Inspection on 07/01/08 for Oldway Heights

This inspection was carried out on 7th January 2008.

CSCI found this care home to be providing an Good service.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oldway Heights 16/11/09

Oldway Heights 17/08/06

Oldway Heights 19/10/05

Oldway Heights 20/04/05

Oldway Heights 20/10/04

Oldway Heights 20/04/04

Oldway Heights 15/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOME ADULTS 18-65 Oldway Heights 40 Headland Park Road Paignton Devon TQ3 2EL Lead Inspector Michelle Finniear Unannounced Inspection 7 January 2008 07:55a th Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oldway Heights Address 40 Headland Park Road Paignton Devon TQ3 2EL 01803 527088 01803 664738 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 Barry Michael Privett Mrs Jacqueline Ann Privett Mr Barry Michael Privett Care Home 31 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (31), Old age, not falling within any of places other category (31), Physical disability (31) Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. PD Maximum registered 31 service users (both) MD Maximum registered 31 service users (both) OP Maximum registered 31 service users (both) Date of last inspection 17th August 2006 Brief Description of the Service: Oldway Heights is a large detached two storey building situated in Paignton, Devon, close to local facilities (a short walk away). The home predominantly provides care to younger adults who have physical disabilities and/or mental disorder. The home has also retained its registration to care for the elderly, to allow the elderly clients already at the home to remain there. A maximum of 31 service users of either gender can be resident in the home. The emphasis of the home is to ensure that service users with a disability are able to have a good quality of life and to this end the home has provided a number of aids and adaptations to both support service users care needs and allow them to retain as much independence as possible. Most of the home is serviced by a passenger lift with the exception of 4 bedrooms, which are accessed by a number of stairs all other areas of the home are easily accessible for wheelchair users. The home also offers a day care service. Fees are individually based on each persons needs and care package. Copies of the homes inspection reports are available in the home. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This report is a summary of a cycle of Inspection activity at Oldway Heights since the last Inspection cycle in August 2006. This also included a random Inspection visit carried out in October 2007 looking at issues raised in a vulnerable adults meeting called by Torbay Safeguarding team looking at the vulnerability of a person living at the home. To help make us make decisions about what life is like at the home, the home the owner and manager gave us some information in writing about the running of the home; questionnaires were sent to people who live there; documents and letters submitted since the last inspection were examined along with the findings of the last inspection report; a site visit was carried out (with no prior notice being given to the home as to the date and time); discussions were held with the staff on duty; various records were sampled, such as accident books and medication records; and a tour was made of all areas of the home and garden. Time was also spent in private with some of the people who live at the home, talking about their lives and what they think about living at the home. In addition a sample group of people were selected and their experience of care was ‘tracked’ through records and discussions with staff and management from their admission to the current date – looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. This approach hopes to gather as much information as possible about what the experience of living at the home is really like. What the service does well: The home has a safe admission procedure, which helps to ensure that people living at the home can have their needs met before a decision is made for them to move in. One person said they had moved to the home following the closure of a previous placement. They felt the transfer had been managed well, and that they had had the opportunity to visit the home and get a clear idea of the accommodation, the other people at Oldway Heights and the facilities available. This person said that I wish I had moved years before, as there is much more to do here . The home offers a broad range of activities to meet the needs of those living in the home individually and on a group basis. People can make choices about all Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 6 aspects of their lives and are supported to do so. The food in the home is of good quality with plenty of choice. People are encouraged to lead as full a life as possible. Their care needs are fully documented in care plans which they take part in drawing up. This helps to ensure that the staff understand their wishes in relation to their care. The accommodation is well presented and offers people opportunities for privacy and also to share communal space if they wish. Adapted bathing facilities, hoists and a passenger lift are available, which along with ramps help to make sure that people who use wheelchairs or have other mobility problems can independently get around the building. The staff seen were well motivated and organised. Staff who completed questionnaires said that they were happy working at the home, were well supported and had good access to training. One wrote “Oldway Heights is a happy and friendly place to live and work and the team of service users and staff make it a pleasure to come and work” and another “If every care home was run like ours a lot of people would be happier as that is our goal.” What has improved since the last inspection? What they could do better: The Registered Manager must have a National Vocational qualification in both management. It is understood that this is to be addressed very soon by the care manager making an application to become the registered manager. Being registered means she will be legally accountable for the day to day care practice at the home. Care plans would benefit from being more person centred and containing more information on peoples social and personal history. This helps with an understanding of aspirations, goals and behaviour in the context of the life someone has lived before coming into the home. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 7 Radiators should be protected or risk assessed to ensure no-one could be injured by coming into contact with a hot surface. 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. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 Quality in this outcome area is good. Information is available to help people judge if Oldway Heights is the right home for them. People are appropriately assessed before a decision is made about whether the home is suitable to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the form of a statement of purpose and service user guide is available in each persons room and can be given to people when looking around the home. This gives them information about the services the home can offer, the facilities available and some information about their rights and responsibilities when living at Oldway Heights . This helps people to make a judgment about whether the home is the right place for them. Most people who completed questionnaires indicated that they had received sufficient information about the home and had made the decision to move in themselves or with support from family and friends. Three people who completed questionnaires said they had not been asked if they wished to move to Oldway Heights. One person said “I was able to visit some homes on my own and was taken to others by my CPN”. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 10 Information at the home were seen for two recent admissions, and the process that had been followed was discussed with the manager. In both cases a full assessment had been completed before a decision was made at Oldway Heights could manage the persons care appropriately. Discussion was held on the admission process, which included visiting the person in the previous placement or in hospital, and obtaining information wherever possible from social services, physiotherapists, speech therapists or other professionals who have had an involvement in the persons care. This helps to ensure that equipment transfers can happen as smoothly as possible for the individual. Discussions held with one person confirmed that they had moved to the home following the closure of a previous placement. They felt the transfer had been managed one, and that they had had the opportunity to visit the home and get a clear idea of the accommodation, the other people at Oldway Heights and the facilities available. This person said that I wish I had moved years before, as there is much more to do here . Signed contracts were seen in peoples files. These contracts contain some information about peoples rights, and what they can expect to receive for the fees paid. Other contracts supplied by the local authority or purchasers of the service are understood to be in place but were not seen. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8, 9 Quality in this outcome area is good. Peoples needs for care and support are assessed and plans are in place to meet them. Plans are understood by staff supporting people. People are consulted about the care they need, and are able to take risks that support their development. Plans would benefit from containing more information about the individual and being more goal focused. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Support plans were seen for five people living at the home. The plans were signed by the person whose plan it was to show they were in agreement with the contents, and are being reviewed regularly. Plans contain information about the care will support each person needs in their daily routine, and how that person wishes that care to be delivered. Plans would benefit from being more person centred, which means they would be more individually based to reflect the goals and aspirations of each person and reflect as far as possible the way in which they wished to live their life. Discussions were held with a member of staff concerning an individuals plan. This showed that they have a Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 12 clear understanding of how that person wished their care to be delivered. However not all areas of staff understanding and knowledge about the person were reflected in the written plan. It is important that this information is written as it ensures that all staff can support them in the same way. People who completed questionnaires about their care indicated they were happy with the way staff responded and dealt with them. One person found that staff did not ask them enough what they wanted to do and did not listen to them enough. Information supplied by the home prior to the inspection showed that they intend to increase the amount of time that staff can spend working one-to-one with people living at the home, looking at these areas. Risk assessments were also available in peoples files. Risk assessments are a tool for identifying and reducing wherever possible any risks to the individual or others in their lives. Some risk assessments may be based upon mental health legislation, others may relate to safety or activities that people wish to complete on their own. The aim of these is to make sure that any identifiable risks are reduced as far as possible, but still to enable the person to lead as full a life as possible. The manager intends to ensure that staff receive training in the Mental Capacity Act in the near future, as this legislation will impact upon peoples rights and decisions they may make about their future. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. People are given good opportunities to follow their chosen lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most people spoken to or who completed questionnaires indicated they were able to choose what they wanted to do during the day. Evidence was seen during the site visit of people choosing to have a lie in and being encouraged to go out to take part in activities. Some people living at the home are involved in local community college courses, whilst others take part in activities that are more home-based. Discussion was held with the homes activities organiser about opportunities available for people living at the home. Each week day activities are organised, which may include going out with people to local pubs and restaurants, shopping, games, quizzes etc. People are free to join in these Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 14 opportunities or not if they wish, and one-to-one time is also available for people to just talk with staff. The home has a large accessible vehicle, and people can also attend for some limited day-care. People spoken to generally felt the need for activity and stimulation were being met, however some people felt more could be provided during the evenings and weekends. Discussion was held with the manager on this and she said she views the weekends as relaxing time for people. People are consulted to some extent about the operation of the home and regular meetings are held with people living at the home, the minutes of the last one were seen. These link into staff and senior meetings to show that opinions are taken seriously and changes made where possible. The care manager has a good understanding of the rights of people and discussion was held on opportunities for people to form and build relationships. Contact with relatives and friends outside of the home has encouraged as far as possible, as are opportunities to be a part of the local community. The home is in a residential area, but close to local shops and facilities. Evidence was seen in peoples files of holidays, and time people choose to spend away from the home. Plans would benefit from an increase in personal and social history being recorded. This helps people understand peoples behaviour in the context of the life they have lived before coming into the home. People spoken to said that the meals were of a good quality and that they had a choice. Vegetarian options are available each day, and a choice of meals is provided. Discussions were held with the chef around meal options and dietary balances. The home currently provides for people who require support with feeding, either by tube or with staff support. The meals being provided on the day of the side visit for lunch included cottage pie, vegetarian risotto or an omelette. The evening meal was Mexican Fahitas. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, Quality in this outcome area is good. People receive the support they need to maintain their health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home spoken to said that their healthcare needs were being met. People had access to services providing specialised equipment such as wheelchairs, mobility aids, equipment for visual impairment and some specialised transport. The home has specialised baths and some over head tracking hoists for people with complex support needs for moving. Discussions with a staff member indicated a good knowledge of how an individual liked their care to be delivered. People who completed questionnaires mostly said that their care was delivered in the way they wished, and that carers listened to what they said. One person felt that staff did not listen to them enough. A handover between shifts of staff was seen during the course of the site visit. This showed evidence of flexibility in meeting peoples needs and also organisation required to ensure that a specific healthcare need was being Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 16 attended to that afternoon by allocated staff. This communication helps to ensure that tasks do not get forgotten, and that all staff are working in the same way. Discussion was also held with two members of staff about the emotional needs of people living at home and how this also affected staff in their working practice. Staff acknowledged the need to support people at their own pace and in their own way. The homes medication administration systems were seen and found to be satisfactory. Medication is stored in a locked room within a locked cupboard or trolley, and is delivered to the home in a blister pack system. This makes it easier for staff to administer medication safely, and also helps ensure that it is easy to check that medication has been given. All medication given is signed for. Some people living at the home are able to have some control over their own medication, which they can keep themselves. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. People feel confident that they know their complaints will be listened to. Adult protection procedures are clearer and help to protect people from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home who were spoken to or completed questionnaires said that they would feel happy discussing any concerns or issues with staff in the home. The complaints procedure is clear and was is displayed on the notice board in the entrance hall and in the service user guide. There is a ‘suggestions’ box and people spoken to said they had confidence in their key worker or the manager to resolve any issues. People can also attend residents meetings and raise any concerns in a group setting if they wish. Training records seen indicated that most staff have had training on the protection of vulnerable adults including recognition of and reporting of allegations or signs of abuse or negligence. More staff training is planned. The home has a Whistle blowing policy which enables staff to raise concerns outside of the home or with the management if they wish. Since the last Key Inspection an adult protection concern was raised which was dealt with under local safeguarding procedures. The home did not alert the team at the time the of the allegation but are now clear about the process to Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 18 be followed and have done so subsequently for another unrelated concern about capacity and consent. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Quality in this outcome area is good. Oldway Heights provides a comfortable environment to live and work in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit at tour was made of most areas of the home. Not every bedroom was seen, but those that were looked homely and there was evidence that people living at the home have been able to bring personal belongings with them. People spoken to said they were happy with their rooms, that they had enough heat and light and that their beds were comfortable. Bedrooms are furnished to meet individual needs with some rooms having adjustable beds, pressure relieving and moving and handling equipment and adaptations to promote independence. The furniture, furnishings and equipment in communal rooms appeared to be in reasonable order, and it is understood that plans are in hand for the refurbishment of the lounge and activities area in the next few months. Corridor areas now also require some attention to décor so that people can continue to live in attractive surroundings. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 20 Communal areas were mostly clear from obstruction and there are wide corridors, ramps and a passenger lift to enable people with wheelchairs to have independent access around the building. One floor which provides 4 single bedrooms (3 with en suite facility) are accessed by a number of stairs and so these are only suitable for use by physically mobile residents at present. Planning permission is being sought to remedy this. Maintenance records were seen for the lift and for hoists. Water temperature is said to be checked at each bath. Automatic water temperature regulators help to ensure people cannot be accidentally scalded by hot water. Some radiators are not covered and the manager was asked to make sure that all radiators are subject to a current risk assessment and covers provided as indicated by the assessment. The overall environment was found to be clean and odour free and wash hand facilities and disposable gloves were available. The laundry was clean and appropriate arrangements were made for the management and disposal of clinical waste such as used continence pads or soiled bedding. This helps to prevent cross infection. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Quality in this outcome area is good. Staff are well trained and supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff files for two people were seen on the sit visit. Both contained evidence of the recruitment process that had been followed when that person was appointed. The home has equal opportunities practices in place and a full recruitment process which included interviews and taking up of references and criminal records bureau checks. This helps to ensure that people are being cared for by staff who are suitable to be working with potentially vulnerable people. Staff who completed questionnaires said that a full employment process had been followed when they also commenced work. The home has a well- developed programme of training and refresher training for staff. All staff but one either have or are working towards National vocational Qualifications, which are a national award recognising the competency of staff in their working role. Core training such as first aid and food hygiene has been identified and a plan produced for the updates needed. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 22 This makes sure that all staff have up to date knowledge about best practice. Regular supervision is given to all staff and records of this could be seen in staff files. Supervision is a system that combines personal development and performance management and aims to ensure that staff are working to their full potential and in the same way to support people. Staff who completed questionnaires said that they were happy working at the home, were well supported and had good access to training. One wrote “Oldway Heights is a happy and friendly place to live and work and the team of service users and staff make it a pleasure to come and work” and another “If every care home was run like ours a lot of people would be happier as that is our goal.” Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. The home is being well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well run, but the current registered manager does not have the recommended qualifications to manage this service, time scales have been repeatedly extended to allow for the existing manager to enrol on the required training courses or consider registering another person as manager of the home. Discussions with the home owner indicated that an application to register the homes care manager will be submitted without delay. The current care manager is qualified and has previously been a registered manager in other homes. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 24 Discussion was held on quality assurance systems at the home. These help the owner and manager identify what is working well and what could be improved. The home has a good system of questionnaires sent out to people living at the home, the results of which are analysed. A senior member of care staff spoken to identified how the analysis is undertaken and the results used to improve care at the home. Results of these improvements are also collected. Records of the management of peoples personal monies was seen and these were found to balance with the records held. Other records seen such as the fire records and medication records were up to date. Discussion was held on the management of health and safety issues at the home, and the risk assessments seen were completed and reviewed regularly. Staff receive training in areas of health and safety such as Infection control and moving and handling. The home has implemented a system for the safe handling of food and regular fire tests and drills are being carried out. Arrangements for the management of Legionella were not risk assessed and radiator covers are not provided to all rooms. The manager agreed to ensure that all radiators are risk assessed. Oldway Heights DS0000018405.V356124.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x 3 3 x Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 26 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 YA37 Regulation 9 Requirement The Registered Manager must have a National Vocational qualification in both management. Timescales have previously been extended from the end of 2005, 31/12/06 then 16/10/07. Timescale for action 31/03/08 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. Refer to Standard YA6 YA42 Good Practice Recommendations Care plans would benefit from being more person centred and containing more information on peoples social and personal history. Radiators should be protected or risk assessed to ensure no-one could be injured by coming into contact with a hot surface. Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Oldway Heights DS0000018405.V356124.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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