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Inspection on 18/11/08 for Queens Oak Care Centre

Also see our care home review for Queens Oak Care Centre for more information

This inspection was carried out on 18th November 2008.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet residents` needs. Residents were observed to be treated with respect by staff and to have their privacy and dignity respected. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The home has a training plan and intends to train its staff in health care to achieve accreditation. The home`s recruitment procedures protect the residents through vigorous staff vetting.The home is pleasantly designed and furnished, providing communal living, recreational and dining space that meets individual and collective needs. Comments from residents were generally positive, with indication that staff is kind and helpful in meeting their care needs.

What has improved since the last inspection?

The menu was reviewed in June in response to the choice of residents. The "Nutmeg" programme which was introduced in June provides a recipe for all the chosen menus. More importantly it gives the nutritional value of these menus thus ensuring the residents receive nutritional meals. There has been an increase in number of residents who manages their personal allowances. A much wider range of activities both in and out door is now offered. The home is far more "homely" and much refurbishment has taken place. The majority of bedrooms have been redecorated and improvement has been made with the central heating and water systems. The home`s complaints policy has been revised to make it more accessible to residents. It is now in larger print and has been simplified.

What the care home could do better:

The practices for administration, storage and disposal of medications are inadequate and potentially places residents at risk and these must be improved.

CARE HOMES FOR OLDER PEOPLE Queens Oak Care Centre 64-72 Queens Road Peckham London SE15 2EP Lead Inspector Mohammad Peerbux Unannounced Inspection 18th November 2008 10:10 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 Queens Oak Care Centre DS0000007045.V373675.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. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queens Oak Care Centre Address 64-72 Queens Road Peckham London SE15 2EP 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) 020 7277 9283 020 7277 9263 lorna.thomas@excelcareholdings .com Lancewood Ltd Lorna Esmay Thomas Care Home 88 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (54) of places Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To include no more than 34 service users with Dementia at any one time. The service users at Queen`s Oak Care Centre can be approached as to whether they would like to move to another bedroom, though must be moved at their own will. 29th November 2007 Date of last inspection Brief Description of the Service: Queens Oak Care Centre is a care home with nursing for older people, built in 2001. It is owned by Excel Care, a large care provider with homes in London and other parts of the country. There are four floors and care for residents suffering from dementia is provided on two of them. Care for residents with physical frailty and for residents requiring nursing care are provided on the other two floors. The home is near Peckham town centre, close to shops and all community amenities. There are train and bus routes near the home and some parking space in front of it. All bedrooms are single and all but four are fully en-suite. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2008/2009. In writing the report, consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. Some of the residents were spoken to and they commented positively on the care they were receiving. One resident told us “the girls are really nice here” another said “ I have no complaints, everyone treats me really well”. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance assessment (AQAA) .It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from this AQAA is included in the report. We are presently taking enforcement action against the home for repeated failures with regards to medication standard. What the service does well: The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet residents’ needs. Residents were observed to be treated with respect by staff and to have their privacy and dignity respected. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The home has a training plan and intends to train its staff in health care to achieve accreditation. The home’s recruitment procedures protect the residents through vigorous staff vetting. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 6 The home is pleasantly designed and furnished, providing communal living, recreational and dining space that meets individual and collective needs. Comments from residents were generally positive, with indication that staff is kind and helpful in meeting their care needs. 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. Queens Oak Care Centre DS0000007045.V373675.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 Queens Oak Care Centre DS0000007045.V373675.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 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No one is admitted in to the home without having a full needs assessment carried out by a senior member of staff to make sure that the home will be suitable for their needs. This home does not offer intermediate care so this standard does not apply. EVIDENCE: None of the people that we spoke with during the inspection were able to tell us about their experiences when they were choosing where to live. However, when we looked in a selection of care plans we could see that they had all had a comprehensive assessment undertaken to make sure that the home would be suitable for them. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 9 All of the residents are funded through arrangements with the local authority and there was documentation from their care managers to show what support would be needed for them. As well as this they are visited, either in hospital or their own homes, by a senior member of staff who carries out an assessment according to an Excelcare Proforma. This then forms the basis of subsequent care planning, which identifies areas where support will be needed and details how it should be given. All prospective residents are assessed within 48hrs of referral. A copy of the homes Statement of Purpose and Service User Guide, telling people about the homes aims and objectives and the services that are provided are in each resident’s bedroom. They are also displayed in the entrance hall for any one to read. Queens Oak Care Centre DS0000007045.V373675.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 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use this service have their healthcare needs met in a way which suits them and individual care plans are in place which reflect the care, and support that they currently need. The practices for administration, storage and disposal of medications are inadequate and potentially place residents at risk. EVIDENCE: As a large corporate provider this home has a standard care plan in place for each resident. We looked at six of these during the inspection. It was considered that they are quite bulky and some of the information is quite repetitive and might be better stored elsewhere. However, they are comprehensive and cover all aspects of resident’s daily lives, giving staff good Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 11 information about to care for them. They include risk assessments’ regarding the prevention of falls and consent forms for the use of bedroom door keys. Residents are weighed monthly to check that their nutritional needs are being met and factors, which may predispose to a risk of pressure sores, are monitored regularly. Entries in the care plans indicate involvement from other healthcare professionals as necessary such as community nurses and the tissue viability nurse and the doctor visits regularly. Where residents have wounds that need to be dressed there is photographic evidence to support the efficacy of the treatment being used. There are care plans specifically concerned with care at night and all contacts with resident’s relatives are documented. The medication administration records (MAR) were audited. There were two instances where there were medication discrepancies with regards to the amount of medication recorded as received in the home and the number of signatures on the MAR sheets. The home received 21 Amoxycillin 250mg capsules for one resident on 12/11/08. On the day of the inspection, at 13:00 hrs prior to the lunchtime medication being administered, it was noted that there were 17 signatures on the MAR sheets. At that time there were 5 capsules remaining in a box, which made a total of 22 capsules instead of 21. This was discussed with the registered manager who stated that they may have received 22 capsules however the record indicated that 21 were received. The staff were not able to confirm if they had counted the capsules when they were received in the home. Another instance was 200ml of Trimethoprim recorded as received for another resident on 12/11/08. This medication was prescribed as 20ml to be administered twice daily. On checking the MAR sheets it was noted that there were 9 signatures on one MAR sheet dated from 20/10/08 to 16/11/08, and on the MAR sheet dated from 17/11/08 to 14/12/08 there were 3 signatures. This made a total administration of 240ml instead of 200ml. There was also some confusion on the amount that was recorded as brought-forward. On the MAR sheet dated 20/10/08 to 16/11/08 this was written as 20ml and on the MAR sheet dated 17/11/08 to 14/12/08 it was written as 60ml. The staff and manager were unable to comment on why there was a discrepancy in the amount brought forward and administered. It was identified from the MAR that lactulose for one resident was not signed for on 06/10/08 at teatime. Checks of the MAR also identified that a Dipyridamole M/R 200mg capsule was not signed, for another resident with on 17/11/08 at teatime. On 20/11/08 we requested a copy of the medication administration record and it was noted that one member of staff had signed for the omission on 17/11/08 retrospectively where there was a missing signature for Dipyridamole. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 12 During the inspection it was noted that some items of medication were out-ofdate. There were 26 Melonin dressings recorded as expired on 07/2008, one box of Conveen recorded as expired on 02/2005, three Monojet needles recorded as expired on 09/2008, and 19 Monojet needles recorded as expired on 01/2008. All the out-of-date items of medication were double-checked by the care manager at that time. She was unable to comment as to why these items were still in the home. She also stated that there are regular audits being carried out to check on out-of-date medication. We also found two boxes containing paracetamol on top of a cupboard in the clinical room on the nursing floor at around 13:30 hours. These were in two separate and unlocked trays. The care manager witnessed the finding of these boxes of medication and again she was unable to comment, however when she asked one staff member, the staff member stated that the boxes were for returns. We were informed by the management of the home that medications are audited on a regular basis. The Commission is concerned that despite medication audits being carried out on a daily basis to check if staff have signed the MAR sheets, errors in the recording of medication and the out-ofdate items of medication were not identified when stocks were being checked. This was discussed with the care manager, registered manager and regional manager, and they gave assurance that they will take immediate action to resolve this ongoing issue. We will continue to monitor the standard of medication in the home and at present is taking enforcement action. All personal care is delivered in resident’s own rooms and those people who were able to talk with us said that staff were very kind to them. One resident told us “the girls are really nice here” another said “ I have no complaints, everyone treats me really well”. The staff that we met were very pleasant and cheerful and they displayed a good understanding of the needs of the people that they were caring for. There are both male and female staff so that residents are able to have some choice about who delivers their personal care. It was recommended that more work could be done to try and find out about residents past lives and achievements to help staff to understand more about their present behaviour and also to develop activities that will interest them. The Care Manager is aware that this is an area that could be developed and has plans to address this. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The daily life in this home seems to suit the people who live there. They are encouraged to make choices, where possible, and they are able to participate in a wide range of activities, arranged to stimulate and interest them. Meals are very well presented and take residents preferences and cultural differences in to consideration. EVIDENCE: Organisation of the social life in this home is given a very high priority. The home employs an enthusiastic activities organiser and for those people who wish to join in there is a range of different activities offered every day. She explained how she spends time with each resident to try and find out what interests them and compiles a specific care plan outlining their likes and dislikes. If people decide that they do not wish to participate this is reviewed regularly so that they get the opportunity to change their minds. We saw people having a lot of fun participating in sessions during the afternoon and carers also provide sessions on a 1-1 basis if that is more appropriate. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 14 We saw photographs of recent events that had taken place such as a Halloween party and summer barbecue and there are also regular trips out of the home. Birthdays are celebrated and representatives of several local churches visit and hold services in the home. The home has residents of different religious and beliefs. Religious needs of the residents are met by visiting Roman Catholic/Church of England clergy and other denominators. These services are held in the lounge on the 1st and Ground Floors. Holy Communion by the Roman Catholic clergy is given in the resident’s room if requested, or the prayer room on the 2nd Floor. Residents are given peace and quiet to pray and the opportunity to sing hymns of their choice. The home has a new sensory room with brand new state of the art equipment. St Christophers Hospice artists in care homes has taken place and has been well received . Music and movement and reminiscence are all regular sessions. The aim of the home is to involve people with aspects of activity associated with daily living , such as folding sheets, setting tables, gardening, flower arranging and even car washing. Visitors are always welcome in the home and some people are able to go out of the home with staff in order to go shopping or to the bank. The people that we spoke with all said that they enjoyed the meals served in the home. Menus are varied and in order to reflect the background of people in the home there is an Afro-Caribbean menu option every day both at lunchtime and suppertime. Most people choose what they would like to eat the day before. However, of particular note was the use of picture menus on the ground floor. Recognising the limited abilities of these residents there are photographs of the menu choices that day. Residents are shown the pictures to help them decide what they would like to eat and the food is served to them from a hot trolley. The lunchtime meal was observed on the day of the inspection and it seemed to be a pleasurable experience for residents. It is served in a dining room on each floor and was relaxed and unhurried. Everyone had a drink and there was help available for anyone who needed it. People said that they had enjoyed it with one resident telling us “its the best food ever”. Any significant weight loss or gain would be identified and supplements would be given if necessary however, to help monitor residents nutritional status it was recommended that a record should be kept of the food that they actually ate each day. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 15 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 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are managed well, which should ensure that residents’ and relatives’ concerns are listened to. EVIDENCE: The service has a complaints procedure that meets the national minimum standards and regulations. The complaints procedure is available within the home. It keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. The organisation regularly monitors complaints and how they are managed through their quality management and auditing tools. The home understands the procedures for safeguarding adults and will always attend meetings or provide information to external agencies when requested. Staff receive regular training in vulnerable adults protection. The service operates a strict no tolerance approach towards abuse and have clear policies and procedures in place. All unexplained bruises/cuts which cannot be explained are investigated. Queens Oak Care Centre DS0000007045.V373675.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 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet residents’ individual and collective needs in a comfortable and homely way. Residents’ bedrooms are personalised to reflect their individual needs, and personalities. Overall the home was decorated to a good standard throughout and appeared to be very comfortable, bright and warm. The home has a rolling maintenance programme in place. The house keeper conducts regular audits, and high Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 17 cleanliness standards are maintained. Communal bathrooms have been accessorised to make them more homely. There is signage within the dementia unit which helps the residents to identify, e.g. the toilets, dining room, living room. The home is kept clean and hygienic .Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Queens Oak Care Centre DS0000007045.V373675.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 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are always sufficient numbers of appropriately trained staff available to support the people who live in the home and robust recruitment procedures are in place to ensure their protection. EVIDENCE: The home is staffed by care staff on all of the floors and on the first floor,which is registered to provide nursing care, there are also trained nurses. Staffing levels were judged as being appropriate for the number of residents and people told us that they don’t usually have to wait long for staff to help them. There is a training matrix, showing that training that has been undertaken although it is not easy to understand. However, staff were able to confirm that mandatory training has been completed and there have been additional sessions which have been arranged to equip them with the skills that they need to support the people living in the home. This has included dementia awareness and some of the staff that we spoke with were able to explain how their practice had changed after completing this training. They also had a good understanding of the procedures that they should follow should they suspect that abuse was happening in the home. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 19 62 of members of staff have achieved an NVQ qualification at level 2 and several are now studying for a level 3. We looked at the personel files of 4 members of staff. These showed that appropriate pre-employment checks are undertaken to ensure that residents are protected from those who have been judged as being unsuitable to be working with vulnerable adults. Queens Oak Care Centre DS0000007045.V373675.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): 31,33,35,36 and 38 People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home generally provides guidance and direction to staff to ensure residents receive consistent quality care. There is a quality monitoring system and this ensures the home is run in a way that is in the best interests of the residents. EVIDENCE: The manager is qualified and has the necessary experience to run the home. She is aware of and works to the basic processes set out in the NMS. She works to continuously improve services and provide an increased quality of life Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 21 for residents. The Manager of the home has won the company award for best manager in the London Region. With regards to effective quality assurance and quality monitoring systems, there is a system in place based on seeking the views of residents, relatives and other professionals to measure success in meeting the aims, objectives and statement of purpose of the home. The service has a quality assurance department which is represented at Board and Director level. This department has an overview of all aspects of service delivery and also places special emphasis on the handling of complaints and safe guarding adult investigations. The AQAA was received on time and contained clear, relevant information that was supported by a wide range of evidence. The AQAA lets us know about changes the home has made and where they still need to make improvements. It shows clearly how they are going to do this. The home ensures that equality and diversity issues are monitored and assessed as part of its quality assurance arrangements. The manager informed that small amounts of money are kept in separate envelopes for each resident with a running balance sheet appropriately maintained for sundries, such as hairdressing costs. A sample of these was seen and was accurate and well maintained. Receipts of transactions had also been maintained. There was evidence that regular audits of finances had been completed by staff based at the provider’s head office. All staff receive regular performance monitoring, supervison and appraisal by either a more senior member of staff or their line manager. They were able to tell us about the arrangements in place to ensure that this happens approximately every two months. Carers told us that it gave them an opportunity to talk about any concerns that they had before they became serious and also to identify any future training that they might need. Records with regards to health and safety are of a good standard and are routinely completed. Certificates relating to health and safety were up to date servicing certificates. In respect to fire safety, records showed that that weekly fire alarm tests are being carried out on a regular basis. Queens Oak Care Centre DS0000007045.V373675.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 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 X 3 X 3 3 X 3 Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The provider/manager must ensure that any records made by staff on the Medication Administration Records (MAR) accurately reflect the actions that took place. Statutory Enforcement Notice has been sent. The provider/manager must ensure that the person administering any medication to a service user makes an accurate record on the correct area of the MAR immediately after observing the service user taking or refusing the medication. Statutory Enforcement Notice has been sent. The provider/manager must ensure that out-of-date medications are promptly disposed of in an appropriate manner. Statutory Enforcement Notice has been sent. The provider/manager must ensure that medications are securely stored at all times. DS0000007045.V373675.R01.S.doc Timescale for action 23/12/08 2. OP9 13(2) 23/12/08 3 OP9 13(2) 23/12/08 4 OP9 13(2) 23/12/08 Queens Oak Care Centre Version 5.2 Page 24 5 OP9 13(2) Statutory Enforcement Notice has been sent. The provider/manager must ensure that there are suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Statutory Enforcement Notice has been sent. 23/12/08 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 OP15 Good Practice Recommendations It is recommended that a record should be kept of the food that people actually ate each day. Queens Oak Care Centre DS0000007045.V373675.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Queens Oak Care Centre DS0000007045.V373675.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. 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