Inspection on 13/02/07 for Oxford Grange

This inspection was carried out on 13th February 2007.

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

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

Other inspections for this house

Oxford Grange 11/11/05

Oxford Grange 02/06/05

Oxford Grange 18/01/05

Oxford Grange 27/09/04

Oxford Grange 13/07/04

Oxford Grange 29/03/04

Similar services:

Carentan House

Ravensworth Lodge

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

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

CARE HOMES FOR OLDER PEOPLE Oxford Grange 30 Oxford Road Dewsbury West Yorkshire WF13 4LL Lead Inspector Tracey South Unannounced Inspection 13th February 2007 09:20 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 Oxford Grange DS0000045070.V324176.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. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oxford Grange Address 30 Oxford Road Dewsbury West Yorkshire WF13 4LL 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) 01924 463029 01924 455442 northfields@leedscare.co.uk Northfields Care Homes Ltd Rachel H Bedford Care Home 43 Category(ies) of Dementia - over 65 years of age (43), Old age, registration, with number not falling within any other category (10) of places Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th November 2005 Brief Description of the Service: Oxford Grange is owned by Northfield Care Homes Ltd and provides care and accommodation for up to 43 people with dementia care needs. The home is situated in a Victorian detached house in its own grounds. There are three floors of accommodation and the main office for Northfield Care Homes Ltd is situated in the basement. There are two car parks and gardens to the front and rear side of the building. Oxford Grange is situated on Oxford Road, approximately one mile from the local town of Dewsbury and two miles from the town of Batley. The home is also within easy reach by public or private transport. The current charges at the home range from £342.99 to £354.72 per week. Additional charges are made for hairdressing, chiropody and toiletries. The service provider ensures that information about the service is available to prospective residents and the current residents by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection the Commission for Social Care Inspection (CSCI) undertook a visit to the home. Alongside this, the staff at the home also completed a pre-inspection questionnaire, which was returned to the Commission before the inspection, as requested. Information from this questionnaire was also used for this report. One inspector carried out the inspection over two days, approximately 10.5 hours was spent in the home. Surveys were sent to residents, their relatives and GPs. Ten surveys were sent to residents, two were returned. Ten surveys were sent to relatives, two responses were returned. Six GP survey were sent, two were returned. In writing this report, information and evidence was not only obtained by way of visiting the home, but also from notifications sent and information obtained by the Commission for Social Care Inspection. The last inspection report was also consulted. Care practice was observed during the day. The inspector did spend time talking with residents. Residents were not able to comment directly about their care and support because of their level of dementia. Discussions also took place with the manager, deputy manager, two care staff and two ancillary staff. Records were examined and a tour of the home was also undertaken. There were 41 residents living at the home on the day of the inspection. The inspector would like to thank everyone for their assistance and hospitality during the inspection process. What the service does well: Prospective residents are thoroughly assessed before they move into the home. Residents and their relatives are able to visit the home to help them make a decision as to whether this is the right home for them. There was a good atmosphere in the home. Staff were seen making visitors feel welcome. Residents appeared calm and relaxed. Residents are able to walk around the home freely and there are a number of communal areas where residents can sit and rest. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 6 Comments received from relatives include, “I can’t fault the home at all, everyone I’ve met are very caring and understanding. I would certainly recommend it”. “Every member of staff I have come across have been very kind, considerate with the patience of a saint”. The home is well managed and feedback from the care staff is that staff morale is good. What has improved since the last inspection? What they could do better: 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. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 7 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 Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 8 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 the home does not provided intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are thoroughly assessed prior to them moving into the home. EVIDENCE: The manager explained that either herself or the deputy manager visit all prospective residents prior to them moving into the home. The purpose of the visit is to carry out a pre-admission assessment. The assessment allows the manager and senior staff to make a decision as to whether or not they are able to meet the person’s needs. When the placement is funded by the local authority information submitted from the social worker is also taken into consideration. The senior staff are reminded to sign the pre-admission documentation upon completion. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 9 The manager explained that prospective residents and their families are invited to look around the home before making a decision about moving in. In most cases a family member will visit, it is not always appropriate for the prospective resident to visit. One lady who recently moved in spent a day at the home prior to her admission. One gentleman who was admitted during the second day of the inspection did not visit. His family felt it would be too unsettling for him. Staff were observed welcoming the gentleman into the home, by offering him a cup of tea and chatting with him. Two residents were supported by staff, in completing the CSCI surveys. Both responses indicated that they received enough information about the home before they moved in. Residents were also asked if they had received a contract. Neither was sure but stated that their relative, who acted on their behalf, would know. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide only basic information about residents’ care needs. Residents have access to health care services and the management of medication in the home is good. Staff are respectful of residents’ rights to privacy. EVIDENCE: Care documentation was examined in detail. Four care plans were looked at and although they are acceptable, the finer detail about residents’ needs in respect of their dementia was not included. The care plans are based on identified problems rather than looking at the person’s health, personal and social care needs. A number of residents at Oxford Grange are mobile and generally of good health, their primary care needs are that of dementia and with this in mind care plans need to include information about maintaining independence and choice, providing stimulation as well as personal care needs. The management staff at the home realise that this is an area of improvement that they need to address. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 11 Better recording of incidents of verbal and physical aggression needs to be introduced. Although staff report when someone becomes aggressive they do not record how this has been managed. Detailed information about how staff deal with outbursts of verbal and physical aggression will assist other staff when dealing with similar situations. Risk assessments need to include any identified triggers that lead to challenging behaviour as well as the techniques used to manage such incidents effectively. Staff must consider all information they have to hand when completing care assessments. For example, a falls risk assessment had been completed in respect of one resident; the member of staff had recorded that there was no history of falls despite the resident falling the day before and the day after she was admitted to the home. Residents have access to health care services. Visits by the GP and other health care professionals are recorded in the residents’ care notes. Surveys completed by local GPs were positive about the care residents receive. One GP commented, “staff appear knowledgeable about patients and their needs and seem to care well for patients”. Both surveys indicated that residents’ health care needs are met by the care service. The nutritional assessment tool currently being used needs to be amended to allow care staff to evaluate the findings of the monthly review. Without this the staff could fail to address significant weight loss/gain that may warrant further action, that is, referral to the GP. The management of medication is good and staff are following the home’s procedure in ensuring all medication is accounted for. Four residents’ medication and records were examined, no errors were found. The staff were reminded to make sure to record the date of opening in respect of eye drops and other medication that has a specific timescale when medication must be discarded by. Staff were advised to keep the medication keys separate to other keys in the home to avoid misuse of drugs. This was done during the inspection. Staff were observed treating residents respectively, they were courteous and polite when speaking to residents. Care staff were observed whilst hoisting one lady with mobility problems; they explained the process to her and ensured her dignity remained intact whilst carrying out the manoeuvre. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 12 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. Residents are able to join in a variety of activities and visitors are welcome at any reasonable time. Residents receive a choice of meals. EVIDENCE: Residents’ surveys indicated that there are activities arranged by the home that they can join in. The home employs an activities co-ordinator who provides activities on a weekday between 1pm and 4pm. On the first day of the inspection visit one resident was taken out for a short walk. There are photographs in the front entrance of the home of activities that have taken place. Residents appear to be enjoying themselves whether playing games, dancing or listening to singers. The activities co-ordinator explained that she involves residents in a number of different activities such as, dominoes, craftwork, drawing, knitting, baking and sing-a-longs. One of the ladies played the piano whilst fellow residents joined in singing. The co-ordinator was reminded to record the events that take Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 13 place, including those people who join in, as there was very little evidence of this in the care documents examined. Residents were observed walking around the home freely. They didn’t appear to be restricted in anyway or discouraged from doing so. Visitors are welcome at the home at any reasonable time. The visitors’ book shows that the home receives a number of visitors on a daily basis. Two visitors were spoken with during the inspection, both of which gave positive feedback about the home. They said they could not praise the staff enough for looking after their relative. They confirmed that they are always made to feel welcome and that staff are friendly. Surveys completed by relatives confirmed that they are kept up to date with important issues affecting their relative. One comment received said, “They always ring me to inform me what happened and the treatment given if a doctor was called”. Residents were asked as part of the surveys if staff listen and act on what the resident says. One resident said, “yes”, the other said, “sometimes, they seem busy but usually yes”. The staff rely on information they have received from family members and social workers when making sure residents live their lives according to the preferred choices. The majority are no longer able to communicate their choices effectively. For example, one resident is vegetarian and although she no longer remembers this choice she made before developing dementia, staff act as her advocate and provide this person with a vegetarian diet. Those residents spoken to said they enjoyed their meals. Residents are offered two choices for their main meal. The meal on offer during the inspection was roast chicken or cheese pasta, with swede, green beans and mashed potatoes, with apple crumble and custard for dessert. The meal itself looked attractive and the portion size was generous. Tables were set appropriately although there were no condiments, such as salt and pepper in sight. Staff were seen assisting residents with feeding in a discreet and sensitive manner. Those people who have difficulty with swallowing are given a soft diet, which has been liquidised. In terms of presentation the meal looked unappealing, the cook was advised to liquidised food separately, rather than altogether to ensure the meal retains its colour, texture and appearance. As part of the residents’ surveys they were asked if they liked the meals at the home. One person said “sometimes, the other said “always”. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 14 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. The home’s complaint’s procedure is simple, clear and accessible and residents are protected from abuse. EVIDENCE: Information provided by the home prior to this inspection indicated that they have not received any complaints within the last 12 months. The complaints procedure is accessible and is displayed in the front entrance of the home as well as on the back of each resident’s bedroom door. Following discussions with the management staff it is recommended that the home make a record of any informal complaints/concerns raised by residents and or their relatives/friends. The information recorded should include the nature of the concern and the action taken to resolve the matter. This demonstrates that the home is open to comments made by people associated with the home and they will act on what people have to say. All staff have received adult protection training. Those staff spoken to were clear about their responsibilities in reporting incidents of abuse as well as having a good understanding of the different forms of abuse. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 15 All new staff are checked against the Protection of Vulnerable Adults (POVA) list prior to starting work at the home. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Improvements to the décor of the home need to take place and unpleasant odours are apparent in parts of the home. EVIDENCE: A number of fixtures and fittings and the décor of the home require upgrading. The décor throughout the home is looking shabby and worn. The majority of paintwork is scuffed and in need of repainting. Carpets are stained and in need of replacement. A redecoration and refurbishment programme has been implemented and progress is beginning to take place. A copy of the programme has been provided to the CSCI and progress will be monitored as part of future inspections at the home. The main dining room has been redecorated and new Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 17 flooring has been fitted. At least four bedrooms have been decorated and the floorboards in a number of bedrooms and on the middle floor corridor have been taken up and re-laid. The corridor carpet outside bedroom E4 had lifted and was a potential tripping hazard. The manager was advised to make it safe as a matter of urgency. The manager confirmed by telephone, two days after the inspection, that the carpet had been made safe. Relatives were asked in the survey, how could the care home improve? One relative replied, “It could be a bit more modern, but I think it will soon be refurbished”. The domestic staff explained that there is a cleaning schedule in place. There are three domestic staff on duty Monday to Friday and their responsibilities are to ensure bedrooms and communal areas are thoroughly cleaned. Carpets are shampooed as part of a rolling programme. The weekend domestic is responsible for making sure the home is kept tidy. The housekeeper explained that they try to keep unpleasant odours to a minimum by cleaning up accidents promptly as well as using odour neutralisers. The environmental health officer visited the home in May 2006. The home must confirm that all recommendations made as part of that visit have been addressed. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 18 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. There are sufficient numbers of staff to meet the residents’ needs and staff have received training although not in dementia care. The home’s recruitment procedures are robust. EVIDENCE: Staffing levels are currently set at six care staff on the morning shift and five staff on the afternoon shift. Three care staff work during the night. The manager’s hours are supernumerary. Domestic, laundry and kitchen staff cover a seven day rota. The company also employ six handypersons who attend to maintenance issues within the three homes. Information provided within the pre-inspection questionnaire indicates that 56 of the care staff have achieved a NVQ level 2 qualification in care. Four staff personnel files were examined. All contained the necessary documents to confirm that a thorough recruitment process had been followed prior to the new person starting work at the home. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 19 Over the past 6 months the staff have undergone training in health and safety, fire, food hygiene, infection control, manual handling theory and practical, adult protection and seven staff have received emergency first aid training. In most cases the training has been provided within the home and staff have been expected to watch a short video followed by a series of questions they must answer in writing. If successful, they are awarded a certificate completed by the manager of the home. There has been very little dementia training taken place either externally or internally for quite some time. The majority of staff have never received any dementia training at all. The manager explained that ten staff are due to start dementia training in association with Park Lane College at the end of February 2006. The training will take place over a twelve-week period. The training will be made available to all care staff. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed although there is little of evidence of any quality auditing taking place. Residents’ financial interests are safeguarded. Health and safety systems are effective. EVIDENCE: The registered manager of the home is Ms Rachel Bedford. Ms Bedford demonstrates a good understanding of caring for older people and has a genuine desire to make sure people are well cared for. Ms Bedford is supported by the deputy manager, who together manage the home effectively. Staff and visitors were complimentary about the management staff who are said to be supportive and approachable. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 21 Both the manager and deputy manager have recently completed their Registered Manager’s Award. The group manager is responsible for carrying out visits to the home to form an opinion of the standard of care provided. A report is then produced; the inspector read the latest report on the day of the inspection. The report was informative and showed evidence that the visiting manager had spent time talking with residents and staff and recorded their views about the home. The company has recently introduced a robust quality assurance tool in order to seek the views of people who use or who are associated with this service. The deputy manager explained that this is her area of responsibility and to date she has not implemented the system. She explained that she will be doing this over the course of the next few months. This will be monitored as part of future inspections at the home. Small amounts of monies are kept on behalf of residents. Three residents’ monies were checked, all of which were found to be correct. Any transactions made are recorded and receipts are kept in respect of any monies spent. There are good health and safety systems in place. Regular checks such as fire alarm tests, fire drills, gas safety checks and the servicing of equipment are carried out; information provided within the pre-inspection questionnaire includes dates of recent servicing and testing of equipment. Risk assessments are in place in respect of safe working practices. The staff are reminded to record the names of staff who attend a fire drill to ensure each member of staff takes part in at least two fire drills per year. As part of the tour of the home the kitchen area was inspected. The kitchen is in need of a deep clean, this includes equipment being used as well as the surrounding paintwork. The cook explained that this had already been arranged and was due to take place the day after the inspection visit. There appears to be a shortage of decent crockery, a number of pieces of crockery were chipped and an assortment of old crockery is being used. The chopping boards are old and well worn and should be replaced. Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 22 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 1 X X X X X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement All care plans must include the resident’s health, personal and social care needs. More emphasis must be made on promoting independence and choice whilst addressing the mental health needs of each individual. Risk assessments must clearly identify any triggers and the measures to be used to eliminate/minimise the risk. Staff must consider all information they have when completing health care assessments. The nutritional assessment tool needs to be amended to include a reviewing section to assist staff in monitoring weight loss/gain. Work must continue to ensure 30/08/07 the home is kept clean and reasonably decorated. All care staff must receive 30/08/07 dementia training to enable them to care for people within DS0000045070.V324176.R01.S.doc Version 5.2 Page 24 Timescale for action 30/06/07 2. OP8 13 30/04/07 3 4 OP19 OP30 23 18 Oxford Grange 5 OP33 24 their care. Management staff must ensure that the quality audit system is introduced as agreed in order to seek the views of people associated with the home. 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP12 OP15 OP15 OP16 Good Practice Recommendations Better recording of activity events should be implemented. Liquidised meals should be presented in a manner which is attractive and appealing in terms of texture, flavour and appearance. Condiments should be readily available for residents whilst promoting the health and safety of others. The manager should record all informal complaints/concerns raised by residents and or their relatives. The information recorded should include the nature of the concern and the action required. Names of staff attending fire drills should be recorded to ensure they attend at least two each year. New crockery and chopping boards should replace old items currently being used. 5 6 OP38 OP38 Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Oxford Grange DS0000045070.V324176.R01.S.doc Version 5.2 Page 26 - 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!