Inspection on 13/03/07 for Oxendon House

This inspection was carried out on 13th March 2007.

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

The inspector 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

Oxendon House 25/02/08

Oxendon House 07/11/05

Oxendon House 07/04/05

Oxendon House 17/08/04

Oxendon House 07/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Oxendon House 33 Main Street Great Oxendon Market Harborough Leics LE16 8NE Lead Inspector Linda Clarke Key Unannounced Inspection 13 March 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 Oxendon House DS0000040280.V329891.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. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oxendon House Address 33 Main Street Great Oxendon Market Harborough Leics LE16 8NE 01858 464151 01858 461646 pam.morris@jasminehealthcare.co.uk 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) Oxendon House Care Home Limited Position Vacant Care Home 30 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (27), of places Physical disability over 65 years of age (7) Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one falling within the category of PD(E) may be admitted into Oxendon House where there are 7 persons of category PD(E) already accommodated within the home No one falling within the category of DE(E) may be admitted to Oxendon House when there are already 8 persons of category DE(E) already accommodated in the home The total number of service users must not exceed 30 One named service user under the age of 65 may be cared for in Oxendon House. The named service user is detailed on the Commission for Social Care Inspection registration report of 20.02.2006 7th November 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Oxendon House is a care home providing personal care and accommodation for up to 30 persons with Old Age, who may in addition have an associated condition of Dementia or a Physical Disability. There are twenty four single bedrooms of which fourteen have an en-suite facility comprising of a toilet and wash hand basin, there are three shared bedrooms, of which two have an en-suite facility comprising of a toilet and wash hand basin. Bedrooms are located on the ground, first and second floor with access to the first and second floor being via the stairwell or the passenger lift. Communal areas are located on the ground floor, and consist of one lounge/dining area, a separate lounge and dining room. A small additional lounge is located on the second floor. Oxendon House has a large garden to the rear of the property, which is accessible to service users. Information is located on site detailing the range of services offered, which includes the Statement of Purpose, Service User Guide, Oxendon House Quality Assurance Report and a copy of the Commission for Social Care Inspections, Inspection Reports, which are located in the entrance foyer. The weekly fee falls in the range of £310.00 - £520.00, which was detailed within the pre-inspection documentation provided prior to the site visit. There are additional costs for individual expenditure such as Chiropody and hairdressing services, and the fee will depend on the services received. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, reviewing the last inspection report and the reviewing of the Pre-Inspection Questionnaire, Comment Cards/Surveys distributed to service users/relatives and staff by the Commission for Social Care Inspection (CSCI) along with the reviewing of significant events. The unannounced site visit commenced on the 13th March 2007 and took place over 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Oxendon House. Four service users were selected and discussions were held with four of them and three service users who were not part of the case tracking process. In addition two relatives visiting at the time of the site visit were spoken with, along with a brief conversation with a visiting General Practitioner. The method of case tracking included the review of service users’ individual care records, discussions with staff of various delegated responsibilities, which included the Responsible Individual (owner) and the Manager, within the home and reviewing the records, training records and the minutes of service user and team meetings. The CSCI sent out twenty-one Comment Cards to service users, of which 57 were returned. The majority of the comments received were complimentary about the service. Comments incorporated within Service User Comment Cards included: • I take my mother out regularly and I am always greeted with friendliness and problems are drawn to my attention. I have to say whilst nowhere is perfect I feel I have a good relationship with the staff and I am part and partner in my mothers care. More time should be available for staff to communicate with those residents who are immobile and frequently remain in their rooms. (service users name) is very well cared for. The staff are very good and caring. He is happy and contented. The staff put in a lot of effort to arrange coffee mornings etc. Always seem cheerful and friendly with residents, visitors and each other. • • • Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 6 • The home has a happy atmosphere and the new Manager is anxious to improve the overall situation. Survey forms are issued periodically to enable relatives/friends to make comment. The forms are collated and an action plans drawn up. Verbal comments received from Service Users included: • • • • • • • • “I’m happy with my care, I enjoy my view of the garden.” “The meals are good, the staff are always polite, and I have good access to health.” “The meals are very good, I had a visit from my Doctor this morning.” “If I didn’t like something, I would know who to speak with.” “I have a lovely room.” “The meals are so so.” “I’m well looked after, and enjoy being by myself, I don’t wish to participate in the activities.” “I’ve been out with staff to Kettering and purchased items for my tapestry work.” Verbal comments received from Relatives/Visitors included: • • • • “I feel the atmosphere has improved since the appointment of the new Manager.” “I find a majority of staff are polite and courteous.” “Overall staff are kind and work hard.” “The food is excellent, and the meals are homemade.” Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Service users could benefit from additional information being incorporated within the assessment and care plan process, which would provide an opportunity for individuals to have their views recorded as to how they wish to spend their time, with regards to all areas of daily life. This has particular reference for those individuals who are not able to express their views on a day-to-day basis due to their health. The development of care plans could also be improved by incorporating information as to service users hobbies and interests, a holistic approach being supportive of a quality of life with appropriate support. Environmental improvements to décor would improve the surrounding of service users. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 8 Bathing and showering facilities are insufficient to meet the needs and number of service users residing at the home, additional bathing and showering facilities would improve personal care practices for service users, promoting choice and well-being. Staff need to receive regular supervisions by a member of the management team to ensure that they have the opportunity to comment on their daily care practices, discuss issues of concern and identify training needs, all of which should lead to the improvement of care received by service users. 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. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 9 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 Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 10 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): 3. Standard 6 is not applicable, as Oxendon House does not provide Intermediate Care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with information as to the services offered by Oxendon House, enabling individuals to make an informed choice as to where to reside. Service user care needs are well assessed before they move into the home to ensure their needs can be met. EVIDENCE: Individuals considering a residential placement at Oxendon House, can contact the Manager, who will provide them with a copy of the Statement of Purpose and Service User Guide, which provides information as to the services offered by Oxendon House and includes staffing arrangements, environmental details, the admission process, information on activities and hobbies supported by procedures regarding fire and raising complaints. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 11 The Manager confirmed that prospective service users are provided with a copy of the most recent Inspection Report, undertaken by the Commission for Social Care Inspection (CSCI). In addition all documentation is available in the foyer of the home. Records of one service user recently admitted as part of the ‘case tracking’ process was viewed, the Manager of Oxendon House had undertaken an assessment of need. The assessment identified the needs of the individual, and how in the view of the Manager the staff of Oxendon House could meet these. Records of three other service users were viewed, who had resided at the home for sometime, all service users had an assessment undertaken by the Manager, whilst some service users had also had an assessment of need undertaken by a representative of Social Services. The assessment of individuals could be further developed to encompass information as to their lives, for example their family, work and social history. Additional information would enable a comprehensive care plan to be developed which focused on preferred daily routines of living, which is particularly relevant to service users with Dementia. Information on social and family history enables activities and recreational pursuits to be put into place, which reflects the individual’s lifestyle. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. Service users are well cared for having their tailored health and daily care needs met, which is achieved by the their involvement in the development of a care plan in most instances. EVIDENCE: The care plans and records of four service users were viewed as part of the ‘case tracking’ process, the care plan for one service user had not been reviewed, and the information was very limited. The three remaining care plans were detailed and highlighted aspects of personal care, and the role of staff in offering the appropriate support. The Manager, who has been in her current post eight months, is in the process of reviewing all care plans and the format used. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 13 Care plans are regularly reviewed, and are signed in most instances by the service user or their relative. Relatives spoken with confirmed that if they have any concerns as to the content of care plans, they discuss these with the Manager. Two service users spoken with confirmed that they were aware of their care plans, and their content. Care plans could further be improved by detailing services users preferred daily routines, for example what time they wish to get up or go to bed, whether they prefer baths or showers and there frequency, their likes and dislikes with regards to meal preferences for example. For Service users with Dementia additional information as to their care needs and the role of staff in offering support would promote the care of service users, consistent with their condition and lifestyle. Records evidence that service users have access to health care, such as General Practitioners, District Nurses, Community Psychiatric Nurses, Specialist Consultants, Opticians and Dentists. The Inspector noted that on the day of the site visit two General Practitioners were visiting service users, the Inspector spoke briefly to one of them who confirmed that he believes he is contacted appropriately to visit service users within the home and that he is confident that his instructions as to the health care needs of service users are carried out. Discussion with two service users ‘case tracked’ and discussion with two service users ‘not case tracked’ confirmed that have access to healthcare, which they feel is appropriate and proportionate. Service users who are at possible risk of the development of pressure sores, or who have a poor appetite, are assessed to ensure that their health and well being is maintained. Medication and medication records of the four service users were viewed as part of the ‘case tracking’ process; the administration of medication is the responsibility of members of staff who have received the appropriate training. Service users and visitors confirmed that staff are polite and courteous, and are respectful. Either the service user or a relative manages Service users mail. Oxendon House DS0000040280.V329891.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 good. This judgement has been made using available evidence including a visit to this service. Service users continue to make choices about daily living and are offered a variety of meals and social activities of interest. EVIDENCE: Service users have the opportunity to engage in a range of activities, which are provided in part by activity organisers and volunteers, activities include art and craft, board and group games, and one to one sessions talking and reading with service users. During the site visit the Inspector observed a group of service users making preparations for Easter, making cards and decorations. One service user said that she preferred to spend time in her room reading, whilst another service user confirmed he did not engage in activities but preferred to spend time on his own. One lady said she enjoyed the art and craft sessions, and participated in all the activities. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 15 Relatives and service users spoken with confirmed that ‘outings’ are organised by the Manager, recent trips have been to a farm park in Desborough and a garden centre in Ullesthorpe. Comments were received that on one outing staff sat separately from service users at lunchtime, and felt that service users were not offered help and support with their meal. This was discussed with the Home Owner and Manager; the Manager confirmed that staff did sit separately to a majority of the service users, but that their relatives and friends supported service users. Upon reflection the Manager agreed that this could have been handled differently. Records of service users indicated who is responsible for the management of service users finances; in some instances it is the service user or a representative of their family, which may be a formal or informal arrangement. Whilst an advocate supports some service users. The lunchtime meal was observed; some service user ate within the formal dining area, with some eating within the lounge/dining area leading off from the entrance foyer. Service users in some instances were supported to eat, eating in their bedrooms, supported by staff and in one instance a service user was supported by their relative. Recent staff meetings and quality assurance questionnaires highlighted that concerns had been raised with regards to staffing levels, with particular reference to the level of staff on duty to offer support to service users during the mealtimes. The Inspector observed that two members of staff on duty at lunchtime sat separate from service users. Discussions with the Home Owner and Manager confirmed that whilst staff are welcome to eat a meal this should only happen when the needs of service users have been met, and that good practice should promote that staff should sit with service users promoting a social environment, engaging in conversation. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Service users when asked were confident that should they have any concerns, whom they should speak with, in addition there is a written complaints procedure, and information as to how to contact advocacy services. Care staff spoken with had a good understanding of their responsibility and procedures to follow in relation to protecting adults from abuse and were confident to ‘whistle blow’ on poor or bad care practices. Staff files examined contained evidence to show that staff have received training in safe guarding adults as and as part of attaining a National Vocational Qualification (NVQ) in Care. The Manager of Oxendon House has received two complaints to date in the year 2007; records viewed detailed the complaint, the investigatory process i.e. a record of persons spoken with, and the outcome of the complaint. A letter was in place addressed to the complainant detailing the outcome and any actions that would be taken as a result of their concern. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 17 The Commission for Social Care Inspection has not received any expressions of concern with regards to Oxendon House. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of service users with regards to bathing facilities are not met. Service users would benefit from improvements to the décor of Oxendon House. EVIDENCE: Oxendon House provides seating and additional dining facilities, which lead off from the entrance foyer. A separate lounge and dining room are located at the rear of the property both rooms looking out onto the rear garden, with access to the garden. The rear garden is large, some ground floor bedrooms also have direct access into the garden, the garden area is well maintained and several service users spoken with said that they enjoyed going into the garden. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 19 The accommodation at Oxendon House is contained over three floors, with floors being accessible via a stairwell or passenger lift. Communal areas are provided on the ground floor, with a small separate lounge being provided on the second floor. The owners of Oxendon House are currently in the process of a programme of re-decoration, which they acknowledge will take sometime. Plans are in place for specific areas of the home to undergo improvements, which includes the demolition of the stable block, which will provide additional car parking facilities. Oxendon House provides two bathing/shower facilities, which is insufficient to meet the needs of service users. The Home Owner advised the Inspector that they have plans to provide an additional shower facility, however this may well still fall short of service user needs. Of the twenty-seven bedrooms, sixteen have en-suite facilities, which comprise of a toilet and wash hand basin. Of the twenty-seven bedrooms three are shared. Service users spoken with confirmed that they personalised their rooms, often bring personal possessions with them upon admission into residential care. Laundry facilities are provided, and a laundry assistant is employed. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Trained and qualified staff are employed following robust recruitment checks and are employed in sufficient numbers to meet the care needs of service users. EVIDENCE: Oxendon House employs a Manager, Senior Care Assistants and Care Assistants who are responsible for the delivery of care. Care staff are supported by ancillary staff which includes domestic, catering, laundry assistants and a Cook. Three members of care staff are on duty in the morning, whilst the remainder of the day, which includes during the night, has two. Ancillary staff are on duty Monday to Friday, with the exception of the catering staff who work seven days a week. The Statement of Puppose which was revised by the Home Owner in January 2007, states that 71 of have attained a level 2 National Vocational Qualification in Care (NVQ), two members of staff spoken within during the site visit confirmed they had attained an NVQ. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 21 Discussions with staff and through records viewed, it was identified that various topics of training are undertaken, which include moving and handling, health and safety, first aid, dementia care, Alzheimer’s awareness and challenging behaviour. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 22 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, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager demonstrates a clear sense of leadership with regards to day-today management. Quality assurances processes provide an opportunity for service users to contribute and comment on their care provision. EVIDENCE: The Manager of Oxendon House has been in her current post since July 2006; prior to this she was the Deputy Manager. The Manager stated it was her intention to submit an application to the Commission for Social Care and Inspection to become the Registered Manager. The Manager has attained the Registered Managers Award and is working towards NVQ level 4 in Care. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 23 Service users, relative and staff benefit from a quality assurance system, which involves the distribution of questionnaires twice a year, this provides an opportunity for all to comment on the service received and offered by Oxendon House. A quality assurance report is developed for the three separate groups, which includes issues identified and an action plan as to how issues raised are to be dealt with. The staff of Oxendon House have received a variety of letters and thank you cards thanking the staff for the care of their relatives and friends. The Statement of Purpose states that employees of Oxendon House do not take responsibility for service user finances, care plans detail as to whether finances are managed by the service user themselves, their relatives or an advocate. The Manager acknowledged that staff do not receive regular one to one supervisions, however all have recently participated in an annual review. Staff have recently had a team meeting, and the Manager stated her plan for the future is to organise team meetings dependent upon the role of staff within the home, enabling all to discuss issues of concern and promote the welfare of service users. The Pre Inspection Questionnaire submitted prior to the CSCI prior to the site visit detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care plans could be further developed by including information as to a service users life prior to receiving residential care, to include family, work and lifestyle choices enabling the development of care plans reflective of an holistic approach to care, and the promotion of service users individualism, choices and preferences. Care plans could be further developed by including service users preferences for daily living arrangements and by including information as to hobbies, interests and recreational pursuits. It is recommended that additional bathing/shower facilities be provided, which reflects the number of service users and their needs with regards to personal care. Staff should have the opportunity to discuss care practices, including service user welfare, staff training needs etc. within the arena of a supervision. 2. OP7 3. 4. OP21 OP36 Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Oxendon House DS0000040280.V329891.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!