Inspection on 28/04/05 for Tall Oaks Nursing Home

This inspection was carried out on 28th April 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

Tall Oaks Nursing Home 28/06/06

Tall Oaks Nursing Home 08/11/05

Tall Oaks Nursing Home 30/11/04

Tall Oaks Nursing Home 23/06/04

Tall Oaks Nursing Home 13/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Tall Oaks Nursing Home Charles Street Biddulph Stoke on Trent ST8 6JD Lead Inspector Yvonne Allen Unannounced 28 April 2005 09:30 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 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. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tall Oaks Nursing Home Address Charles Street Biddulph Stoke on Trent Staffordshire ST8 6JD 01782 518055 01782 511772 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Speciality Care (Rest Homes) Limited Care Home 55 Category(ies) of DE(E) 3 registration, with number OP 55 of places PD(E) 55 Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30 November 2004 Brief Description of the Service: Tall Oaks is a care home providing personal care including nursing care for up to 55 elderly service users. This includes care for up to three service users with dementia and care for elderly service users with physical disabilities. The home is owned by a company - Speciality Care (R.E.I.T. Homes) LimitedCraegmoor Healthcare.The home is located on the outskirts of the town of Biddulph in the North Staffordshire district. There are no amenities within the immediate vicinity but Biddulph town centre is approximately a ten-minute walk away where there is a choice of shops, public houses, banks and churches.The home was purpose built several years ago and consists of two floors served by a passenger lift. There is ample car-parking facility at the entrance car park. Gardens are accessible around the home to service users including wheelchair users.The accommodation provides for single bedrooms, none of which have en-suite facilities. There are six double bedrooms with en suite facilities. There is ample provision of communal and seating areas. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over six hours by two inspectors. A tour of the home was conducted where all the communal areas and a selection of bedrooms were inspected. The inspection focussed on meeting service users, staff and visitors and discussions were held with the manager and deputy manager. At the end of the inspection verbal feedback was given to the manager and deputy manager of the home. What the service does well: What has improved since the last inspection? NVQ training for staff has improved; ensuring that there is a good skill mix of staff. The standard of care planning has improved at the home as highlighted above. The quality and variety of activities at the home continues to improve. There had been no further complaints received by the CSCI since the last inspection. The maintenance of staffing levels at the home had improved, including catering hours provided. The prospective manager had implemented a process for monitoring dependency levels of residents within the home. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 6 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. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 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 standard(s) 3 and 4 New service users are admitted to the home on the basis of a full assessment of needs. The registered person was not able to demonstrate that the home had the capacity to meet the assessed needs of all the individuals accommodated there. EVIDENCE: A selection of care plans was examined and found to contain an assessment of needs. This had been carried out prior to admission to the home. Following this the home confirms in writing that the assessed needs of the individual can be met. There was also evidence of assessments by other professionals involved in the admission procedure. Service users spoken to were happy with the care and services provided by the home. The visiting relatives spoken to at the time also confirmed this. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 9 The home is registered to accept up to 3 service users with dementia care needs. At the time of the inspection this number was exceeding the registration figure of 3. There is an urgent requirement for the manager to carry out an assessment of needs in relation to these service users. The assessment must involve other healthcare professionals as necessary. Following this assessment the home will need to apply for a variation to their registration category. In light of the above, there will need to be evidence of staff training in dementia care. This will need to be developed and implemented as a matter of urgency and a requirement has been made for this to be undertaken within 2 months of the inspection date. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10 The standard of care planning for individual residents was good. The registered person promotes and maintains the general health for residents and ensures access to health care services, but will need to ensure that psychological health care needs are assessed and met. Care is delivered in a manner, which promotes dignity for service users. EVIDENCE: A sample of care plans was examined and case tracking was undertaken throughout the inspection. The standard of care planning was generally good with plans having been evaluated on a regular basis. It was identified that a resident whose needs were not being fully met by the home, due to her degree of dementia, was being considered for an alternative placement on 26/11/04. This had been a multidisciplinary decision but had not been carried through. The resident was observed throughout the visit as requiring specialist care and attention. Staff were attentive to her needs but were unable to meet them fully. This was discussed with the manager at the time of the inspection. The manager stated that the resident had improved Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 11 somewhat since the assessment date. It was agreed that the resident would undergo a further assessment of needs by a specialist consultant along with other residents. There was evidence contained within care plans of the monitoring of general healthcare needs and visits by GPs and other healthcare professionals. It was identified that not all residents receive a healthcare review annually. This was discussed with the deputy manager who would be liaising with the GP surgery regarding this. Residents spoken to at the time of the visit confirmed that they are able to see their GP whenever they need to and that they receive visits from the chiropodist, dentist and optician. Discussions and observation also revealed that staff are aware of the need to maintain privacy and dignity for residents. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The meals in this home are good offering both choice and variety but further advice must be sought from the dietician in relation to the residents receiving liquid diets. The routines of daily living are flexible and residents have the opportunity to participate in a varied activities and entertainment programme. EVIDENCE: The home employed an Activities Co-ordinator for 20 hours per week and who was in the home on the day of the inspection. The Co-ordinator indicated that she endeavoured to give individual attention to as many service users as possible during the week. She was seen assisting one service user with gardening activities. She also initiated group games, board games, craftwork and outings. She mentioned that service users had said that they missed activities when she was off duty at weekends and so she had organised a Weekend Activities Programme that involved external entertainers visiting the home on Saturdays. Discussions took place with the chef on the day. A rotational menu was served that included fresh vegetables and fruit and a varied diet for service users. Alternative choices were offered at each meal sitting. Special diets were catered for and on the day it was identified that 15 people were on soft Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 13 (liquidised) diets. The manager was advised to seek the advice of a dietician to monitor these individual’s dietary needs. The daily menu was displayed on the chalkboard in the entrance hall. It was identified that the 2 Kitchen Assistants did not have Food Hygiene Certificates. It is a requirement of this report that all staff who are involved in food preparation should obtain Food Hygiene certificates Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 Residents did not have the opportunity to participate in the civic process. Not all staff were aware of the homes policies and procedures in relation to the protection of vulnerable adults and further training in this area is required. The home has a satisfactory complaints system with some minor additions necessary. EVIDENCE: The complaints procedure was displayed in the entrance to the home. This was clear and invited complainants to approach the manager of the home in the first instance. This procedure will need to include the telephone number of the local CSCI office. There had been no complaints received by the CSCI in relation to the home since the last inspection. Discussions took place with the registered manager regarding the arrangements to enable residents to take part in the forthcoming General Election. It was confirmed that those individuals who needed assistance to visit the Polling Station to vote would be assisted to do so. There had been no arrangements made by the home to obtain postal votes for residents and the manager was advised to investigate this issue on behalf of those individuals who wished to take advantage of this system. From information provided, it was not possible to confirm that all staff had received training in the Protection of Vulnerable Adults from Abuse. A requirement has been made to address this issue. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 15 It was noted that information regarding the organisation’s Whistle Blowing Policy (Public Interest Disclosure Act 1998) was displayed in the foyer for the information of staff. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 24, and 26. There had been some redecoration of the home in the last twelve months. This will need to continue and include the exterior of the home. Infection control guidelines are not adhered to in relation to the laundry process and this puts residents at risk of cross infection. The home will need to review its policy on restraint as a matter of urgency. EVIDENCE: It was found that the areas of the home accessible to service users were in the main clean, pleasant and hygienic. There were sufficient domestic staff on duty for the size of the home and the needs of service users. There were, however, concerns regarding laundry services. The laundry was very compact with one automatic washing machine and one tumble dryer. In view of the level of laundry processed in the home and the shortage of space to store it, a plastic storage facility located outside was being used to store Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 17 dirty linen. On the day of the inspection there was dirty linen in the outside storage facility and seven bags/baskets of dirty linen in the laundry (amongst the clean linen) that was being sorted in readiness to put in the washing machine. This situation was brought to the attention of the registered manager on the day as it was considered to be a risk to hygiene. It was also found that sheets and foul linen were being sent to a laundry off premises. The registered manager was reminded of the need to ensure that appropriate records were maintained in relation to this practice. The registered manager was asked to seek the advice of the Health Protection Agency and requirements have been made as part of this report regarding these issues. Bedrooms seen were personalised and had been adapted to meet the needs of individual residents. In bedrooms 16 and 17 there were trailing electric cables posing a tripping hazard. Toilet number 23 had no toilet seat in place. This was a communal toilet and a requirement has been made to address this. The redecoration programme will need to include repapering of the corridor area along by rooms 15 and 16. The wallpaper in this area was hanging off in places. The garden area was seen to be in need of attention including the fencing, which was broken down in some places. The poor fencing was of concern in the last inspection due to the lack of a secure boundary to the home. The prospective manager stated that quotes had been obtained by the company and work was planned to address this during the summer months. There were mobility aids and adaptations throughout the home and residents had been assessed before using these. It was noted that, in the second floor lounge, three service users were sitting in kirton chairs with lap belts fastened around their waists. All three residents were asleep at the time. The care assistant did not know the reason for the use of the lap belts when asked and no information was contained within the individual care plans of these residents. The residents had been assessed as requiring the use of a kirton chair. This was discussed with the deputy and manager of the home at the time of the inspection and it was made clear that such restraint was inappropriate and unnecessary. A requirement has been made that lap belts are only used when the resident is being transported in the kirton chair. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 18 Risk assessments were contained within care plans in relation to the use of bedrails. Bedrails were used only with protective bumpers. There will need to be evidence that regular checks are carried out on the bedrails to ensure that each one used conforms to Health and Safety requirements. These checks must be carried out by a person suitably trained to do so. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staffing numbers are appropriate to the assessed needs of the service users and the size, layout and purpose of the home. Howerver the skill mix was geered to meeting the needs of the general resident and not those suffering from dementia The recruitment procedure will need to be tightened up and include all the information outlined in the regulations. Staff NVQ training was very good but will need to be expanded further to include clinical updates and all mandatory training. EVIDENCE: The home had a care staff complement of seven trained nurses (including one Enrolled Nurse) and 31 care assistants. There were adequate staff on duty on the day to meet the needs service users. It was normal practice for the early shift to be covered by two nurses (one on the ground floor and one on the first floor) and eight care assistants. For the afternoon shift from 2.00pm there were two nurses and seven care assistants. The evening/night shift (8pm – 8am) was covered by one nurse and four care staff. A tour of the home found that the staffing during the time of the inspection was as indicated. An inspection of a random sample of the staffing rotas found that staffing was maintained at these levels on those days inspected. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 20 The prospective manager had implemented a process for monitoring the dependency levels of residents within the home and this was examined at the time of the inspection. The home had worked hard to ensure that care staff undertook National Vocational Qualification (NVQ) level 2 in Care and 17 had attained this award, thus ensuring that they had more than the minimum ratio of 50 trained members of care staff. Three care staff were currently undertaking NVQ level 2 in Care. Staff spoken with in the home confirmed that they were well supported by management and that they were satisfied with their roles in the home. Several commented that they worked well as a team and helped each other. The registered manager confirmed there had been no use of agency staff since the last inspection. An inspection was made of the files of the two most recently recruited care staff. From the information provided, it was found that the following documents/information had not been obtained as required by regulation: Birth Certificate (for one individual) Criminal Record Bureau Enhanced Disclosure (for one individual) Proof of address (for one individual Copy of Passport (for one individual) 2 references (only one on file for one individual) Documentation to confirm residence/ID (for one individual) A requirement has been made in relation to these issues. The home was to be commended for its commitment to training its care staff to NVQ level 2 in Care with 17 having attained the award and 3 currently working towards it. The registered manager had recently received Career Development Programmes from its HQ in relation to Infection Control, Control of Substances Hazardous to Health, Fire Training, Food Hygiene and Health and Safety. These documents have not yet been implemented. The home had a mentor for overseas nurses. Discussions took place regarding the difficulty in understanding some overseas care staff as they did not speak very much English. The care manager indicated that she was seeking support and training for those staff for whom English was not their first language. From the documentation provided it was not possible to confirm that all care staff in the home had received mandatory updates for moving and handling training. The appropriateness of recent moving and handling training was Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 21 questioned as the qualification of the home’s trained trainer for moving and handling had lapsed. A requirement has been made in relation to this issue. From the documentation provided it was not possible to confirm that nurses were undertaking regular clinical training updates. The training records seen showed that one nurse had undertaken Diabetes training but the record was not dated. The only other training recorded for the same nurse was for wound management on 20.11.03. Two other nurses’ records showed that they had undertaken the Wound Management training on the same date. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 and 38 The systems for service user consultation in this home are poor with little evidence that service user views are sought or acted upon. The overall management of the home was unable to be assessed, as there was still no registered manager in place. Attention to some health and safety requirements is needed. EVIDENCE: Up to the time of the inspection there had been no application for registered manager from this home. The prospective manager had been in post for 18 months and was completing her application forms at the time of the inspection. This is of concern to the CSCI and an urgent requirement has been made in Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 23 relation to manager application. This requirement must be addressed within the timescale of this report. The company carries out quality audits but the results of these were unavailable for inspection and for residents and visitors to see. This was a requirement of the last two inspection reports. On discussion with the prospective manager, it was identified that she would be carrying out her own auditing and that this would include the views of service users and relatives. The results would then be displayed within the home and would include any action taken to improve the services provided. Staff spoken with said that they attended occasional staff meetings with the last one taking place in December 2004. They took part in hand over sessions at each shift. Evidence was seen to confirm that supervision/ appraisal sessions for staff had been arranged during April and May 2005. This, together with on-going supervision and staff meetings, will be monitored at the time of the next inspection visit. A full audit of maintenance records was not undertaken on this inspection. However, from the information provided, it was not possible to confirm that staff had received mandatory fire training i.e. six-monthly. It is a requirement of this report that such training is carried out and recorded as required by regulation. It was noted that the Accident Book was not being used as required by Data Protection Act 1998 and a recommendation was made to the registered manager regarding appropriate storage of such information. Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 2 2 x 2 x 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 Standard No 16 17 18 Score 2 2 2 1 1 2 x x 3 x 2 Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 25 yes Are there any outstanding requirements from the last inspection? 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 15 Regulation 13 (1) (b) Requirement That the registered person seeks the advice of a dietician to monitor the needs of those individuals on soft diets. The registered person shall ensure that all staff involved in food preparation receive appropriate certificated Food Hygiene training. The registered person shall ensure that service users rights to participate in the political process are upheld. The registered person shall ensure that all staff in the home receive training in the Protection of Vulnerable Adults from Abuse. The registered person shall make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. The registered person shall maintain robust recruitment practices at all times in order to ensure that all persons deployed in the home are fit to work in the care home. The registered person shall ensure that all appropriate staff in the home receive mandatory Timescale for action By 30/6/05 2. 15 18 (1) By 30/6/05 3. 17 16 (2) (m) 18 (1) Ongoing 4. 18 By 30/6/05 5. 26 16 (2) (j) Immediate and on going Ongoing 6. 29 19 (1) & (4) 7. 30 18 (1) By 31/5/05 Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 26 8. 30 18 (1) 9. 38 17 (2) & schedule 4 10. 4 Regs 2001 part 11 schedule 4.5 (b) Regs 2001 part 11 schedule 4.5 (b) Regs 2001 part 11 schedule 4.5 (b) 11. 4 12. 4 13. 4 Regs 2001 part 11 schedule 4.5 (b) 13 (1) 22 (7) (a) 13 (7) 13 (4) 14. 15. 16. 17. 8 16 22 22 & 38 moving and handling training and that persons providing such training are appropriately qualified to do so. The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working in the care home. The registered person shall ensure that appropriate fire training is provided for staff which takes place at least threemonthly for night staff and sixmonthly for day staff. It is a Requirement that an assessment of needs, involving other relevant healthcare professionals, is carried out on those service users exhibiting dementia behaviour. It is a Requirement that the home applies for a variation to Registration depending on the outcome of the assessments. It is a Requirement that the home does not accept any more admissions under the category of Dementia Care until requirement has been undertaken and the CSCI have been informed of the outcome. It is a Requirement that staff training is organised for all grades of staff in relation to meeting the needs of service users with Dementia. All residents should receive a healthcare review by their GP at least annually The complaints procedure must include the telephone number of the local CSCI area office. lap belts must not be used to restrain residents except during transportation. There will need to be evidence that regular checks are carried Ongoing By 30/6/05 By 3/6/05 By 10/6/05 Until 10/6/05 By 10/6/05 Ongoing With immediate effect with immediate effect with immediate Page 27 Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 18. 19. 21 33 23 (2) (j) 24 (1,2,3) out on the bedrails to ensure that each one used conforms to Health and Safety requirements. These checks must be carried out by a person suitably trained to do so and that risk assessment are in place. A toilet seat must be fitted to toilet number 23 effect 20. 21. 19 19 23 (2)(0) 23 (2) (0) Quality audits and surveys must be carried out to imporive services. These must include the views of the residents. The results must be displayed in the home. The fencing must be repaired By 1/9/05 and made good so that it offers a secure boundary to the home. The garden must be made safe By 1/6/05 and accessible for residents with immediate effect with immediate effect 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 38 Good Practice Recommendations It was recommended that the registered person ensure appropriate storage of information contained in the Accident Record Book(s). Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Tall Oaks Nursing Home E51-E09 S26969 Tall Oaks NH V223975 280405 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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