Inspection on 05/10/05 for Shire Oak House

This inspection was carried out on 5th October 2005.

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

Other inspections for this house

Shire Oak House 06/07/06

Shire Oak House 26/04/05

Shire Oak House 08/01/05

Shire Oak House 01/09/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Shire Oak House 33 Lichfield Road Shire Oak Walsall West Midlands WS9 9DH Lead Inspector Maggie Bennett Announced Inspection 5th October 2005 08:30 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 Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shire Oak House Address 33 Lichfield Road Shire Oak Walsall West Midlands WS9 9DH 01543 372331 01543 372331 petedavies38@hotmail.com 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) Quality Homes (UK) Limited Ms Michelle Louise Ward Care Home 26 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (26) of places Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 residents (max) Dementia Care age 55 years and above Date of last inspection 26th April 2005 Brief Description of the Service: Shire Oak House is a large detached residence in the Shire Oak area of Walsall. It is surrounded by open countryside. The home has been extended and provides accommodation for up to 26 people. It is registered to care for residents who are over 65 years of age. 5 of its 26 residents may have dementia and may be 55 years of age and above. All the bedrooms at the home are single and the majority have an en suite toilet and wash hand basin. There is a passenger lift to the first floor. The home has parking facilities to the front and extensive gardens to the rear. It is owned by Quality Homes (UK) Limited, who have other homes in the Walsall and Wolverhampton area. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out on a weekday between the hours of 8.30 a.m. and 6.40 p.m. Prior to the inspection a Questionnaire was completed by the Registered Manager and forwarded to the Commission. Residents and their relatives were invited to complete anonymous comment cards and these were also forwarded to the Commission. During the course of the day discussion took place with several residents, a relative, two members of staff and the Registered Manager of the home. The assessments and care planning information for a number of residents were seen. The systems for the administration of medication were inspected. Various documents were seen in order to verify the maintenance and servicing of systems and equipment. The whole building was not inspected on this occasion, although communal areas and some bedrooms were seen. What the service does well: What has improved since the last inspection? Although there was an issue with assessments (see below) there is no doubt that the Registered Manager has improved the assessment procedure at the home and the home no longer accepts inappropriate referrals or offers care to people that it is not registered to care for. In addition there has been further improvement in care planning. Residents’ personal files are now in good order. Although there are still outstanding requirements to be met, considerable improvements have been made to the recording and administration of medication. All staff who administer medication have now either completed or are undergoing accredited training in medication administration. The quality of food is mentioned above, but it should also be noted that has been an improvement here, particularly with regard to the provision of fresh milk and accessibility to food during the evening. Staff skills and understanding have Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 6 been enhanced by training provided in Dementia Care and Adult Protection. The appointment of the Registered Manager has improved staff morale and, despite a difficult period, the manager appears to be asserting her authority and has her staff’s backing. 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. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. All prospective residents are assessed prior to their admission to the home. The home’s own assessment would benefit from more detailed information in order to ensure that the individual’s needs are fully met. The home has maintained its improvement in this area. EVIDENCE: The assessment information of the three most recently admitted residents was seen at the inspection. In all cases the home had received a full assessment from the social worker prior to admitting the resident. Two of the assessments were, however, dated prior to the admission, with one being nine months’ old. The registered manager must insist that assessments are up to date and relevant for the needs of the person at the time of admission. There was evidence that the registered manager had carried out her own assessment of each of the residents. It is recommended that the manager refers to Standard 3.3 when completing her assessment, to ensure that all these areas are covered. A care plan had been compiled for the residents, based on the assessment information. The home does not provide an intermediate care or rehabilitation service. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 9 Since the last inspection all staff have taken part in Dementia Care Training. It is recommended that training and advice is sought with regard to epilepsy care. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. There has been further progress on care planning. The addition of more detailed information will assist staff to have the knowledge to ensure that residents’ social and health care needs are met. Considerable progress has been made on improving the administration of medication. When all outstanding requirements are met, clear and comprehensive arrangements will be in place to protect residents. Residents confirm that they are treated with respect. EVIDENCE: The home has maintained its improvement in care planning. Care plans seen were in good order and now contain a photograph of each resident. There is, however, room for further improvement. Care plans give details of assessed needs, but need to contain more information on how these needs are to be met. Risk assessments are on file, but again need more detail of the particular risks pertinent to each individual and how these risks are to be minimised. There is evidence that care plans are regularly reviewed. It is recommended that the home involve the residents more in their care planning and, where possible, request that they sign their care plans. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 11 The home is now assessing each resident for risks of developing pressure sores and this is documented in their care plans. Daily notes, however, referred to one resident having a “sore bottom” and this could not be cross-referenced to the care plan. Pressure relieving equipment is provided for two residents. Professional advice about continence is available and the home keeps continence charts where appropriate. Community psychiatric nursing advice and assistance is available locally when needed. Staff and a visiting entertainer carry out light exercise sessions with the residents from time to time. Residents are regularly weighed. Not all are able to stand on the scales and it is recommended that a set of seated scales is purchased. There is a Nutritional Guide Plan in place, but this would benefit from more detail, with a nutritional screening assessment for each individual, stating their individual dietary needs. One resident, who had recently been unwell and needed a hospital admission, said she had received prompt help from the staff at the time. She said: “they do look after us – if we have any conditions they get help.” The home received an inspection from the Pharmacy Inspector in July 2005, and received 26 statutory requirements from that inspection. It was found on this occasion that 14 of those requirements have been met. Further monitoring visits will be made to inspect compliance with the remaining requirements. The home now have in place a Policy and Procedure for the receipt, recording, storage, handling, administration and disposal of medicines. This policy should be signed and dated. Medication Administration Record sheets are now in good order, all being filed separately, with dividers and containing a photograph of each resident. Records are now maintained of any medication not taken. The home must have a copy of specimen signatures of all staff who administer medication. It was observed during the morning medication round that a resident was given her medication and left to take it unsupervised. The person who administers the medication must observe the resident taking it and sign the administration sheet immediately afterwards. The Responsible Individual has still not purchased a suitable storage unit for Controlled Drugs or for any medication “stock”. An immediate requirement was made that this be obtained by 14th October 2005. The home must also obtain a maximum/minimum thermometer and use it to record both temperatures of the medication fridge on a daily basis to ensure that the temperature of the fridge remains at between 2 and 8 degrees centigrade. As stated by the Pharmacy Inspector, all medicines within storage areas must be organised so that each resident’s medication is kept together. All staff who administer medication (apart from those who already hold the qualification) are taking part in an accredited medication training course. A sample of the administration sheets and cassettes were seen during the inspection and there were some gaps in recording. It was noted that one resident, prescribed morning medication, had not been given it. A staff member said that this was because the Consultant had stated it should be given at noon. The home must obtain written instructions from the prescribing Doctor in such cases. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 12 All the residents at Shire Oak have single rooms and all personal care giving takes place in private. Residents confirmed during the inspection that they choose their own clothes. Those spoken to also confirmed that they were treated respectfully. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Social activities are regularly arranged and these are enjoyed by the residents. Residents are able to see their visitors whenever they want and their wishes are respected. The meals have improved and offer both choice and variety. EVIDENCE: A number of activities are organised for the residents and several recently enjoyed a holiday to Blackpool. Residents confirmed that they could choose whether or not to join in activities. Entertainers visit the home and a craft session is organised on a regular basis. This is particularly enjoyed and the residents’ work (such as floral displays for the table) are used in the home. All residents have single rooms, where they are able to receive their visitors, if they wish. The registered manager confirmed that residents’ wishes as to who they choose to see and do not see are respected. Information on the home’s policy on maintaining involvement with residents once they have moved to the home is contained in the Service User’s Guide. The local Vicar visits on a regular basis and leads the residents in a short service. None of the current residents choose to look after their own finances. The registered manager is recommended to obtain up to date information from the Age Concern Advocacy service in case this is needed by a resident or relative. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 14 As at the last inspection, residents said they were happy with the quality of the food provided at the home. There has been an improvement in this area, with good supplies of fresh milk being available and adequate supplies of foods observed, including fresh fruit and vegetables. One member of staff spoken to felt that the quality of the food had improved and that more choice was available. Menus showed that a choice is offered for each meal, including a hot choice at tea-times. Diabetic foods are supplied when needed. During the inspection the residents enjoyed their meal of roast chicken with vegetables, followed by bread and butter pudding or fruit flan. Cakes had been baked for the afternoon. The kitchen was found to be in good order, with fridge and freezer temperatures being taken daily and recorded. Floor covering in the pantry was torn and this is referred to in Standard 26 below. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 There is a clear Adult Protection policy in place, to make staff aware of their responsibilities to provide a proper response to any suspicion or allegation of abuse. The home’s guidance to staff on practices regarding residents’ financial affairs needs to be stated clearly in its policies. EVIDENCE: The home have in place an Adult Protection Policy, which is in line with the Social Services Policy and the Department of Health document, “No Secrets”. All staff have taken part in Adult Protection Training. Staff spoken to during the inspection were aware of their responsibilities under the Protection of Vulnerable Adults Scheme. Although the home makes gives clear guidance to staff on their preclusion from any involvement in the making of or benefiting from residents’ wills, there should be a clear policy on this. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26. The standard of décor within the home is generally good and residents’ daytime accommodation is warm and comfortable. There continue to be problems with maintaining a suitable temperature in some bedrooms. Standards of cleanliness are good in the majority of areas but the home needs to be more vigilant in checking individual beds. EVIDENCE: The home was found to be clean and generally well maintained. All communal living areas were warm and comfortable. There are attractive grounds to the rear of the property. The Registered Manager states that the home complies with the requirements of the Fire Officer and Environmental Health Officer. All bedrooms, apart from one, have an en suite toilet. There are two assisted bathrooms and one unassisted, in addition to a shower room. Statutory requirements made with regard to furnishings and fittings in individual rooms at the last inspection have now been met. One bedroom was found to have an offensive smell and the mattress was wet. This bed was disposed of during the inspection and a replacement provided. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 17 The home must ensure that beds are checked on a regular basis and that proper mattress covers are provided where needed, rather than a plastic sheet. In some instances it may be necessary to consider changing the carpet for washable floor covering. Bedrooms in the extension part of the building were found to be cold and could not be occupied by residents because of the temperature. The Registered Person found that the boiler for this area was not operating and had it attended to that day. Bedroom temperatures will continue to be monitored at subsequent visits. Water temperatures at outlets accessible to residents must be checked and recorded on a weekly basis. Not all radiators are guaranteed low surface temperature or are guarded. The floor covering in the pantry must be replaced as it is torn and cannot be cleaned properly. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. There are sufficient staff on duty to meet the needs of the current group of residents. Staff are enthusiastic and keen to pursue opportunities for training, which is of benefit to the residents. There are clear recruitment procedures in place, to protect the residents. EVIDENCE: Rotas seen indicate that there are sufficient care staff and domestic staff on duty to meet the needs of the current group of residents. The Registered Manager’s hours are supernumerary. Staff at the home are making good progress with their National Vocational Qualification training, several have achieved Level 2 and gone on to Level 3. The files of newly appointed staff were seen at the inspection. The files were in very good order and contained the majority of the required documentation, including two written references. Any gaps in employment history on application forms must be explored before the person is recruited. Criminal Records Bureau checks and POVA checks are maintained at Head Office. The home must receive written verification from their Head Office that satisfactory checks have been obtained and this documentation must be retained on individual staff files. There are no volunteers employed at the home. Up until recently the home have not been providing new staff with induction training to Skills for Care specifications. They have, however, recently Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 19 engaged the services of a trainer, who is introducing a full induction programme for new staff. All staff receive a minimum of three paid days training per year, but several undertake additional training in their own time. Staff spoken to have clearly benefited from the increased training they have received and this is reflected in their improved morale. Residents spoken to said that the staff looked after them well. One said: “There isn’t a bad one among them.” Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The Registered Manager is enthusiastic, hard working and persevering and has demonstrated her commitment to the residents and staff through a difficult period. Systems for the home to “self-review” are in their infancy and need to be developed further. Residents’ monies are kept securely, but they must be checked on a daily basis. The health and safety of staff and residents is given priority, but the home must ensure that all maintenance checks are carried out at required intervals. EVIDENCE: The Registered Manager was successful in her “Fit Person” interview with the Commission and has now enrolled to commence her Registered Managers’ Award. She has been managing the home for 12 months now and has been responsible for many of the improvements to the running of the home. Staff morale has improved and staff spoken to feel that this is in no small part due Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 21 to the influence of the manager. The home has had a difficult year and it is to the manager’s credit that she has dealt with these problems in a positive way. She has sought and acted upon advice from social and healthcare professionals and arranged relevant staff training. The manager has continued to update her own skills by taking part in Dementia Care Training, Adult Protection Training and Conflict Management. A system for assessing quality assurance is in its infancy at Shire Oak. Satisfaction questionnaires have been sent to relatives, but no survey has yet been conducted among the residents. Residents do, however, have regular meetings to voice their opinions about food and future social activities. The home is visited on a regular basis by the Area Manager, who represents the Responsible Individual, and monthly reports are written and forwarded to the Commission. The home is aware that continuous self-monitoring must take place, involving residents and their representatives and an annual development plan produced. The home takes charge of some of the personal allowances of a number of residents. All monies are stored individually and records retained. Some discrepancies were noted during the inspection. It was later explained that monies had been withdrawn to pay for hairdressing, but records had not been amended. Monies and records must be checked on a daily basis. It is recommended that individual monies are kept in secure containers to minimise the risk of loosing coins. The home does not act as Appointee for any resident. Staff training in the mandatory areas of fire safety, first aid, moving and handling, food hygiene and infection control must be documented on a training plan, which gives details of staff who have up to date training, training arranged and dates when refresher training is needed. The registered manager stated that she had been able to obtain training in all areas apart from first aid, which was proving difficult. Fire alarms are tested weekly and emergency lighting on a monthly basis. Fire drills take place every six months. There is a fire risk assessment in place. Evidence was seen of the regular servicing and maintenance of the gas system and electrical system. Electrical equipment is tested regularly. The lift was serviced in July 2005. The servicing and maintenance of the hoists is overdue. Testing for legionella has been arranged. Risk assessments have been carried out for all areas of the building. The home’s trainer is ensuring that induction training meets the Skills for Care specifications. Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 X 17 X 18 3 2 X X X X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 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 2 Standard OP3 OP8 Regulation 14(1) 12(1)(a) Requirement The registered manager must insist that assessments are up to date. When staff notice pressure areas, details of how such problems are to be addressed must be recorded in care plans. A formal protocol for assessing and monitoring residents wishing to self-administer must be developed. (Previous timescale of 30/09/05 not met). All medicines administered/non administered must be recorded immediately after the transaction with either a signature or a defined abbreviation. (Previous timescale of 01/07/05 not met). All medication within storage areas must be organised so that each resident’s medication is kept together. (Previous timescale of 30/09/05 not met). All medication must be securely stored so that unauthorised personnel do not have access to it. (Previous timescale of 30/09/05 not met). Timescale for action 05/10/05 05/10/05 3 OP9 13(2) 30/11/05 4 OP9 13(2) 05/10/05 5 OP9 13(2) 31/10/05 6 OP9 13(2) 31/10/05 Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 24 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 11 OP24 OP25 16(2)(c) 23(2)(p) 12 OP25 13(4)(a) 13 OP25 13(4)(a) 14 15 OP26 OP26 13(3) 16(2)(j)(k ) The home must obtain a maximum/minimum thermometer and use it to record both temperatures of the fridge on a daily basis to ensure that the temperature of the fridge remains at between 2 and 8 degrees centigrade. (Previous timescale of 01/07/05 not met). Controlled drugs must be stored in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. (Previous timescale of 31/05/05 not met). The home must ensure that the resident’s G.P. confirms any changes to the resident’s medication in writing before the changes are actioned. (Previous timescale of 01/07/05 not met). All bedrooms must be provided with a clean and comfortable bed. Residents’ rooms must be warm enough for them to use at all times of the day. (Previous timescale of 29/04/05 not met). Water temperatures at outlets accessible to residents must be checked on a weekly basis to ensure that they do not exceed 43 degrees and be recorded. The registered person is required to ensure that all radiators are guarded or have guaranteed low temperature surfaces. (Previous timescale of 30/06/05 not met). Dissolvable bags must be used for soiled laundry. (Previous timescale of 31/05/05 not met). The home must be kept clean, hygienic and free of offensive odours. Staff must be vigilant and check beds on a daily basis. Proper mattress covers must be purchased where needed. DS0000020828.V256445.R01.S.doc 14/10/05 14/10/05 05/10/05 05/10/05 05/10/05 05/10/05 31/10/05 31/10/05 05/10/05 Shire Oak House Version 5.0 Page 25 16 17 OP26 OP29 13(3) Care Standards Act S89. Schedule 2 Reg.7, 9, 19. 19 The floor covering to the pantry must be replaced. There must be written verification in the home that satisfactory Criminal Records Bureau and POVA checks have been obtained. Any gaps in employment history must be explored before recruiting a new member of staff. The home must develop a quality assurance and quality monitoring system, based on the views of residents. Correct and up to date records must be kept of monies looked after on behalf of residents. The registered manager must forward to the Commission a copy of the staff training and development programme for the home. This must include details of training in the mandatory areas of first aid, fire safety, food hygiene, moving and handling and infection control. (Previous timescale of 30/06/05 not met). Hoists must be serviced and maintained at regular intervals. 31/10/05 14/10/05 18 OP29 05/10/05 19 OP33 24 31/01/06 20 21 OP35 OP38 17(2) Schedule 4: 8, 9. 18(1)(c) 05/10/05 30/11/05 22 OP38 13(4)(c) 05/10/05 Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 26 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 5 Refer to Standard OP4 OP7 OP7 OP8 OP8 Good Practice Recommendations It is recommended that training and advice is sought with regard to epilepsy care. It is recommended that care plans contain more information on how the assessed needs of the residents are to be met. It is recommended that residents are more involved in their care planning and that, where possible, they are invited to sign their care plans. It is recommended that a set of seated scales is purchased. It is recommended that nutritional needs are documented more comprehensively. There should be a nutritional screening assessment for each resident, stating their individual dietary needs. The home needs to develop a clear policy on staff preclusion from any involvement in the making of or benefiting from residents’ wills. 6 OP18 Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 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 Shire Oak House DS0000020828.V256445.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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