Inspection on 25/02/08 for Oxendon House

This inspection was carried out on 25th February 2008.

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

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 13/03/07

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 Irene Miller Unannounced Inspection 25th February 2008 10: 45 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.V359942.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.V359942.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 christine.skellham@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.V359942.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 13th March 2007 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 older persons 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. Within the front lobby of the home there is information available to residents and visitors to include a copy of the homes statement of purpose and service User Guide, the homes complaints procedure and the homes most recent inspection report published by CSCI. The current weekly fee falls in the range of £310.00 - £520.00, 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.V359942.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon outcomes for Service Users and their views of the service provided. This visit was unannounced and focused on ‘key standards’ under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for older people. The care needs of three people living at the home were looked at in depth this involved looking through written information available on their care, such as the care plans (a care plan sets out how the home aims to meet the individual service users personal, healthcare, social and spiritual needs). Discussion took place with the residents, staff and visitors that were present. Some of the service users were unable to comment on their care therefore observations of staff and service users interactions were made, with an aim to establish if service users were satisfied living at the home. Sample checks were carried out on the homes policies and procedures and records in relation to staff recruitment, complaints, and general maintenance and upkeep of the facility were viewed. Prior to the visit the Commission for Social Care Inspection sent out to the home the Annual Quality Assurance Assessment (AQAA) for the registered provider to self assess their performance, the AQAA was returned to the Commission for Social Care Inspection prior to this visit taking place and it provided additional information on the homes management and administration, processes. The commission for Social Care Inspection (CSCI) sent out satisfaction questionnaires to residents, visitors and staff prior to the visit and the comments received from these questionnaires provided additional information on how the home is managed. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The instruction for staff to follow on moving and handling of residents needs to be clear, this will ensure that staff have a consistent approach and do not place the resident or themselves at risk. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 7 Staff should ensure that residents who choose to retain the responsibility for taking their own medication, comply with the homes self medication policy. and procedures. Consideration needs to be given to having risk assessments in place for all radiators (hot surface temperatures), as it was noted that throughout the home there was some radiators without protective covers and some with thermostatic valves fitted. To ensure that should any person wish to address any concerns to the home or CSCI the contact details need to by current within the homes complaints procedure to include the name of the current registered person and the address of the local CSCI office. 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.V359942.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (standard 6 is not applicable to this service) Quality in this outcome area is good. Information is made available to people who are considering moving into the home, which enables them to make an informed choice as to whether the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the care plans viewed there was records of pre assessments having been carried out by the manager and Social Services. The assessments had identified the health and social care needs of the prospective residents. Within the care plans there was information on the residents daily routines, their individual preferences and social contacts and a pen picture on their life history. This information is useful when providing care for people living with advancing dementia whose ability to verbally communicate may be complex. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 10 A copy of the most recent Inspection Report, undertaken by the Commission for Social Care Inspection (CSCI) was available within the front entrance to the home and there were copies of the homes Statement of Purpose and Service User Guide available to prospective residents and their families. The satisfaction surveys received by CSCI prior to the inspection visit included comments such as ‘I did receive a contract some time ago’, ‘I received information about the home before I moved in, ‘I have just moved into a new ground floor bedroom so am awaiting a new contract’ Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 &10 Quality in this outcome area is adequate. The health and personal care needs of people living at the home are met, however a lack of clear guidance on when to use hoisting equipment has the potential to place the staff and residents at unnecessary risk. Residents who maintain the responsibility for taking their own medications need to comply with the homes medication policy and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the care plans viewed there was information available on the health and personal care needs, this included information on the residents medical history, and the health care support required from other healthcare professionals involved. There were nutritional assessments in place and care plans for the support required with eating & drinking, there were records of the resident’s weights Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 12 being closely monitored to identify weight losses and gains. There were records of the General Practitioner and the district nurse having been involved where there had been concern over weight losses and gains. The satisfaction surveys received by CSCI prior to the inspection visit included comments such as ‘I have had access to see my doctor and the district nurse when necessary’. There were mobility assessments in place, however within one of the assessments viewed a resident had been identified as not being able to fully weight bear and identified as at a high risk of falls. The care plan for this resident had conflicting information available, it stated that the resident requiring minimal staff assistance with their mobility. This resulted in there being conflicting information on whether the resident required the use of moving and handling equipment or not. This was discussed with the manager who said that the resident had days where their mobility ability fluctuated. The manager recognised that to place the responsibility on individual staff to decide on a day-to-day basis as to whether a hoist is to be used or not, has a the potential to place staff and the resident at a greater risk. The manager confirmed that in an effort to meet the mobility needs of this resident a standing aid and turntable had recently been ordered. There were records within the care plans of continence management plans being in place and there was evidence that the staff encourage residents to eat a high fibre diet and drink plenty of fluids. There was records of pressure area care assessments having been carried out by the district nurse and pressure-relieving equipment was seen to be in use. There was records available within the care plans viewed on the best methods of communication with individual residents who’s ability to communicate may have been effected through sensory loss and those living at the home with dementia. There were records within the care plans of the residents being seen by their general practitioner, and other healthcare professionals, such as the community psychiatric nurse (CPN), specialist consultants, opticians and dentists, and records were kept on changing needs. The care plans viewed had been regularly reviewed and 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. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 13 Residents spoken with confirmed that they were aware of their care plans. The medication storage and administration systems were viewed and found to be generally satisfactory. One resident retained the responsibility for taking their medication, and there was a policy in place for residents that self medicated and there was a lockable storage facility available within their bedroom. However it was noted during the visit that the medication was not stored within the lockable storage facility, this was brought to the attention of the manager during the visit to ensure this was addressed. In general the residents were satisfied with the medication systems in place, although one comment from the service users satisfaction surveys indicated that there might be the occasion when residents may not receive their medication at the correct time of day. Staff that hold the responsibility for administering medication had received the appropriate training. During the course of the visit the staff were observed to treat residents and visitors to the home with respect and courtesy. Oxendon House DS0000040280.V359942.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): Standards 12,13,14 & 15 Quality in this outcome area is good. The people that live at the home are supported in making choices as to how they wish to live their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit residents were observed to spend time within the communal areas and within their own private bedrooms. The residents spoken with confirmed that they are supported in pursuing their own interests. On the day of the inspection visit a new activity person who was due to take up post was visiting to discuss future plans with the manager on the activities to be carried out. There was an awareness of being flexible with activities to ensure they are individually tailored to the needs, abilities and preferences of each resident. On the residents notice board within the front lounge/communal area there was information for residents on planned events such as an invitation to an Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 15 afternoon tea party, an Easter Bonnet competition, Easter Egg Hunt, and dates of when a visiting Pottery specialist comes to the home, there dates of other events such as bingo sessions the date of the next residents meeting and information as to when the new activity person was due to start working at the home. During a tour of the building residents who were observed to be spending time in their own bedrooms said that they preferred to spend time in their own bedrooms watching TV or reading, one resident said that they liked spending time on their own. Comments received from the service users satisfaction surveys in relation to the activities provided at the home were, ‘I am partially blind and rather deaf. I am happier away from lots of people’, ‘my deafness and state of health mean I cannot really take part in activities and I really don’t want to’, ‘I have began to join in with some of the activities’ and one person stated that ‘I have not had any activities for the past three weeks’, this comment would substantiate that the home has been without an activity person in post. Time was spent with the residents over the lunchtime period and staff were observed to offer support to residents who required this, residents were asked about the quality and choice of the food available. In general the residents were satisfied with the meals provided. Comments received from the service users satisfaction surveys were, ‘the meals are of a good standard’, ‘some days I struggle with a knife and fork as I have Parkinson’s and would benefit from my food always being cut up and help with eating sometimes’. Pets are welcomed into the home, one of the residents have their dog living with them and the manager also takes their dog into the home, the residents were observed to take pleasure from having animals around them. Comments received from the residents during the visit were that they liked living at the home, they had made friends there, and that the staff were kind and helpful. Oxendon House DS0000040280.V359942.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): Standards 16 & 18 Quality in this outcome area is good. People using the service can be assured that any concerns they may have will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection visit three complaints had been brought to the attention of the registered provider of which one of the complaints was still in the process of being addressed by the home and was undergoing a full investigation. As a result of receiving this complaint new procedures had been put into place, and this action demonstrates that the registered provider listens and learns from concerns and complaints that are raised with them. In discussion with residents they confirmed that if they were unhappy with the services provided at the home that would know who to speak with. There was a mixed response within the comments received from the service users satisfaction surveys, with comments such as: ‘Any points I have raised are usually dealt with immediately.’ ‘If I am unhappy with anything I usually tell my daughter when she visits’. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 17 A comment received from a resident’s survey that was returned to CSCI was that ‘complaints never get attention’ and a relative had commented that they were concerned when they had tried to telephone the home during the evening and staff had not answered the telephone. There was a written complaints procedure in place, however the contact details were out of date. To ensure that any person who may wish to address concerns/complaints to the home or CSCI the contact details need to include the name of the current registered person and the address of the local CSCI office. In discussion with the care staff on duty they demonstrated that they have a good understanding of the importance of ensuring that residents living at the home are protected from abuse and of their reporting responsibilities are in this area. Within the staff training records viewed there was certificates available to evidence that formal training was provided on the different types of abuse and the safeguarding adults procedures. Oxendon House DS0000040280.V359942.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): Standards 19 & 26 Quality in this outcome area is good. People using the service are provided a pleasant and homely environment, however people could be placed at risk from unguarded radiators. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A limited tour of the building was conducted to include communal areas, the kitchen and laundry facilities, and a sample viewing of resident’s bedrooms. The communal areas looked clean and homely; there was a mix of seating available to include recliner chairs. Some of the communal areas had been redecorated and re carpeted and residents and visitors spoken with expressed their satisfaction as to the standard of the environment. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 19 The bathrooms and WC’s were clean, one of the bathrooms had a shower cubicle available, and the manager advised that staff assist residents when using this shower facility. It was noted that this facility would benefit from having a walk in style of shower screen made available. One of the residents was happy to show their bedroom, and this bedroom along with others viewed was personalised, to contain small items of personal furniture, ornaments, photographs and pictures. The laundry facilities were clean and tidy. The home plans to increase the number of bedrooms, and three new rooms were viewed. The rooms were spacious and included en-suite facilities. Consideration needs to be given to having risk assessments in place for all radiators (hot surface temperatures), as it was noted that throughout the home there was some radiators without protective covers and some with thermostatic valves fitted. To protect residents who may be a risk of being harmed from hot surface temperatures the risk assessments need to be aimed at an individual level too take into consideration residents who may wish to alter the settings to a higher than acceptable temperature. Comments received from the service users satisfaction surveys were, ‘the home has had a substantial amount of refurbishment, and I feel they make a good effort to keep the bedrooms fresh even in difficult circumstances’. One resident made a comment that their bedroom was clean during the week, but at the weekends their bedroom can be left ‘untidy not dirty but untidy’. There was plans for the hairdressing facility to be improved, and this had been an area mentioned in the relatives satisfaction surveys where a relative had commented that the home could improve the service for the residents by having a back sink for the hairdressing room. The kitchen was viewed during the visit there were records of food hygiene checks having been carried out regularly and staff were seen to wear protective clothing. The fire risk assessment had been recently updated. Oxendon House DS0000040280.V359942.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): Standards 27,28,29 & 30 Quality in this outcome area is good. The people living at the home are supported by a staff team that promotes their health, safety and welfare, however poor staff moral, has the potential to place people at risk of not receiving the full attention of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection visit there was three care staff, three domestic staff one cook, one kitchen assistant and one laundry person on duty. The recruitment files of three staff were viewed and documentation was available to demonstrate that pre employment checks had been carried out on the staff prior to taking up employment at the home. These included checks being carried out on the protection of vulnerable adults register (POVA) 1st, and with the criminal records bureau (CRB). There was evidence of references having been obtained prior to staff taking up employment. There were records of staff having received training on moving and handling, fire awareness, infection control, first aid, medication, dementia care, and challenging behaviour. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 21 The manager confirmed that one member of the catering staff was due to take up a National Vocational Qualification (NVQ) with a local college in professional cookery. In discussion with the manager she confirmed that moving and handling refresher training was being rolled out to all staff following a complaint that had been raised with the home. Following a visit to the home from the fire authority it had been identified that staff training was to be provided on fire awareness, on checking the fire logbook there were records of staff having attended this training. On the day of the visit a test of the fire alarm was scheduled and the staff were observed to respond promptly to the fire alarm being activated and in accordance with the fire procedure. In discussion with the staff on duty they expressed satisfaction at working at the home and confirmed that they had been provided with training to include training to gain a National Vocational Qualification in Care (levels 2 & 3). Comments received from the service users satisfaction surveys were in the main positive to include comments such as: ‘The staff are generally cheerful, attentive and considerate’. ‘I could not manage without the staff’. ‘In general help is always available when necessary’. Comments from the relative’s surveys were in the main positive to include comments such as: ‘The home always responds to our wishes’, ‘the relationships between care home staff and relatives is very good, I always feel happy that if there are any problems they will do their best to solve them’ ‘A notice board has been set up to tell relatives all that is going to happen this is a good idea!’ ‘There has been a few issues recently regarding staffing, hopefully these are now being addressed. This includes some one to do activities with the residents’. ‘One or two concerns have been made and the home now endeavours to sort these out, if this goes well then all will be greatly improved’. ‘The atmosphere within the home has improved’. Within the staff satisfaction surveys received the positive comments were: Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 22 ‘The home provides proper care for the resident’s in a loving friendly home, and the needs of the service users are met’. ‘The care plans are now up to date, now that we have a head of care, before that we were really in the deep end and had to find out things for ourselves’. Some of the comments within the staff surveys that had expressed dissatisfaction with working at the home were in the following areas: • • • • A lack of communication between the manager and staff Staff being tired through working long hours, and not having sufficient breaks between shifts. That when information is passed on via a telephone conversation with the GP and district nurse, that this often caused a breakdown in communication. There was concern at catering staff not wearing uniforms and in general other staff having access to the food preparation area, and that some equipment in the kitchen needing replacement, such as the waste bin, and the fly screens In discussion with the manager efforts were being made to improve on the communication within the home, a staff meeting was due to take place. The manager has implemented one to one staff supervision sessions in an effort to support staff and improve further on the internal communication. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 & 38 Quality in this outcome area is good. The home is run in the best interests of the residents, and systems are in place To promote their health, safety and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager has been in post since July 2006 and prior to this she was employed as the deputy Manager. She has attained the Registered Managers Award and she is working towards achieving an NVQ level 4 in Care. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 24 The Manager has submitted an application to be considered as the registered manager with CSCI. There was evidence of quality assurance systems being in place to include the distribution of questionnaires to residents and there families twice a year, this provides an opportunity them to have their say on how the home can continue to improve on the service provided. The cash held at the home on behalf of the residents was sample checked and there were accurate records of cash transactions and evidence of receipts having been obtained. There was evidence that steps have been put in place to improve on the communication between the staff and management, this includes one to one supervision, and the introduction of team meetings to provide the forum for staff to raise any concerns directly with the manager and to focus on improving the service to the residents. The homes Annual Quality Assurance Assessment (AQAA) was submitted to CSCI within the timescale and provided a self-assessment of the services provided by the home in which areas for improvement had been identified. Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 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 2 X 3 X 3 X X 3 Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13 (4) Requirement The care plans must have clear instruction for staff to follow on the residents moving and handling requirements. The registered person must ensure that residents who retain the responsibility for administering their own medication comply with the homes medication policies and procedures. Timescale for action 30/04/08 2 OP9 13 (2) 30/04/08 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 Refer to Standard OP19 Good Practice Recommendations Risk assessments should be carried out to identify where residents may be at risk of being harmed from hot surface temperatures e.g. Radiators The fitting of a shower screen to the shower facility within the first floor bathroom should be considered. 2 OP21 Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 27 Oxendon House DS0000040280.V359942.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V359942.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!