Inspection on 14/11/07 for Oakview

This inspection was carried out on 14th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oakview 17/11/08

Oakview 24/04/06

Oakview 29/11/05

Oakview 17/05/05

Oakview 03/11/04

Oakview 04/05/04

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

CARE HOMES FOR OLDER PEOPLE Oakview 19 Oakwood Avenue Gatley Stockport Cheshire SK8 4LR Lead Inspector Mrs Fiona Bryan Unannounced Inspection 14th November 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oakview DS0000008571.V351877.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakview Address 19 Oakwood Avenue Gatley Stockport Cheshire SK8 4LR 0161-491 0106 F/P 0161 491 0106 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) Mr Mohedeen Assrafally Mrs Bibi Toridah Assrafally Mrs Bibi Toridah Assrafally Care Home 12 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12) Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 12 service users to include: *up to 12 service users in the category MD(E) (Mental Disorder over 65 years of age); *up to 3 service users in the category of DE(E) (Dementia over 65 years of age). Service users can be under the age of 65 years but not under the age of 50 years in both categories 12 MD(E) and 3 DE(E). 24th April 2006 2. Date of last inspection Brief Description of the Service: Oakview is a care home owned by Mr and Mrs Assrafally and managed by Mrs Assrafally. The home can accommodate 12 older people who may have or had a mental health problem and including up to three people with a dementia type illness. The home is semi-detached with lounge, dining room, kitchen, bathrooms, toilets and four bedrooms on the ground floor; and two bathrooms and six bedrooms (two of which are shared) on the first floor. There is no passenger lift between floors. The home is located in the Gatley area of Stockport and is close to local shops and other amenities, such cafés, restaurants, public houses, banks and post office. There are churches of most denominations, a library and a selection of health centres, dentists and opticians. Motorway network and public transport are easily accessible. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Wednesday, 14th November 2007. The manager was not told beforehand of the inspection visit. All key inspection standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with people who live at the home, the manager and other members of the staff team. Three people were looked at in detail, looking at their experience of the home from their admission to the present day. A tour of the building was conducted and a selection of staff and care records was examined, including medication records, employment records and staff duty rotas. Before the inspection, we sent the manager a form (AQAA) for her to complete and tell us what she thought they did well and what they need to improve on. Information from this has been used in the report. What the service does well: Routines seemed to be flexible and residents were free to move around the home, sit in their own rooms or spend time in one of the lounges, and said their visitors were made welcome. Residents were able to get up when they chose and one resident said she liked to go to bed around midnight. Residents said staff were “very good” and understood what help they needed with day-to-day living. One resident said, “Staff are very friendly, there is no sharp telling you off and all that – they are very kind. If I wanted a walk round someone would take me”. From the AQAA it was reported that 75 of the care staff had successfully completed NVQ training. Residents and staff said there were usually enough staff on duty to meet the needs of the residents. The meal seen on the day of the site visit looked appetising and tasty and residents seemed to enjoy it. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 6 On the day of the site visit the home was clean and tidy, although in need of quite extensive refurbishment and redecoration. What has improved since the last inspection? What they could do better: The manager acknowledged that record keeping in general was not a strong point and needs to be improved. Care plans need to be more detailed and must address all the care needs for each resident. The manager needs to ensure that risk assessments are carried out for each resident to identify risks, especially in respect of nutrition, pressure areas, moving and handling and falls. Failure to undertake these leaves residents at risk that some healthcare needs will not be recognised and treated within appropriate timescales. Further consideration is needed as to how some residents’ social care needs are met. There was limited evidence of any opportunities for social stimulation and staff need to discuss with the residents what their interests are and use this information to plan events that suit their abilities and expectations. As previously stated, the home needs a lot of refurbishment and some new equipment and accessories are required, such as bath hoists, a stair lift, privacy screens, bedding, towels and bedroom furniture. The manager had failed to follow appropriate recruitment procedures in respect of care staff employed at the home. The procedures used for the recruitment of staff at the home did not provide adequate protection to residents. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 7 Staff training records need to be improved so it can be clearly demonstrated that induction training meets Skills for Care specifications and also so the manager can plan refresher training in health and safety topics and identify specific training needs for staff that meets the needs of the residents they are caring for. Quality assurance monitoring and auditing of the care services need improving so that continuous improvements are made in the home. 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. The summary of this inspection report can be made available in other formats on request. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. Information is available to prospective residents so they can choose a home that will meet their needs. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The statement of purpose and service user guide available in the home were dated 2003. Following the site visit the owner sent updated versions to the CSCI, which contained all the information required for people making a decision about their choice of care home. The owner was requested to ensure that the out of date statements of purpose and service user guides were replaced with the new editions so anyone calling at the home “on spec” could be given copies straight away. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 10 No new residents had been admitted to the home since the last inspection so it was not possible to determine if pre-admission assessments of prospective new residents were undertaken before a decision was made as to whether the home could meet their needs. However, it was reported that this was the normal procedure. Due to the layout of the environment and the existing aids and adaptations, which are discussed more fully later in this report, the home is only able to accommodate people who are physically quite independent. When a resident’s physical abilities deteriorate, the manager must be pro-active in arranging a review of their care to ensure that the home can still meet their needs. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. Care plans do not always address all the residents’ needs, and are not always reviewed appropriately which leads to a risk that some needs may not be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three residents were case tracked. Care plans had been developed for all of them following an assessment of their self-caring abilities and daily living needs. These assessments were recorded using a scoring system to denote how independent or dependent the resident was in a number of areas, such as safety, communication, dressing, hygiene, mobility, mental ability and social needs. Space was available for additional comments. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 12 Some records were quite basic, mainly just providing the scores for each area, whilst others contained additional comments detailing the resident’s preferred routines and giving a better overview of their abilities. All the assessments had been updated and reviewed monthly. Care plans had then been written for specific areas that the residents needed assistance to manage. Care plans were not, however, very person-centred and did not always appear to address all a resident’s needs, for example, staff had been recording for a period the food intake of one resident but there was no care plan to explain why they were doing this or how the information they were getting would be assessed and used. Some residents’ care plans had not been reviewed for some time, for example, the care plans for one resident had not been reviewed since January 2007. Formal risk assessments to identify residents at risk of falls, poor nutrition or pressure ulcers had not been undertaken. Moving and handling assessments had also not been completed. This leads to a risk to residents that health care needs in respect of these areas may not be met. Daily records showed that one resident had fallen in August 2007 but no accident report had been completed and the resident had not been assessed to determine and minimise the risk of further falls. Residents’ weights had been recorded in a separate book for most residents. However, no record could be found for one resident’s weight and this was the resident who had been having their food intake recorded. This resident told us that they had a poor appetite and were unable to walk very well. It was recommended at the last key inspection that sit-on scales were obtained for residents who found it difficult to stand whilst they were weighed. Since the last inspection staff have started to keep a record of other healthcare interventions accessed for residents; therefore evidence was available that residents had seen GP’s, psychiatrists and opticians and had attended hospital outpatient appointments. It was recorded that one resident had refused to attend a hospital appointment and instructions had been given to staff to observe the resident for signs of infection. There was no evidence that this was being monitored. Residents said that staff were prompt in calling their doctor if they were ill and said the carers tried to help them and treated them well. However, residents spoken to were unaware of their key workers and no-one could recall their care plans being discussed with them, although one resident was aware that a care plan had been written for them. There was no evidence that reviews had taken place recently for any of the residents’ case tracked. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 13 One resident’s needs had increased due to their poor mobility and a review should be arranged for them as the home may not be able to meet their needs soon, due to the physical environment – the resident said they were unable to get downstairs or get in the bath. Staff knew which residents they were key workers for and had a good understanding of residents’ abilities and preferences but more work is needed to ensure that the residents are involved in reviewing how their needs are being met. Examination of the medicines records for residents showed that medicines were generally managed satisfactorily. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. More person-centred care planning is needed to ensure that people’s social, cultural and recreational expectations can be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Residents are able to make choices and decisions for themselves. They were observed getting up when they wished and can plan their own daily routines. Some residents prefer to stay up until the early hours of the morning, whilst others like to retire early to their rooms. One staff member said staff were free to change working patterns in the home and adapt routines for the benefit of residents. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 15 Some residents attend day centres and art classes and are independently able to leave the home to visit places of interest and family and friends within the community. A shopping trip to the Trafford Centre had been arranged but most residents refused to go. There is no designated activities organiser so staff try to encourage residents to socialise and arrange activities, such as card evenings, which are usually held on Friday evenings. It was reported that a musician is invited to the home once a month to entertain the residents and most residents enjoy this, and the hairdresser visits every Wednesday. On the day of the site visit about four residents were sitting in the lounge in the morning. Several were dozing and one resident said that she did nothing all day, other than sit and read. Neither the television nor the radio was playing and the room was very quiet. Another resident stayed in their room all day and liked to watch television but was not interested in joining in with anything else. Another resident was pottering about in her room and said she did not get bored, as she liked to watch TV in the morning and then chat with other residents in the lounge in the afternoon and evening. Several residents said they did not go out much as they did not really want to, although one resident said if she wanted a short walk outside, staff were happy to accompany her. One resident said there were no social activities to speak of “the activity is moving from the lounge to the dining room for meals”. Several residents seemed to be a bit depressed and further development of the key worker system and more involvement of them in reviewing their care at the home may help staff identify other creative ways for helping some residents towards better social fulfilment. A record of activities mainly listed events such as bingo or card games on a Friday evening, hand massages and manicures and visits by friends and families. The records were only completed intermittently and therefore did not provide a good overview of how people’s social care needs were met. The week’s menu was displayed on a notice board in the hallway outside the lounge. This showed that residents had the choice of roast pork, mashed potato or chips and peas or sweetcorn, with profiteroles being offered for dessert. This did not actually correspond with what the residents were given, as the lunch, when it was served, was ham and pineapple followed by tinned fruit. However, the meal looked and smelled appetising and residents said they enjoyed it. One resident particularly liked the pineapple and the manager went and got them some more from the kitchen. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 16 Residents said that breakfast was cereal and toast. No cooked breakfast was available; one resident said she would occasionally enjoy bacon and eggs, another said she didn’t like a lot to eat at breakfast and preferred to wait for lunch. All the residents spoken to said no choice was offered at lunchtime and some were unclear as to whether anything else would be available if they didn’t like what was on the menu. Residents said that a lighter meal was provided at teatime and that a small choice was usually offered, such as eggs on toast or sandwiches. One resident said they used to be served homemade soup, which she really enjoyed but they didn’t seem to get that much any more. Some residents said that the owner sometimes made curries which several of them really enjoyed. On these occasions, residents who didn’t like curry were given an alternative –“they don’t leave you out”. During the morning of the site visit, residents were observed being offered tea or coffee with scones for a mid-morning snack. One resident said, “You don’t go hungry”. Most residents seemed generally satisfied with the meals provided at the home. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. Residents generally felt confident that their complaints would be taken seriously and acted upon. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The complaints policy was displayed in the reception area of the home. Residents spoken to could identify someone at the home, either the owner or a member of staff, who they would speak to if they had a complaint and felt that any concerns would be properly addressed. One resident said, “they are very good – they would definitely sort it out. I don’t like to complain unless it’s absolutely necessary but if I didn’t they’d say, “Why didn’t you tell us?”” Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 18 The complaints record in the home did not contain any entries, although in information provided by the manager prior to the site visit it was stated that two complaints had been received and investigated. The purpose of keeping a record of any complaints and how they had been resolved, as an audit tool and a means of demonstrating how the manager listens and responds to complaints and uses them to improve the service, was discussed with the manager. Staff spoken to were aware of the procedures to follow if they suspected any resident was at risk of abuse. One staff member said she had completed specific training in this topic, whilst another said they had covered it as part of their NVQ training. The manager said that the owner had attended training and was cascading that to other staff but that they planned to send staff on the training run by Stockport Social Services. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 and 26 Quality in this outcome area is poor. The home is clean and free from odours, but requires extensive upgrading and is not sufficiently adapted to meet all residents’ needs. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A tour of the home was undertaken. Since the last inspection a new mobile hoist had been provided and carpets had been replaced in the lounge, dining room, hallways and one bedroom. The downstairs toilet had been replaced, the kitchen ceiling replaced and the kitchen redecorated. The downstairs bathroom was being upgraded. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 20 The home was clean and tidy but does still require extensive refurbishment. Furniture was worn and shabby and several carpets were threadbare. Bed linen and curtains were tatty and old. The home offers accommodation to older people who, due to their age, may have increased dependency. As a consequence, the home should have aids and adaptations to support their increasing needs. Currently, the home does not have a bath hoist; one bath had a rotating bath chair but this did not lower fully into the bath and a wooden bath seat was provided with the other bath, which was peeling and rough. One resident said she had not had a bath “for months”. The toilet upstairs had a broken toilet roll holder and needed upgrading and personalisation. One resident whose mobility had deteriorated said they were unable to get downstairs and the home has no stair or passenger lift. Residents said they were satisfied with the cleaning and laundry arrangements and liked their rooms, which they had personalised with their own ornaments and photographs, etc. The manager needs to review the double rooms to check that the privacy screens or curtains provide enough privacy for residents. The curtains in one double room were inadequate. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. The home was sufficiently staffed to meet residents’ needs but the procedures for the recruitment of staff at the home did not protect them from potential abuse. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Examination of the staff duty rota for the week commencing 12th November 2007 showed that the rota was being completed with full staff names and times of shifts worked. Residents and staff generally thought there were enough staff on duty to meet the needs of the residents. One staff personnel file was examined. The date of commencement of employment was not entered onto the file but training records indicated that they had undertaken training from 10th June 2007. The CRB was dated 2nd July 2007 and a POVA First check was confirmed on 20th June 2007. This means that the carer started working at the home before all the checks had been confirmed. References were also dated after the person started working at the home and the references were not sufficient, as they were provided by colleagues rather than the staff member’s previous employer. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 22 Staff said that they had undertaken various training since the last inspection including first aid, basic food hygiene, dealing with challenging behaviour and “positive caring” via Stockport Partnership. Training in the management of medicines had been provided by the pharmacist. It was reported that all staff had received fire safety training. One staff member said that she felt enough training was provided to her to enable her to do her job properly. The manager said that staff training records and certificates were kept in the individual staff personnel files. It was recommended that a system be devised whereby the manager could have an overall view of what training had been completed to date for the whole staff team in order to plan future training and to enable her to easily identify when update and refresher training was due. The manager reported in the AQAA that 75 of care staff at the home had successfully completed NVQ level 2 training. Although the manager said that induction training for new staff was provided that met Skills for care specifications, there were no records to confirm this. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. The manager needs to be more pro-active in developing systems to monitor and assess the quality of the service provided, to demonstrate that policies and procedures are followed, care is given that meets best practice guidelines, residents’ needs are met and their views are taken into account. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Since the last inspection the manager has completed the Registered Manager’s Award and reported that she had also completed training in food hygiene and first aid. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 24 Most of the residents said they saw the manager on a fairly regular basis, although a couple said they did not see her as much as they used to. One resident said when the manager was not in the other owner would come in instead. Resident surveys had been distributed a few weeks before the inspection and were available to read. The surveys contained a lot of questions with tick boxes for response and very few residents had written any additional comments. A discussion was held with the manager regarding the potential benefit of making the surveys easier for residents to complete in the hope that more detailed responses would be obtained. Staff had also helped some residents to fill the surveys in; residents should be able to give feedback anonymously if they feel more comfortable doing so. Residents could not recall attending any residents’ meetings, although the manager said she frequently had informal chats with them, asking them for suggestions about social events they would like and food they wanted on the menu. One such meeting, on 14th May 2007, had been minuted. The manager said that she did undertake regular checks on different aspects of the service delivery, such as the medicine management and record keeping, but that she did not record these checks formally. A proper system of audit needs to be established so that the manager can demonstrate that she is monitoring care practices and procedures within the home and is identifying and rectifying shortfalls as they occur. The manager acknowledged that in general records were not maintained well and recognised that this was an area for improvement. It was reported that the home does not deal with any residents’ monies, as they are assisted by their families or are able to manage their finances independently. Staff said that they had enough personal protective equipment, such as gloves and aprons, to carry out their jobs safely. However, no liquid soap or paper towels were provided in the staff toilet. This is essential in order to promote hand hygiene and prevent cross-infection. There was evidence that staff were not always completing accident reports every time residents had accidents. An accurate record of all accidents must be maintained and audited by the manager so that she can determine any underlying risk factors and take action to minimise them. Regular checks had been made of the premises and equipment to ensure that everything was in good working order and well maintained. Since the last inspection, the electrical wiring has been checked and a certificate of conformity issued. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 2 X 2 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 15/12/07 2 OP7 15 3 OP29 19 The manager must have in place detailed care plans, which address all the residents’ identified care needs. This includes risk assessments and care plans for pressure area care, moving and handling, nutrition and falls. Care plans and risk assessments must be reviewed at least monthly with the involvement of the resident if possible, and updated to reflect their changing needs. The manager must arrange a 15/12/07 formal review for the resident identified during the inspection, to consider if the home is still able to meet their needs. The manager must ensure that if 15/12/07 a person is required to start working at the home before their CRB has been returned, a POVA First check is obtained before they commence employment. The manager must also ensure that two appropriate written references are obtained before the person starts working at the home. DS0000008571.V351877.R01.S.doc Version 5.2 Oakview Page 27 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. 4 Standard OP38 Regulation 16 (2) Requirement Timescale for action 10/12/07 5 OP38 17 (1) Liquid soap and paper towels must be provided in the staff toilet to ensure that hand hygiene is promoted and the risk of cross-infection is minimised. Accident reports must be 10/12/07 completed each time a resident has an accident and the manager must monitor these to ensure that avoidable risks are minimised. 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 2 3 Refer to Standard OP1 OP7 OP7 Good Practice Recommendations Up to date copies of the home’s Statement of Purpose and Service User Guide should be available at the home to give to prospective residents or their representatives. Where possible, residents should be involved in planning and reviewing their care to ensure that the care given meets their needs. The registered person should, as far as possible, obtain service users’ weights and routinely monitor fluctuations in weight. If necessary, appropriate equipment should be purchased to ensure accurate weights. Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 4 Refer to Standard OP12 Good Practice Recommendations The key worker system should be developed to increase the opportunities to meet the social needs of people living at the home. Residents should be consulted about what activities and social events they would like to participate in. Menus should be reviewed and amended to include a choice at each mealtime. Consideration should be given to offering a cooked breakfast to residents at least twice a week. Staff should attend safeguarding training arranged via Stockport local authority. A programme of refurbishment and redecoration should be developed. Worn bedding, towels and curtains should be replaced. Aids and adaptations within the home should be reviewed to ensure that the environment is suitable and easily accessible for the residents. Extra privacy screens should be provided in the double room identified during the inspection to ensure the privacy of both residents can be maintained. All staff should complete induction training within the timeframe set by Skills for Care and records should be available to evidence this. The manager should develop a training programme so that she can identify when refresher training in mandatory health and safety topics is due and plan training for staff in topics that are specific to the care they need to deliver. A system of audit should be developed and recorded to show that the manager is monitoring the quality of care being delivered by staff and identifying and rectifying shortfalls. 5 OP15 6 7 8 9 10 OP18 OP19 OP22 OP24 OP30 11 OP33 Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Oakview DS0000008571.V351877.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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