Inspection on 23/03/06 for Oakmount

This inspection was carried out on 23rd March 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 10 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 21/06/06

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 Unannounced Inspection 23rd March 2006 10:00 Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 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.V281935.R01.S.doc Version 5.1 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.V281935.R01.S.doc Version 5.1 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.V281935.R01.S.doc Version 5.1 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 22nd September 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 and games room; 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 the owner of the home 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. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 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 report also summarises two complaints that were made to the CSCI at the end of 2005. The inspection took nine 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. One member of staff also talked to the inspector. The eight service users living in the home at the time of the inspection were seen, and 5 spent time in conversation with the inspector. The service users returned completed comment to the CSCI. Some of their views are included in the 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 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 and staff had been on such a holiday last year and those spoken with stated they had enjoyed it. One service user said they had “had a whale of a time”. The food was varied, nutritious and tasty and most service users said they enjoyed the food. One said “no problem with the food, it’s good” Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 6 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 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 working in the home for some time and service users were benefiting from a group of staff who 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 provided to service users’ about the home had been updated and developed to include all the useful information the service users needed. Some policies and procedures, such as the adult protection procedures and those for the giving out of medication in the home had been developed and improved. Some parts of the home had improved since the last inspection. Three bedrooms had new carpets, and the hall way had a laminated wood floor. The kitchen was being refurbished. The “smoke lounge” had been converted into a games room (with smoking) and there was a pool table and a darts board. The home was free from unpleasant odours. There was more staff with the right qualifications and training than at the previous inspection. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 7 The manager and owner had set up a way of finding out how good the home is, and for finding out what the residents and staff think of the home. What they could do better: 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. The ways that residents are kept safe, such as from incidents of self – harm, aggressive behaviour and the self - administration of medication should be written down to help staff know what to do. The needs of the residents regarding meals and diets should also be assessed and written down. Some aspects of medication management could be even better, such as the recording of the administration of medication and the blood sugar testing for one resident. Some parts of the home still needed redecorating and repairing. Some of these improvements were planned, including the replacing of carpets and decorating. The cleanliness in some parts of the home must be improved, including getting rid of cobwebs and cleaning skirting boards. The owner must provide the inspector with a plan for how the premises will be improved. The manager should make sure that she notifies the CSCI of all the illnesses, incidents and events that affect the well - being and safety of the service users. The owner and manager should make sure that all the requirements made under the law, and listed at the end of the report, are carried out in the time stated. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 8 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.V281935.R01.S.doc Version 5.1 Page 9 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.V281935.R01.S.doc Version 5.1 Page 10 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 The admission procedures, including updated written information, would assist prospective service 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 Service User Guide and Statement of Purpose had been updated and improved. The admission procedures could not be fully assessed, as there had not been a new resident admitted for about 2 years. However one resident had left Oakmount, to live in another care home, indicating that residents had a choice about whether or not they wanted to live at Oakmount. Discussion with the manager and the senior support worker indicated that the service users’ emotional, psychological and physical needs were being met. A recent “Care Programme Approach” review for one resident showed improved behaviour. Some staff were booked to attend a course on mental health and this should help to ensure that staff have specialist knowledge about this service user group. However according to the comment cards that were completed 5 residents stated that they only “sometimes” felt well treated and well cared for. One stated that she “did not” feel well cared for but “did” feel that staff treated her well. In conversation some residents stated that there were matters that concerned them, but they would talk to their key worker about them. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 11 Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 12 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 The written information about service users assisted staff in understanding service users’ needs but requires further development, and more frequent updating, of this information to reflect the complexity and changes of needs. Service users were assisted in making choices, and taking risks, to promote independence, but this needs to be detailed on the care plan. EVIDENCE: The viewing of care plans showed that the previous requirements and a recommendation had not been met and the plans had not been improved. There was insufficient detail about service users’ behaviour and the strategies employed to manage behaviour. The written information did not reflect the complexity of some issues for example the risk of self - harm. 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 still 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.V281935.R01.S.doc Version 5.1 Page 13 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. There were risk assessments on some issues, such as for aggressive behaviour, but these did not include details of how risks are managed and minimised. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 14 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 & 17 Service users were encouraged to take part in suitable fulfilling activities that promoted personal development and encouraged links with the local community. 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. Service users were encouraged to maintain links with the local community. They met friends and families both inside and outside the home, went shopping, and had trips out for walks and meals. A recent quality monitoring exercise in the home indicated that the service users would like more activities, including leisure activities and the manager and owner were addressing this. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 15 Positive personal and family relationships were encouraged. Service users met family and friends, who were welcome in the home. One service user met her husband most days, and told the inspector that she hoped she could go back to live with him. Other service users receive advice regarding safety and protection in intimate personal relationships. The meals served appeared to suit the preferences and needs of the service users, who were involved in planning the menus. According to the menus supplied the meals were varied and appetising. Service users helped themselves to breakfast and the mid - day (snack) meal, to suit their routines and preferences. A two course cooked meal was served in the evening when all the service users were in, and which some service users helped to prepare. This was observed at the time of the inspection and it appeared nutritious, appetising and plentiful. Drinks and snacks could be prepared throughout the day. However the nutritional needs of all the service users had not been assessed and monitored. Six service users who completed comment cards stated that they liked the food served and two stated they “sometimes” did. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 16 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 & 20 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 controlling their own medication. EVIDENCE: None of the service users required assistance with personal care. Some needed prompting with personal hygiene matters to ensure acceptable standards were maintained. Service users choose their own clothes with or without assistance from staff, and independence and choice with respect to personal appearance were encouraged. Records and discussions showed that staff ensured that service users’ physical and mental health was monitored, and matters addressed. One service user had been supported through recent physical illnesses and had made a good recovery. The district nurses carried out nursing intervention. Of the 8 service users who completed comment cards, two said that they “felt well cared for”, four said they “sometimes” did and two said that they didn’t feel well care for. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 17 The residents’ health and safety was promoted by the home’s medication policies, procedures and practices, which had been developed, according to the Royal Pharmaceutical Society Guidelines. Appropriate records were being kept of all medications received, administered and leaving the home, and a record was maintained of current medication for each service user. All staff administering medication had completed accredited training. Service users had given consent to medication being administered by staff. However there was no evidence of a risk assessment being completed and reviewed for one service user who had administered her medication, but was no longer. This was outstanding from a number of inspections and must be addressed with priority. The home did not have a lockable facility for medication requiring storage at fridge temperature. There was no evidence that the “diabetic nurse” had trained all the staff in the testing of blood sugar levels required for one service user. Also the MAR sheet for one service user was incorrect, with a record of “refusal” being made for one medication that she was currently not prescribed. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 18 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 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 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 and the manager stated that service users often stated they did not want things written down. Service users stated on the comment cards that they knew who to speak to if they are not happy with any aspect of the service. Two service users who spoke with the inspector stated that they could speak to the manager if they had concerns or problems. Since the previous inspection two complaints had been made to the CSCI. One concerned the living conditions in the home and the other concerned the outside of the premises. The CSCI investigated the former and provider investigated the latter. Both are summarised in the next section. Oakmount had a “protection from abuse” policy, which included a “whistle blowing” policy. Since the previous inspection the home’s policies and procedures had been developed to include step-by-step procedures to follow in the event of suspicion or allegation of abuse according to the “No Secrets” guidelines. There had been no allegations of abuse reported in recent years. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 19 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, 28 & 30 Oakmount provided a homely safe environment for the service users, and the décor and cleanliness of some parts of the home had been improved since the previous inspection. However there needs to be further improvements to the environment. EVIDENCE: Since the previous inspection two complaints had been made about the living conditions and the premises. One complaint was about some areas of the home being unacceptable living conditions for service users, with particular reference to one of the bedrooms and the then smoking lounge. It also made reference to a strong smell of urine. The CSCI investigated this complaint and found it to be upheld. Requirements were made for the immediate improvement of some areas of the home. Compliance with these requirements has been monitored by the CSCI and resulted in the improvement of certain areas of the home. The smoke room had been converted into a games room (smoking), with a pool table and dart - board, some carpets had been replaced and one of the bathrooms had been redecorated. At the time of this inspection the kitchen was being refurbished and some landing carpets had been ordered. However there were still some areas of the home, including the communal areas and bathrooms, in need of repair, decorating and refurbishment. Some of these were highlighted to the manager. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 20 A recent fire safety inspection had been undertaken and a number of requirements had been made. The fire service will monitor compliance. Since the previous inspection a complaint from a neighbour had been made regarding the accumulation of rubbish outside Oakmount, and the provider’s lack of action in tackling the problem. The provider had investigated this complaint and provided evidence to the CSCI that he and the manager had taken sufficient steps to resolve this problem with the local Council. This complaint was not upheld. At the time of the inspection none of the areas of the home were malodorous. Since the complaint referred to above some carpets had been replaced with laminate wooden floors and the behaviour of the person responsible for the odour of urine had been modified. There were appropriate infection control procedures in place. Since the previous inspection the state of cleanliness in some parts of the home, including service users’ bedrooms, had improved. This could be further improved in some other areas of the home. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 21 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 & 35 Service users benefited from a stable and experienced staff team who were undertaking the appropriate qualifications and training. EVIDENCE: The existing members of staff had worked in the home for some time and were experienced in working with the service users. Three out of the six support workers (including the registered manager) were qualified to at least NVQ level 2. Two other support workers had almost completed NVQ level 2. They understood the individual service users’ needs. No member of staff had left, or been recruited since the previous inspection, and service users therefore benefited from a stable and familiar staff team. The manager and the senior support worker stated that they felt there was a good team now working in the home, all of who “pulled together”. A key worker system was operating which facilitated one to one meetings between support workers and service users. Regular staff meetings were held and which served as in house training sessions. 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 were booked on a 6 - week mental health course. The senior support worker spoken with confirmed that there were good training opportunities in the home. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 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): 38, 39 & 42 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: Mrs Burnett and the registered provider Mr Dangare communicated a clear sense of direction according to the home’s aims and objectives. The staff member interviewed described them both as being open, approachable, supportive and accessible. She felt the direction the home is taking in terms of promoting the independence of the service users is beneficial to them. There were regular staff meetings which offered staff an opportunity to air their views and influence service delivery. Since the last inspection the home had begun to implement a quality monitoring system which involved collecting and analysing information from, service user meetings, one to one meetings with service users and meetings Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 23 with social workers. The CSCI was provided with a brief report of the outcomes and action taken. The manager and the provider ensured a safe environment and safe working practices. Fire safety precautions and training were satisfactory and all the home’s appliances, installations and equipment had been tested satisfactorily. The home’s water supply was assessed as being at a low risk of a threat of Legionella. Staff undertook appropriate health and safety training as part of their NVQ courses and the training records showed that support workers had undertaken first aid training and food hygiene training. However staff had not completed training in “infection control”. No accidents had been recorded nor had the CSCI been informed of any illness or incidents affecting the well - being or safety of the service user. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 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 3 2 X 3 3 4 x 5 x 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 x 26 x 27 x 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 x x 3 3 X X 2 x Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 25 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 YA6 Regulation 15(1) & 17(1)(a), Requirement The care plans must contain 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 timescales of 30/05/05 & 31/10/05 not met) Timescale for action 31/05/06 2. YA6 15(2)(b)(c) The care plans must be reviewed and updated to reflect the changing circumstances of the service users. (Previous timescale of 31/10/05 not met) 13 (4)(b)(c) 31/05/06 3. YA9 The risk assessments and care 30/04/06 plans must contain details of how risks are managed and minimised. (Recommendation at the previous inspection) 31/05/06 4. YA17 14(1)(a)(2) Service users nutritional needs 17 (1)(a), must be assessed and reviewed sch 3 and include risk factors associated with low weight, DS0000044999.V281935.R01.S.doc Oakmount Version 5.1 Page 26 5. YA20 13 (2) diabetes, obesity and eating and drinking disorders. Risk assessments for those 23/03/06 service users administering their own medication must be completed and regularly reviewed. (Previous timescales of 30/05/05 & 31/10/05 not met) 30/04/06 6. YA20 7. YA20 8. YA24 9. 10. YA30 YA42 The home must ensure that all staff involved have training from the diabetic nurse in the testing of blood sugar levels and that there is documentary evidence to support this. 13 (2) The manager must ensure that the MAR sheets accurately record the current medication prescribed and administered 23 (2)(b) & A full audit of all the premises (d) must be undertaken to identify all the repairs, maintenance, decorating and refurbishment required and an action plan produced with time scales. This must be forwarded to the CSCI by the date stated 23 (2)(d) All parts of the home must be kept clean. 37 (1) The registered person must ensure that the CSCI is notified in writing of all illnesses, injuries and incidents/events in the home which adversely affects the well being or safety of any service user. 13 (2) 23/03/06 23/04/06 23/03/06 23/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 Page 27 1 2 YA20 YA42 Medication required fridge temperature storage should be kept in a lockable facility. Staff should undertake appropriate training in infection control. Oakmount DS0000044999.V281935.R01.S.doc Version 5.1 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.V281935.R01.S.doc Version 5.1 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. 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