CARE HOME ADULTS 18-65
Oakmount 68 -70 Westgate Burnley Lancashire BB11 1RY Lead Inspector
Mrs Pat White Unannounced Inspection 22nd September 2005 09:30 Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 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.V252597.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 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.V252597.R01.S.doc Version 5.0 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 Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 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 30th March 2005 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 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. 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 numerous relevant qualifications including the Registered Managers Award. The aim of the home was to provide a stable and emotionally secure environment in which service users were encouraged to pursue their individual full potential. A wide range of policies and procedures, which were in accordance with the Care Home’s Regulations 2001 and the National Minimum Standards, underpinned the care and the services and facilities provided. The service users were encouraged in a wide range of activities, such as attending college, therapeutic employment and group and individual social activities. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection, the purpose of which was to assess important areas of life in the home that should be inspected over a 12 month period, to check the legal requirements and recommendations from the previous inspection and to check other matters which came to the inspector’s notice. The inspection took eight hours, and comprised of talking to service users, a tour of the home, looking at service user’s care records and other documents, and discussion with the registered manager, Mrs Susan Burnett. Two members of staff were interviewed. Seven service users were seen and two spent time in conversation with the inspector. Some of their comments are included in the report. Most of the residents did not wish to talk to the inspector about the running of the home. Comment cards were left for service users and relatives to complete and return to the CSCI. These had not been returned at the time the report was completed but the views expressed can be included in the next inspection report. This summary is particularly aimed at service users, and the home should ensure that the full report is widely available to all those who are interested. 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 a wide variety of activities and 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 and staff had recently been on such a holiday and those spoken with stated they had enjoyed it. One service user said they had “had a whale of a time”. The service users were well looked after and they had all the necessary medical attention and treatment for illnesses. One service user said she had been well looked after during two recent operations. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 6 The home was well run and managed by people who had the right experience and qualifications. Support workers felt that Mrs Burnett and Mr Dangare supported them, and that they were always available to deal with problems. Support workers, Mrs Burnett and Mr Dangare met together regularly to organise the running of the home and to help each other. What has improved since the last inspection? What they could do better:
The written information provided to the service users about the home (the statement of purpose and the service user guide) still needed more details, and service users must be provided with an up to date contract / terms and conditions so they know what their rights and responsibilities are The written information about service users’ needs and how they are cared for could be further improved, and more frequent updating of this information is needed to help staff and service users understand the complexity, and changes, of needs. As a matter of urgency the service users concerns, which are said to staff, must be written down properly so that these concerns can be checked, and
Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 7 used to further protect service users and to plan developments in the home. Also the home’s written instructions that protect service users from being badly treated by staff, must be improved. Further improvements for the home were planned, including the replacing of carpets and decorating. The cleanliness in some parts of the home must be improved, including getting rid of the smell of urine. One of the bathrooms has been in urgent need of improvement and cleaning for some time. These matters should be dealt with urgently. The manager and owner must immediately set up a way of finding out how good the home is, and for finding out what the staff and service users think of the home. The owner and manager should make sure that all improvements required under the law are carried out in the time stated in the inspection report. 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.V252597.R01.S.doc Version 5.0 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.V252597.R01.S.doc Version 5.0 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): 1, 3 & 5 Information about the home, and the admission procedures carried out, would assist prospective service users and their relatives to make a decision about whether or not service users would want to live at Oakmount. Staff were committed to meeting the needs of the service users. EVIDENCE: The home had a statement of purpose and service user guide, which provided service users and prospective service users with useful information about the home. All the service users had a service user guide including a copy of the complaints procedure. The statement of purpose must include details of the methods used to consult with service users about the running of the home. It should include more details in some matters listed in schedule 1 of the Care Homes Regulations 2001. The service user guide must include all the matters listed in Regulation 5 of the Care Homes Regulations. There had been no recent admissions, but the admission procedures including the procedures for assessing prospective service users’ needs remained the same as at previous inspections and should determine whether or not a placement would be appropriate. The inspection methods showed that the service users’ emotional, psychological and physical needs were being met. The registered person and the manager ensured that these needs were met according to relevant clinical guidance, and that staff had the necessary knowledge and skills. The registered person must ensure that service users have an updated contract and which includes all the matters listed in standard 5.
Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 10 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, 8 & 9 The written information about service users in the care plans had been developed, since the previous inspection, to assist staff and service users in understanding service users’ needs. Further development, and more frequent updating, of this information is needed to reflect the complexity, and changes, of needs. Service users were assisted in making choices, and taking risks, to promote independence. Service users were consulted about the running of the home. EVIDENCE: The viewing of care plans showed that some of these plans had been developed since the previous inspection to include details of challenging, difficult and obsessive behaviour. However they would benefit from greater detail about the strategies employed to manage this type of behaviour and to reflect the complexity of some issues. A key worker system was in operation to facilitate continuity, and the reviewing of care plans. However there was evidence that the care plans would benefit from more frequent reviews and updates to reflect the changing circumstances and needs of the service users. Service users were assisted in making decisions and choices in their lives, for example in leisure activities, relationships and daily routines. Decisions to
Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 11 restrict choices were made through negotiation with service users and in some instances in conjunction with other involved professionals. All service users managed their own “personal allowance” spending money. Service users were encouraged to participate in the running of the home. Service users’ meetings were held fortnightly and there was ongoing dialogue between the service users and staff regarding the home’s routines and policies. The risk assessments had been developed since the previous inspection but need to include details of how risks are managed and minimised. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 12 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, 16 & 17 Service users were encouraged to take part in suitable fulfilling activities and their right to independence and choice was promoted. 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 throughout the day and at the time of the inspection some service users were at the local therapeutic supported workshop and at a day centre. One service user had recently completed a cookery course at college. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 13 Service users’ independence and rights to choice and dignity were promoted. The rules and the routines of the home were continually reviewed to encourage these. Service users participated in household chores and took some responsibility for food shopping, making their own snack meals, cleaning / tidying bedrooms and laundry. The staff on duty were seen interacting positively with service users; spending time in discussion and offering support. Bedroom doors had appropriate locks and service users had been given their own keys. Service users could spend time in their bedrooms, and there was sufficient communal space for privacy for individuals. The meals served appeared to suit the preferences and needs of the service users, who were involved in planning the menus every fortnight. Service users had snack meals at lunch – time, which they prepared themselves at a time to suit their routine and preference. A two course cooked meal was served in the evening which some service users helped to prepare. Drinks and snacks could be prepared throughout the day. Service users’ nutritional needs were assessed and monitored, and for at least one service user for whom it was particularly relevant, there had been an improvement in the recording of such information. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 14 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): 19 Service users’ physical and psychological health was well monitored, and appropriate action was taken. Service users were encouraged to take responsibility for their own health and healthcare and were supported by staff as necessary. EVIDENCE: Discussion with the manager, service users and the viewing of the care plans indicated that the service users’ psychological and physical needs were well monitored and addressed. At the time of the inspection there was several instances of service users receiving all appropriate medical care for physical illnesses and symptoms. Service users confirmed this in discussion with the inspector and that they were supported by staff throughout and were encouraged to take responsibility for their own health and health care where possible. The recording of health care issues had improved since the previous inspection. The standard relating to medication management in the home was not fully inspected, but progress on the previous legal requirements was monitored. Policies and procedures had been developed in accordance with the Royal Pharmaceutical Society Guidelines. However these must be further developed to include step by step procedures in some areas of administration, for example “when required” medication. The registered person must also ensure that there is a policy and procedure regarding “refusal and covert
Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 15 administration of medication” and must ensure with priority that risk assessments are undertaken for those service users who administer their own medication and which are kept under frequent review. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 16 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 In order to assure service users that their concerns are taken seriously all matters of concern which require action should be recorded fully and should include the outcome. Service users were protected from abuse and harm, but staff need step by step procedures to follow in the event of suspicion or an allegation of abuse. EVIDENCE: The home had a complaints procedure which service users had access to. However most grumbles and issues of concern were not dealt with as a formal complaint investigation. Many were not recorded. Service users know who to speak to if they are not happy with any aspect of the service. The manager must ensure that all issues of concern that require action are recorded fully and to include action taken and outcomes. Oakmount had a “protection from abuse” policy, which included a “whistle blowing” policy. However to further ensure the protection of service users the home’s policies and procedures must be developed with priority to include step-by-step procedures to follow in the event of suspicion or allegation of abuse according to the “No Secrets” guidelines. Staff interviewed stated that they would inform the manager if they had any suspicions of abuse. There had been no allegations of abuse reported in recent years. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 17 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, 27, 28 & 30 Oakmount provided a homely safe environment, and some parts of the home had been improved since the previous inspection. However some areas of the home would benefit from cleaning and redecorating. The bedrooms suited the service users’ tastes and needs and afforded opportunity for privacy. There was sufficient communal space for privacy and recreation. EVIDENCE: Oakmount is of an older type property and is the result of two care homes that have been amalgamated. It was homely in style, furnishing and décor, and had suitable heating and lighting. Some redecorating and refurbishment had taken place since the previous inspection and this was being done on a priority basis. Further refurbishment was planned, and there were plans for this. However a bathroom was in urgent need of cleaning and decorating and a toilet seat needed replacing. These matters must be addressed with priority. The home met the requirements of the fire service. There were two double bedrooms and five single rooms. All bedrooms remain the same as prior to the implementation in April 2002 of the National Minimum Standards on room sizes. The use of the shared rooms was kept under review. All bedrooms were adequately decorated and furnished and service users were able to choose some of the furnishing and fittings. Bedrooms appeared
Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 18 personalised. Two service users confirmed that their bedrooms had been redecorated and furnished and that they were pleased with the results. There were appropriate locks on bedroom doors and service users had their own key. Service users were responsible for tidying and cleaning their rooms and some kept their rooms to a satisfactory standard. However some were reluctant to do this, and for them there was ongoing conflict between promoting service users’ choice and independence and maintaining a reasonable level of cleanliness in these areas. The manager stated that this is addressed with individuals on an ongoing basis. For 9 service users there were 3 bathrooms with WCs, 1 WC, and a shower room. Appropriate locks were fitted. One double room was en - suite. As a home in existence before April 2002, Oakmount meets the standard on the ratio of bathing facilities and WCs per service user. The communal space consisted of two non - smoking lounges, a smoking lounge, a dining room and a recreational room. The service users had in excess of 4.1sq ms each of communal space and there was enough space for service users to receive visitors in private. Some upstairs areas of the home had an odour of urine due to the recent behaviour of one service user. The multi disciplinary team was addressing this problem but the registered person must ensure that all parts of the home are free from offensive odours at all times. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 19 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): 31, 32, 34 & 35 Though staff appeared to understand their roles and responsibilities, they would benefit from up to date job descriptions. Staff appeared well motivated and enthusiastic and the home’s policy on staff training should ensure that all staff complete relevant qualifications. The home’s recruitment procedures were in accordance with legal requirements and should ensure the protection of service users from unsuitable staff. EVIDENCE: The staff did not have current job descriptions. At the time of the inspection, an employment consultant was preparing these. However staff spoken with appeared to understand their roles and responsibilities. The home had a key worker system, which facilitated greater understanding and positive working relationships between staff and service users. The staff spoken with appeared enthusiastic and motivated. There were regular team meetings and “workshops” which were used as training opportunities about mental health issues specific to the service users. There was evidence of good relationships with other professionals and with those in the multi disciplinary team. Two out of 7 support workers had successfully completed NVQ courses to at least level 2, and 4 others were working towards this qualification. There was a staff training matrix based on the needs of the staff and the service users, and all members of staff had attended a college based “induction” course in accordance with “Skills for Care”. There had been no new members of staff recruited since the previous inspection. An employment consultant was reviewing the home’s employment and recruitment procedures and documentation. It is recommended that a
Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 20 “tracking form”, to date CRB/POVA and reference applications and follow up contacts, be developed. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 21 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 & 40 The manager was competent, qualified and experienced to run the home, but must ensure that the legal requirements outstanding over a number of inspections are met, including the establishment of a service user centred quality monitoring system. Staff and service users benefited from open, accessible and supportive leadership. EVIDENCE: Mrs Burnett, the registered manager is qualified, competent and experienced to run the home. She had completed the Registered Managers Award and expected to complete NVQ level 4 in “Care” by the end of 2005. She demonstrated commitment to training and development. Mrs Burnett and the registered provider Mr Dangare communicated a clear sense of direction according to the home’s aims and objectives. The staff interviewed described them both as being approachable, supportive and accessible. There were regular staff meetings which offered staff an opportunity to air their views and influence service delivery. The registered person and the manager must as a matter of priority establish a quality monitoring system under Regulation 24 of the Care Homes Regulations,
Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 22 which involves service users and other stakeholders, and which underpins the development plan for the home. The home was reviewing the policies and procedures, and a consultancy firm was preparing policies and procedures relating to employment and staff recruitment. Staff spoken with stated that they had access to these policies and procedures and covered some of them in the home’s induction. Standard 42 was not fully assessed but the previous legal requirements and recommendation were monitored. One legal requirement was still outstanding – to ensure the home’s water supply does not pose a threat of the spread of Legionella. This must be complied with and the CSCI notified when the appropriate tests have been carried out. Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X 3 X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 x Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 2 3 x 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 2 2 X 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Oakmount Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 1 3 X 2 x DS0000044999.V252597.R01.S.doc Version 5.0 Page 24 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 YA1 Regulation 4 Requirement Timescale for action 31/10/05 2 YA1 3 YA6 4 YA6 5 YA20 The statement of purpose must include details of the ways used to consult with the service users about the running of the home 5 The service user guide must include all the information listed in Regulation 5 of the Care Homes Regulations 15(1) & The care plans must contain 17(1)(a), enough details on all aspects of health and social care to reflect the complexity of the support needed. This must include details of the strategies for the management of challenging behaviour, difficult and obsessive behaviour. (Previous timescale of 30/05/05 not met) 15(2)(b)(c) The care plans must be reviewed and updated to reflect the changing circumstances of the service users. 13 (2) Step by step procedures must be developed in all areas of medication administration and a policy and procedure must be developed for “refusal and covert administration of medication”. (Previous timescale of 30/05/05 not met)
DS0000044999.V252597.R01.S.doc 31/10/05 31/10/05 31/10/05 31/10/05 Oakmount Version 5.0 Page 25 6 YA20 13 (2) 7 YA22 22 (8) Risk assessments for those 31/10/05 service users administering their own medication must be completed and regularly reviewed. (Previous timescale of 30/05/05 not met) The registered person must 22/09/05 ensure that all issues of concern that require action are recorded fully The home’s adult protection policies and procedures must be developed to include step-bystep procedures and guidelines for dealing with any allegations or suspicions of abuse according to the “No Secrets” guidelines. (Previous 3 timescales not met) The registered person must ensure that all parts of the home, including the bathroom identified are clean and reasonably decorated. (Previous timescale of 30/06/05 not met) The registered person must ensure that all parts of the home are free from offensive odours. The registered person must ensure that regular quality monitoring exercises are conducted and that the information collected from this must be collated, documented and analysed and the results / outcome made known to all parties including the CSCI. (Previous timescales not met) The registered person must ensure that the home’s water supply does not pose a threat of the spread of Legionella.
DS0000044999.V252597.R01.S.doc 8 YA23 13 (6) 31/10/05 9 YA27 23 (2)(d) 31/10/05 10 YA30 16 (2)(k) 30/09/05 11 YA39 24 (2) 14/11/05 12 YA42 13 (3) 14/11/05 Oakmount Version 5.0 Page 26 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 YA1 Good Practice Recommendations The statement of purpose should included greater detail in some matters listed in schedule 1 of the Care Homes Regulations 2002, for example the way in which service users’ privacy and dignity are respected. The risk assessments and care plans should contain details of how risks are managed and minimised. The registered person should establish whether or not the services and facilities complied with the Water Supply (Water Fittings) Regulations 1999. The registered person should ensure all job descriptions are updated to reflect the recent changes in the structure of the home. The registered person should ensure that 50 of care staff achieve at least NVQ level 2 by the end of December 2005 It is recommended that a “tracking form”, to date CRB/POVA and reference applications and follow up contacts, be developed. 2 3 4 5 6 YA9 YA30 YA31 YA32 YA34 Oakmount DS0000044999.V252597.R01.S.doc Version 5.0 Page 27 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.V252597.R01.S.doc Version 5.0 Page 28 - 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!
