Inspection on 24/04/06 for Oakview

This inspection was carried out on 24th April 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Oakview 17/11/08

Oakview 14/11/07

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 Sylvia Brown Unannounced Inspection 24th April 2006 08:30 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.V290524.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 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.V290524.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oakview Address 19 Oakwood Avenue Gatley Stockport Cheshire SK8 4LR 0161-491 0106 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.V290524.R01.S.doc Version 5.1 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). 29th November 2005 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.V290524.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the overall inspection process two site visits were undertaken at Oakview. The first was unannounced and focused on the day to day routines of the home. The inspector sat and talked with five service users and obtained their views of the services offered. Comment cards were provided to service users, staff and visitors on the first day. At the time of writing the report one had been returned by a service user, four by staff and three by relatives. Comments received are, where appropriate and relevant, included within the report. On the first day if the inspection required records were not available for inspection. Furthermore, the registered owner who is also the registered manager was unwell and a second site visit, which was announced, took place. On the second visit the registered provider, Mr Assrafally, had prepared well and had the required records available. An evaluation of the records was undertaken and time was spent talking with the registered provider about administration systems and the management of records and how they could be developed. Time was spent talking with one service user about the services at the home and her life experiences. What the service does well: The service users at Oakview are generally content with the services offered by the home. The younger adults appeared to live the lifestyles they prefer and the older service users were observed to receive the care and attention they required and all seemed satisfied with the services provided. Oakview provides those accommodated with a homely environment and service users have a room which they can personalise and arrange as they like. Though hot food options are not available at breakfast, service users commented favourably about the food served. The registered owner/manager stated she prefers to, as far as possible, make all meals to ensure service users receive good wholesome food. Drinks were served throughout the day as well as at routine times. All service users spoken to stated their satisfaction with the meals served. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Oakview is homely in its general appearance, however it appears worn, tired and in need of some upgrading. Such conditions may impact on service users’ mental health and enjoyment in their surroundings. The external parts of the home need painting. Internally, aids and adaptations, particularly in the bathing areas, are required to ensure that the home can meet the current and future needs of older people. As service users age, the home must also provide correct equipment to support their increased needs. Consideration should be given to the provision of a stair lift and bath hoist to aid service users. General redecoration and upgrading is also required. Bathrooms and toilets require curtains, some chairs need replacing and one shower unit base needs repairing. Part of the hall carpet was frayed and marked and required attention and some paintwork would benefit from repainting. Staff were observed entering the kitchen and preparing food and drinks without putting on protective clothing and hand washing procedures were not evident. Because space is limited within the home, some records are stored in the kitchen area. This is not advisable and arrangements should be made to improve where records are stored. The general layout of the main lounge could be improved to provide more suitable seating areas and workable space. On the first visit, books were placed on the floor which increases the risk to service users. The storage of wheelchairs in the lounge is inappropriate, as no service user was identified as requiring a wheelchair. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 7 Medication recording systems require development to ensure that records are maintained to the required standard and the registered persons should ensure that medication guidance from the Royal Pharmaceutical Society is known to all persons with responsibility for administering medication and have it available for reference purposes. Routines for obtaining prescribed medication in a timely manner should also be improved. As on previous inspections, required records were not readily available for inspection. 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. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 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.V290524.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5. Standard 6 is not applicable to this home. Quality in this outcome area is good. Service users receive information about the home and have their needs assessed prior to moving in however the procedures for this are unclear. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The registered provider stated he has produced up to date Statements of Purpose and Service User Guides, however the copies presented to the inspector were out of date and required some amendments. Copies of the new documents should be submitted to the CSCI. Assurances were given that the new documentation was provided to prospective service users. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 10 The one service user comment card returned stated they had received enough information about the home before they moved in and received a contract of residency. Evaluation of records confirmed that the two people case tracked had contracts of residency in place. Whilst they also had pre-assessments in place, undertaken by placing authorities, there was no clear information to confirm that pre-assessments had been undertaken by the home, if they had visited the prospective service user before moving in or who they had consulted about the resident’s care needs and personal preferences. There was no information on file that after assessment the home had confirmed they could meet the prospective service user’s needs. However, there were ongoing assessments in place which were kept under review and were up to date. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. Service users were treated with dignity and respect and, in the main, had their health care needs met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans in place and ongoing assessments were up to date. Two service users were cased tracked. It was evident that one had been involved in discussions about their care and had signed to say they agreed with the care plan and support in place. One service user’s record was not up to date. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 12 The care plan stated that the service user had some mental health issues which required monitoring, however there was no information regarding the service user’s recent paranoia which had led to the person receiving medical attention and requiring additional medication. The resident informed the inspector that they were waiting for the medication as it had not arrived. After seeking further information, the inspector confirmed the medication had not arrived or been obtained in a timely manner to aid the service user. The registered provider/manager informed the inspector about some difficulties they were experiencing with the chemist. Notwithstanding that information, the home must make arrangements to obtain all prescribed medication in a timely fashion. On both visits signature omissions were evident within the medication administration records. It was unclear if medication detailed as not dispensed this month was still required and not ordered because stock was still available. When asked, the registered provider was unsure if such things as scalp lotions and creams were still in use but were not being signed for. Medication prescribed in variable dosages were not detailed as to the amounts given at any one time, i.e., one or two tablets. It could not be evidenced what systems were in place for monitoring medication systems, its management and recording. Furthermore, staff practice was not monitored or evaluated to ensure their continued competency. Though service users stated they felt well cared for, records did not fully detail how their health care needs were met by medical professionals. Such things as district nurse visits were not recorded. Service users’ weights were not up to date. The registered provider explained various difficulties in obtaining weights for some service users. Notwithstanding that, weights should ,as far as possible, be obtained and appropriate sit-on scales should be provided for those who have difficulty standing or standing still. Relatives’ comment cards indicated that they were kept informed of any changes to the health of their relative. Throughout the inspection residents spoke positively about the care they received and were observed being supported in a respectful and dignified manner. Residents confirmed that staff listened and acted upon what they say and that they were usually available when they needed them. One relative made the comment “All staff are respectful and kind to residents”. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. Residents able to make individual choices and make decisions for themselves. They receive a varied diet. Activities are not planned to meet all service users’ needs and social environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are able to make choices and decisions for themselves. They were observed getting up when they wished and plan their own daily routines. Records demonstrated the individuality of the service users and the flexibility of the home. Some service users prefer to stay up until the early hours of the morning, whilst others like to retire early to their rooms. Some service users attend day centres and are independently able to leave the home to visit places of interest, family and friends within the community. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 14 The more frail and older service users spend the majority of the day in the home. On both visits the home lacked stimulation. The registered provider explained that most service users like quiet and leave the room when entertainment is provided. Both visits identified that residents sat in the lounge without television on or music. One service user stated that she slept a lot as there was nothing much to do. Staff were attentive and were observed manicuring service users’ nails. Daily papers and magazines were also provided to give them some occupation. The home’s statement of purpose states that it provides ‘therapeutic activities’, however there was little evidence that they were carried out either in a group setting or with individuals. Most service users spoken to were non-committal about activities and had seemed to accept the routines within the home. It may be advisable to seek professional advice regarding which activities which would benefit those with mental health issues and older people, after which an activities programme can be developed to meet their needs. Some of the service users are able to be independent, however there was limited opportunity for them to make drinks and light snacks for themselves. There were no records to substantiate how their independence was promoted within the home and if they had opportunities to wash their own clothes and complete small tasks. Notwithstanding all the areas for development, most residents spoken with felt well cared for and lived as they desired. On both visits service users were observed having breakfast and receiving lunch. Cereals, toast and drinks are served at breakfast times. Service users stated they were not offered hot options like eggs or bacon and though satisfied with the arrangements, one resident said “I wouldn’t mind a bacon sandwich now and then”. The main meal is served at lunch time and, as previous inspections have identified, full roast lunches are provided. One relative’s comment card stated their dissatisfaction with the meals served and the quality of food. Although the home food supplies were not evaluated, all service users spoken to stated they enjoyed the meals. Alternative options are not recorded on the home’s menu, however the registered provider/manager stated that she prepares alternatives and is aware of service users’ likes and dislikes. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 15 The registered provider/manager takes responsibility for cooking, however it is not evident if she has completed sufficient training to undertake such duties. It is expected good practice for cooks to have knowledge of the preparation of specialist diets and nutritional value elements of food and ensure that food served meets the required individuals’ needs as identified within their care plan. Whilst the registered provider manager has completed basic food hygiene, further training is recommended. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. A complaint procedure is in place which is not known to all residents and relatives and is not followed in practice by staff. Staff have received training in protection of vulnerable adults. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Oakview has a complaints procedure in place. Details are included within both the Statement of Purpose and service user guide. Evaluation of the complaints record identified that no complaints had been recorded. One relative spoken to stated that they had made a complaint which eventually had been dealt with. One relative’s comment card also recorded that they had raised a number of dissatisfactions with the home. Whilst two comment cards stated they had no cause for complaint, they also identified that they did not know about the complaints procedure. The service user’s comment card indicated that they knew about the complaints procedure and felt safe talking to staff. The CSCI has had no complaints about the home. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 17 Training information indicated that seven members of staff had received training in the protection of vulnerable adults. Two of the four staff survey forms confirmed this, two stated they were not aware of any procedures regarding adult protection. There have been no allegations of abuse raised at the home between the previous and current inspections. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 25 & 26 Quality in this outcome area is adequate. Service users live in surroundings which are clean, homely and free from odours, but require some upgrading. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Oakview offers a homely environment to those who are accommodated. A tour of the premises identified that some upgrading is required to ensure it is maintained to the correct standard. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 19 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, service users have use of a wooden bath seat which does not allow for full soaking. Furthermore, it was peeling and rough. The shower room also required upgrading through decoration, curtaining and repairs to the base of the shower. The shower on the ground floor would not support the needs of the more dependant service users. Comments received from staff also identify that additional aids and adaptations are required to support and safeguard service users and staff. It was also evident that staff feel some service users may benefit from a stair lift. One staff member stated “there is not enough equipment for certain residents”; another that “there is not enough equipment for mobility for some residents”. The ceiling paper in the main lounge appeared to be peeling and cracks were apparent. The carpet in the downstairs corridor showed signs of wear and tear with one small part fraying. The toilet upstairs had a broken toilet roll holder, no curtains, looked dark and shabby and in need of upgrading and personalisation. The home accommodates both service users who smoke and who are nonsmoking. To aid comfort, service users who smoke are requested to smoke in the dining room when meals are not being served. This causes the room to smell of smoke which is not acceptable to all service users. There appears little that can be done currently about this matter, however plans will be discussed in the future to improve these arrangements. The laundry area in the cellar was inspected. The home’s washing machine is domestic in style and does not have a sluicing facility, as required to safeguard against infection control. Floors and wall finishes are not to the required standard; they were not painted or sealed to ensure they are washable. One relative spoke of the laundering and quality of the towels within the home stating “flannels and towels are dried on lines and/or pipes, they are stiff and very thin”. The relative stated she has complained about this matter “to no avail”. One relative stated that they had had to make a strong request to have their relative’s bedroom repainted in a bright colour which may assist in more positive mental health and had the room rearranged to ensure that it was more suitable to support daily living. The service user has purchased their own bedding, curtaining and furniture, however there was no record of this or their personal possessions on file. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 20 Even though the above findings identify that upgrading and investment are required, service users spoken with were, in the main, satisfied with their surroundings. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. Staff were in appropriate numbers to meet the needs of residents. They are appropriately trained, competent and recruited correctly. Staff do not complete appropriate induction and staffing records require some development. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Staff are recruited in the correct manner; references and statutory checks were in place, as were application forms and employment histories and there was information confirming interviews had taken place and offers of employment were on file. The staffing survey identified that some staff did not have contracts or job descriptions. Staff had not completed the appropriate induction training as set by Skills for Care. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 22 Staff training records were collectively maintained and identified that some staff had completed adult protection, first aid, mental health, difficult behaviour and moving and handing. Staff’s individual records did not contain training and development plans and training certificates or certificates of attendance records. The registered provider should ensure that all levels of staff complete mandatory and additional training to meet their individual roles and responsibilities. The staff rota failed to identify staff’s full names and their actual positions of employment. Furthermore, their ‘other duties’ were not identified. It is necessary to detail allocated time for domestic, laundry and cooking duties as these detract from the care hours allocated. Though the registered owner/manager’s hours are recorded on the rota, it became evident it was not an exact record. The actual hours of attendance at the home need to be clearly identified to ensure an accurate evaluation of the management hours can be obtained. Without exception, all persons spoken to and comment cards stated that staff are caring and dedicated. They are liked and appreciated by the service users and indicated themselves that they enjoy working at the home and supporting the service users. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38 Quality in this outcome area is good. The home is managed and run in the interests of residents, however management practice in other areas of the service need development. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The registered owner/manager is in attendance most days of the week, she is qualified to manage a care home and is currently completing the registered manager’s award. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 24 The home has yet to complete a quality assurance audit. Service users’ finances are, in the main, managed by themselves with support from their families. Stockport Social Services also provides advice and guidance when and where required. Staff do not receive formal individual supervision at the required frequency, however they do receive informal guidance when the registered owner/ manager is on the premises. Health and safety records were in place and, in the main, up to date. The electrical wiring certificate was out of date and there was some indication that some electric sockets were not working. As at other the previous inspection, records were not readily available for inspection. The registered providers are aware that the records required should have been available at the first visit and, as a consequence, a requirement to ensure their availability in the future has been repeated. Notwithstanding that, Mr Assrafally has retired from his employment and is taking responsibility for the administration systems of the home. It has been agreed that staffing records will be held off the premises but be available to the CSCI when required. The registered provider stated that a full review of the administration system will be undertaken and action taken to ensure that they are completely compliant with the regulations and standards in the future. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 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 3 3 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 1 3 X 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 3 3 Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12 & Schedule 3 Requirement Timescale for action 01/07/06 2 OP7 17 & Schedule 3(3)(m) 12 3 OP9 4 OP9 18 & 13 The registered person must ensure that residents’ care files and daily records reflect up to date details on their health care, particularly regarding their mental health status and its management. The registered person must 01/07/06 clearly record health care support provided by visiting professionals in service users’ individual records. The registered person must 25/04/06 ensure systems are in place to obtain prescribed medication in a timely manner. The registered person must 01/06/06 introduce systems which ensure that medication administration procedures, including recording and provision of medicines, comply with the Royal Pharmaceutical Society’s Guidance for Care Homes and that a copy of such guidance is readily available to staff. Oakview DS0000008571.V290524.R01.S.doc Version 5.1 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. 5 Standard OP16 Regulation 22 Requirement The registered person must ensure that all current and prospective residents and visitors have the complaints procedure made known to them. All complaints must be recorded.. The registered person must ensure all staff receive up to date adult protection training. The registered person must ensure that the home maintains an accurate record of the hours worked by staff and manager, their individual positions and allocated time for ancillary chores. The registered person must ensure that all staff employed at the home receive a contract of employment and a job description. The registered person must ensure that all staff complete induction training within the timeframe set by Skills for Care. The registered person must complete a quality assurance audit which meets the required elements of Regulation 24. The registered person must complete formal supervision at the required frequency. Timescale for action 01/08/06 6 7 OP18 OP27 18 & 6 Schedule 7 01/08/06 01/06/06 8 OP27 17 & Schedule 4 19 01/07/06 9 OP28 01/07/06 10 OP33 24 01/11/06 11 OP36 18 01/07/06 Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 28 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. 12 Standard OP37 Regulation 19 Requirement The registered person must make sure that the staff records are kept on the premises, and that these meet with all the requirements. (Timescale of 31/01/06 not met). The registered person must ensure the home has an up to date electrical wiring certificate. Timescale for action 25/04/06 13 OP38 23 01/10/06 Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 29 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 OP3 OP7 Good Practice Recommendations The registered providers should submit copies of the homes current Statement of Purpose and Service Users Guide to the CSCI. The registered person should ensure that the homes process for visiting prospective service users and assessing their need before admission can be evidenced. The registered person should as far as possible obtained service users weights and routinely monitor fluctuations in weight. If necessary appropriate equipment should be purchased to ensure as far as possible accurate weights. The registered person should ‘box in’ the pipe work in the downstairs bathroom when it is being upgraded. The registered person should ensure that records of all service users possessions are maintained on their individual file and are up to date. The registered person should ensure that an accurate training and development record is maintained on staffs individual file. The registered person must complete formal supervision at the required frequency. 4 5 6 7 OP19 OP24 OP28 OP36 Oakview DS0000008571.V290524.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. 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