swimming baths and pubs. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 14 The frequency and type of leisure activities had increased since the last inspection and service users spoken with were enthusiastic about this. This was as a result of service users’ requests for more activities. The number of trips had also increased and service users were looking forward to a day at Blackpool. Two service users were having a supervised trip to London. It was clear that staff were trying to find different things to interest and motivate people. One service user had been supported in going swimming. A seven day holiday is included in the contract price and service users were looking forward to another caravan holiday. Service users were supported in forming and maintaining relationships. They were encouraged to have contact with relatives, and several service users had regular meetings with members of their families. One service user visited her husband most days. Service users rights to choice and independence were respected. Restrictions were agreed with individuals and the multi disciplinary team. There were appropriate locks on the bedroom doors. Rules on alcohol and smoking were stated in the terms and conditions. Service users were strongly encouraged to join in the activities but can choose not to. Service users help to plan the meals to be served. The food served was healthy and suited the service users’ preferences. Service users spoke positively about the food served, and the meals observed and those on the menus showed the main meals were nutritious and appetising. The food suited different tastes ranging from curries to traditional Sunday lunch. Breakfast and lunch - time meals were flexible around the service users routines and they were responsible for their own meals at these times. Service users ate the main meal together in the evening and sometimes helped staff to cook it. Since the previous inspection more details regarding food and nutrition were written on the care plan and useful information about diabetes and the food required was available for one service user. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Appropriate personal support was provided to service users, and in such a way as to promote independence. Medication was administered safely but there should be more evidence of the decisions made regarding whether or not service users are capable of managing their own medication and minor improvement in the recording and clarifications of instructions on the MAR sheets. EVIDENCE: The service users did not require personal care support but some required prompting regarding personal hygiene at times. Service users were expected to take responsibility for keeping their rooms clean and doing their washing. Most need prompting and supervision. Service users were encouraged to choose their own clothes and styles etc. Continuity of support was facilitated by the key worker system. The service users physical and mental health care needs were promoted. There were many examples of service users having the health care that they needed, and the records kept in the home confirmed this. Some of the service users had ongoing contact with the mental health service. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 16 Medication procedures and practices in the home were safe and staff had undertaken appropriate training. Policies and procedures were previously checked and found to be satisfactory and there were many areas of good practice. No service user was responsible for managing their own medication, but at least one service user was capable of doing so. However there was still no risk assessment to support a recent decision to pass this responsibility to staff. This was outstanding from the previous inspection. Also the following errors were noted. One service user’s MAR sheet had a hand written entry of a medicine for which there was no supply in the home and which the manager stated was no longer prescribed. Another MAR sheet had been completed incorrectly on one occasion, indicating that a medicine had been given when it had not. Also for another service user paracetomol was prescribed as “when required” for pain relief, but it was being given continually on the advice of the district nurse for another reason. There was no clarification of this, or instructions, on the MARs. The dose given for variable dose medication was not being recorded. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. There was no written evidence of how issues of concern were addressed but service users felt that they could speak to the manager about problems and concerns and the home’s policies and procedures protected service users from abuse and harm. EVIDENCE: The home had a complaints procedure of which the service users had a copy in their service user guides. There had been no complaints recorded in the home, and none had been made to the CSCI, since the previous inspection. Service users expressed grumbles and concerns in one to one meetings with staff, and in service users’ meetings. In general these matters are not written down at the service users’ request. Service users spoken with stated that they had no complaints and that they thought things in the home had improved recently. Service users’ were protected from abuse by the home’s “protection from abuse” policies and procedures. These included a “whistle blowing” policy and step-by-step procedures to follow in the event of suspicions or allegations of abuse and according to the Government guidance. There had been no allegations of abuse reported in recent years. Discussions with staff confirmed that they had undertaken intervention training , including how to deal with aggressive behaviour. Training in adult abuse was included in the NVQ courses. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. Oakmount provided a homely, safe environment for the service users and the service users’ bedrooms met their needs and promoted independence. However the décor, maintenance and cleanliness in some parts of the home must be improved. EVIDENCE: Some parts of the premises had improved since the previous inspection and the stairs and landing carpet had been replaced. A bench and seats had been purchased for a patio area that was being developed as a facility for the service users. The registered person had submitted an action plan, with timescales, for the improvement of the premises. However the jobs listed on the action plan to be completed by the end of June had not yet commenced. These included the completion of the kitchen, replacing fire strips on doors (see below), and repairs in the bathrooms. The bedrooms were personalised, and regarded as the service users’ private space. The rooms appeared to meet the needs and tastes of individuals. The service users were encouraged to be responsible for their rooms and this was Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 19 seen as a way of promoting independence. Since the last inspection another bedroom carpet had been replaced and worn beds were being replaced. The home provided a safe place for the service users. A recent fire safety inspection had been undertaken and a number of requirements had been made. The fire service will monitor compliance. The level of cleanliness in the bedrooms was acceptable and there were no unpleasant odours in the home. However some parts of the home were not sufficiently clean, particularly the bathrooms. This has been outstanding over a number of inspections and must be rectified with priority. This could be done through the home’s policies and procedures which should be reviewed, developed if necessary, and enforced to ensure the home is kept properly clean in all areas. Also the home’s infection control procedures did not include the cleaning of body fluids and the use of protective clothing. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. Service users benefited from a stable and experienced staff team who were undertaking the appropriate qualifications and training. Staff recruitment procedures were in general safe but could be improved to ensure that the procedures comply with the regulations. EVIDENCE: Support workers were developing the necessary skills and competences to do the job. The Manager and deputy manager had just completed a mental health course and were very enthusiastic about what they had learned and how they were going to apply this in the home. Support workers had completed training in “managing aggression” and “intervention”, and over 50 of staff had completed NVQ courses to at level 2. There was an effective and stable staff team with a low turnover of staff, which benefited the service users who commented on this. According to the rotas and observation at the time of the site visit, the number of staff on duty was satisfactory. The member of staff spoken with stated that there was a good atmosphere in the home, and felt that this was largely due to increased activities which was motivating the service users. The service users confirmed this in discussion. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 21 There were regular staff meetings, which were often used for in house training. Since the previous inspection no new members of staff had been fully recruited. One person was being recruited as bank staff. Whilst the procedures appeared safe in this case they must be improved overall to help ensure the protection of the service users from unsuitable staff. For the applicant whose records were viewed, the police checks (CRB & POVA) had not been obtained and there was no written record of an application being made. This person had however completed the home’s induction and her first shadow shift. Only one written reference from a previous employer had been obtained and there was no explanation of why she had left a care job and why one of the referees was not listed as a previous employer. The inspector was assured that she would not be commencing work until all the necessary checks had been completed. The staff training programme was being developed according to the needs of the service users and staff. All staff had undertaken an induction course in accordance with the Skills for Care specifications. The manager and senior support worker had completed a 6 - week mental health course. The senior support worker spoken with confirmed that there were good training opportunities in the home and that the owner was committed to training and staff development. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Staff and service users benefited from open, accessible and supportive leadership, and the views of the service users were used to develop the service. The health and safety of the service users and staff was promoted. EVIDENCE: The registered manager, Mrs Burnett had completed the appropriate manager’s qualifications and had managed the home since 2002. She had attended other relevant training, for example the recent 6week mental health course. She was also an NVQ assessor. The owner Mr Dangare is a registered nurse mental health and has managed a nursing home. He visited the home frequently and is supportive of the manager, staff and service users. All spoken with described him, and Mrs Burnett, as approachable and supportive. There were regular staff meetings and the general view was that the manager and the owner listened to and accepted what staff and service users had to say. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 23 A service users survey had been carried out earlier in the year and the general view was that there should be more activities. Since then these have been developed and extended, and service users stated that they were benefiting. The manager was advised to include professionals in the quality monitoring excercises. The home provided a safe environment for service users and staff. The home’s fire precautions had been checked during a recent fire safety inspection in March. A number of recommendations were made and the fire officer is to return in July to ensure compliance. A new fire risk assessment had been completed but other recomendations have yet to be completed. All staff had undertaken external fire training and the system of fire drills and alarm tests were satisfactory. The gas installations and boiler and an electrical wiring had current certificates of testing. The testing of portable appliances was due. All support workers had appropriate training in first aid and food hygiene. The service users had also undertaken training in food hygiene. The support workers are to do a course in infection control in September. Since the previous inspection the manager had begun to notify the Commission of the appropriate incidents and accidents. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 2 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 x 28 x 29 x 30 1 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 X x 2 X Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 1. YA6 15(2)(b)(c) The process of updating all the 31/07/06 care plans must be completed so that they all contain enough up to date information on all aspects of care and support needed, and which reflects the complexity of these needs. 2. YA20 13 (2) Risk assessments for those 31/07/06 service users capable of administering their own medication must be completed and regularly reviewed. (Previous timescales of 30/05/05 31/10/05 & 23/03/06 not met) YA20 3. 13 (2) The MAR sheets must be an 07/07/06 accurate record of the medication prescribed and given, and any medication no longer prescribed must not be listed on the MARs. (Previous timescale of 23/03/06 not met). 4. YA20 13 (2) Entries on the MAR sheets must 07/07/06 be accurate, and must show whether or not medication has been given. Medication must not be omitted without clarification of the reason. 5. YA20 13 (2) The registered person must 07/07/06 clarify with the GP the use of paracetomol for the service user identified and obtain the appropriate prescription. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 26 6. 7. YA20 YA24 13 (2) 23 (2)(b)&(d) The actual dose administered for “variable dose” medicines must be recorded on the MARs. The registered person must ensure that the action plan for improvement of the premises is followed through and completed. The registered person must ensure that all parts of the home are kept properly clean, including the areas identified on inspection. (Previous timescales of 30/06/05, 31/10/05 & 23/03/06 not met) The home’s policies and procedures should include appropriate procedures for cleaning of the home and infection control, including the cleaning of body fluids and the use of protective clothing. Staff must receive appropriate training 07/07/06 31/05/07 8. YA30 23 (2)(d) 14/07/06 9. YA30 13 (3) 14/07/07 10. YA34 19 (1), The registered person must schedule 2 ensure that persons do not amendment commence work in the home until all procedures have been followed according to the Regulations, including CRB/POVA checks, two written references from employers as listed on the application form and a written explanation of why applicants leave care jobs. 13 (4)(a) The registered person must ensure that the portable appliances are tested. 07/07/07 11. YA42 14/07/07 Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations Standard 1. YA34 It is strongly recommended that a tracking form, to record the dates of CRB/POVA and reference applications and returns and follow up contacts, be developed. 2. YA39 The registered person should extend the quality monitoring exercises to visiting professionals. Oakmount DS0000044999.V295788.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Oakmount DS0000044999.V295788.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!