Inspection on 28/06/06 for Tall Oaks Nursing Home

This inspection was carried out on 28th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 08/11/05

Tall Oaks Nursing Home 28/04/05

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 Staffordshire ST8 6JD Lead Inspector Mrs Yvonne Allen Key Unannounced Inspection 28 June 2006 10:00 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 Tall Oaks Nursing Home DS0000026969.V301610.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. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 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 tall/oaks@craegmoor.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Speciality Care (Rest Homes) Limited Craegmoor Healthcare Care Home 55 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (55), of places Physical disability over 65 years of age (55) Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2005 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. A company owns the home - Speciality Care (R.E.I.T. Homes) Limited Craegmoor 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. The fees in this home range from £325 to £627. There are additional charges for hairdressing, chiropody (if private), newspapers and some of the outings. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out over four hours by one inspector. The inspection had been planned using the gathering of evidence and information about the service prior to the visit. All the key standards were assessed along with previous requirements and any, which have not been addressed by the Company, have been highlighted for urgent action in this report. The following methods were used to gather information and evidence during the inspection. A tour of the home including all communal areas and a sample of bedrooms. Examination of records and documentation. Discussions with residents, staff and visitors. Telephone discussion with the Regional Manager. Direct observation. Case tracking of individuals. Discussion with the Deputy Manager including verbal feedback at the end of the inspection visit. The inspector found this home to be very busy and quite noisy. There was a lot of activity going on at the time of the visit with a staff training session being held in the conservatory area and the activities co-ordinator organising activity sessions with the residents. There were some residents shouting in the lounge area making it difficult for other residents to talk. The nurse call bell was going off frequently and sometimes for long periods of time. One lady stated that she didn’t particularly like having to get up early – at 6.30am every morning. She went on to say that she understood that the staff needed to do this as they had “such a lot of residents to attend to.” A comment made stated– “The time varies on going to bed and getting up in the morning. A better routine would help.” What the service does well: Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 6 The inspector was made to feel welcome by staff and residents in the home. Individual Care Plans were well organised, thorough and comprehensive with evidence of multidisciplinary working. There was a dedicated activities co-ordinator at the home who was enthusiastic and endeavoured to include all residents in the programme of activities and entertainment. She had some good ideas and ensured that she also visited those residents who were bed bound or who preferred not to join in large groups offering one to one therapy sessions instead. Staff were observed to treat residents with respect and were mindful of maintaining dignity for individuals. Residents were complimentary about the staff and their attitude toward them. What has improved since the last inspection? What they could do better: The Home is only registered to accommodate up to 3 residents with dementia care needs and, during the course of the visit, it was identified that this was exceeded. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 7 It was observed that there were several residents with dementia care needs accommodated in the home. Some of who were exhibiting challenging behaviour including verbal aggression. This was having a detrimental effect on the well being of the other residents in the home, especially in the ground floor lounge area where all the residents were seated. The Providers have been extremely slow in applying to the CSCI for Registration of Manger at this home. Despite a letter of serious concerns being sent to the Company, there has been little action in this area. Finally, once the application had been received and processed by the CSCI the inspector was informed that the acting manager had been moved to another home within the Company. An urgent requirement for the Providers to provide a Manager at this home and to apply for Registration of Manager has been made with a three-month timescale attached. The Providers must also supply the CSCI with a letter outlining what arrangements are in place to manage this home in the interim. The home will need to ensure that all diverse needs of residents are catered for and that the home is run in the best interests of individual residents. This is in respect of ensuring that residents with dementia and other related mental illnesses are catered for and that environment suits their needs. Individual preferences must be upheld wherever possible in relation to the meals served and the routines of the day. The Providers will need to ensure that they do not breach their Registration details and that an application for variation of Registration is received by the CSCI for those individual residents whose needs fall outside that for which the home is registered prior to the home admitting these individuals. The Providers will need to ensure that all staff delivering care have the necessary skills and expertise in order to meet the needs of residents accommodated in the home. This is in respect of providing staff with training in dementia awareness and managing challenging behaviour. Overall the Providers must review dependency of residents regularly and adequate staff must be provided accordingly. Finally staff files must contain evidence of staff identity. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 8 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 DS0000026969.V301610.R01.S.doc Version 5.2 Page 9 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 Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 10 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, 5 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are given adequate information about the home in order to make a decision. However, the admission of individuals residents must be kept in line with Categories of Registration in order to ensure that all assessed needs can be fully met by the home. EVIDENCE: The examination of individual care plans identified that a suitably trained individual from the home carried out pre admission assessments. There was also an assessment from the funding body where applicable. Pre-admission assessments were seen to be thorough and comprehensive. Two of the residents spoken to remembered having been to look around the home prior to being admitted. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 11 It was identified that the individual needs of residents receiving personal and general nursing care were being met on a continuous basis. However, there were some residents accommodated in the home who were exhibiting challenging and sometimes aggressive behaviour and whose needs the home does not have the capacity to meet. The home is not registered to care for residents with progressive dementia or other enduring mental health conditions. This has been raised before at previous inspections and must be urgently addressed by the providers. It was also identified that a resident had been recently admitted to the home with a diagnosis of dementia despite the home already accommodating over the three for which it is registered. No application for variation had been received by the CSCI in respect of this resident. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is average. This judgement has been made using available evidence including a visit to this service. Care was delivered by staff with dignity and respect. It was identified that the needs of some individuals were too challenging for the staff in this home to manage. It was also evident that the behaviour of these residents was having a detrimental effect on the well being of some of the other residents in the home. EVIDENCE: This evidence was gathered by examination of three individual care plans, case tracking, discussions with residents and staff, direct observation and examination of medication records. Care plans were found to be thorough, comprehensive and contained regular reviews. There was evidence of multi disciplinary team involvement and visits by healthcare professionals. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 13 There was a full assessment of need and development of a full care plan. Daily records had been maintained, risk assessments developed and safeguarding referrals where required. There was a short- term treatment plan in place for one of the residents who had a pressure sore. This sore had been acquired during a hospital stay. The plan was comprehensive and evidenced improvements to the healing of the sore. Throughout the visit it was observed that care was delivered in a professional manner and as according to the plans. Care staff were seen to be courteous and respectful toward residents. It was observed that, whilst seated in the lounge areas, some of the residents were visibly upset by the shouting and verbal aggression of a few of the other residents. It was difficult for the inspector to talk to some residents due to the noise level in the ground floor lounge. This shouting could be heard from all over the home on the ground floor. From observation it was clear that there were a small number of residents accommodated whose mental needs appeared to be greater than their physical needs. Whilst physical needs were being met very well by the staff at the home, they have not had the training to care for residents with this degree of mental health needs. There were also more residents then the three for whom the home is registered, accommodated with dementia needs. The acting manager will need to organise a review for these residents and, if applicable, will need to apply to the CSCI for a variation to Registration. Variations will only be granted if it is identified that individual needs can be met by the staff in the home and that the needs of other residents are not compromised. It was also observed that the call bell was left ringing for long periods of time during the morning. Staff were busy at this time and some residents were waiting for quite some time before being attended to. The morning working pattern and staffing numbers will need to be reviewed in order to ensure that residents are attended to in within an acceptable period of time. The medication administration records relating to the three residents case tracked were examined and the nurse was observed administering medication. Medication procedure was followed as required. The medication needs were also documented as an identified need in individual plans including the ability and desire to self medicate. None of the three residents who were case tracked were self-medicating at the time of the visit. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is average. This judgement has been made using available evidence including a visit to this service. Social and therapeutic needs were being met at the home. There was evidence to suggest that autonomy and individual choice in relation to life in the home in general was limited and in need of improvement. EVIDENCE: The inspector met with the activities co-ordinator at the time of the inspection visit. Activities were planned and organised very well by the co-ordinator and she is very dedicated to this. Activities also included regular in-house entertainment and trips out. Those residents who did not wish to take part received one-to– one therapy in the privacy of their rooms. One resident stated that she used to go to Church every Sunday and that she enjoyed the Church services held at the home. Another resident commented that these were held monthly. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 15 One of the residents commented that he enjoys a walk to the nearby shops on occasions and also likes to walk around the garden. The garden had been tidied and a new fence erected since the last inspection. This had made it more accessible to residents. The grounds were also accessible to wheelchair users. Discussions were held with the residents who were case tracked as well as other residents in the home. One lady stated that she didn’t particularly like having to get up early – at 6.30am every morning. She went on to say that she understood that the staff needed to do this as they had “such a lot of residents to attend to.” A comment included in one of the comment cards read – “The time varies on going to bed and getting up in the morning. A better routine would help.” In relation to the meals provided one relative commented – “recently supplied crockery is too thick and heavy. Residents find it difficult to lift these when given a drink.” Another comment from a resident read – “Better variety would be good and the food is very often cold when it arrives.” Menus were examined and were found to offer variety and catered for special diets. One of the residents case tracked was assessed as needing a pureed diet and this was provided to her. She was observed being helped to eat her meal by the staff. General comments from residents indicated that overall standards of meals provided to individuals were satisfactory but that they accepted that individual choice and preferences were limited due to the number of residents having to be catered for. The same applied to autonomy and choice generally in relation to the routines of the day and life in the home. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that their concerns will be listened to and taken seriously. The policies and procedures in place at the home help to protect residents from harm and abuse. EVIDENCE: The requirement of the last report for inclusion of CSCI telephone number had been addressed and the complaints procedure was on display at the entrance to the home. The CSCI had not received any complaints about the home since the last inspection. The acting manager and regional manager had dealt with concerns and complaints up to this inspection but this was now difficult to assess as the acting manager had very recently left the home. Discussions with some of the residents identified that they would know who to go to should they have any concerns. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 17 Staff members spoken to were aware of the issues in relation to Protection of Vulnerable Adults, as this was an area covered during the induction process. The Deputy Manager who was acting as Manager was also aware of her role in ensuring that local procedure was followed. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is average. This judgement has been made using available evidence including a visit to this service. The home provides a clean and safe environment for the residents who live there. Although the home has been adapted to meet some diverse needs there will need to be further adaptations in order to ensure that the physical environment meets the needs of all individuals accommodated in the home. Further improvements are required in relation to redecoration throughout. EVIDENCE: At the time of the inspection the home was clean and well presented. Comment cards from residents indicated that the home was usually clean and tidy. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 19 A tour of the home was conducted during which all of the communal areas; some of the bedrooms and the kitchen were inspected. Where individuals were wheelchair users or had other physical limitations the bedroom had been adapted to meet the diverse needs of the individual. The provision of aids and specialist equipment was evident. The environment, however, had not been as well adapted to meet the needs of individuals with dementia and dementia related illnesses. There was very little signage or pictures around the home to help with orientation or to increase sensory awareness. This will need to be developed in order to ensure that the physical environment meets the needs of all individuals accommodated in the home. At the time of the inspection the conservatory area was being used for staff training purposes so all of the residents who use the ground floor lounge were accommodated in one lounge. The second floor lounge was also in use by residents accommodated on this floor. It was identified that there was an uneven floor surface along the corridor floor area outside room 22 on the second floor. This posed a tripping hazard and will need to be addressed. The home was generally in need of redecoration and an action plan must be provided for this including timescales. At the time of the inspection the flooring in the Manager’s office and corridor area outside this room had been stripped in readiness for new carpeting. The kitchen was found to be clean, hygienic and well presented and there were no issues of concern raised at the time of the inspection visit. The laundry was not inspected during this visit but the laundry assistant was spoken to and she confirmed that the laundry procedure had not changed, in the respect of the home only laundered personal clothing with bedding and towels being sent to an outside laundry contractor. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is average. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff provided at the home was generally found to be adequate. However there is need for improvement and the home must evidence that all identified needs of residents are met. Improvements will need to contain further staff training, review of the working routine and review of resident dependencies. EVIDENCE: At the time of the inspection there were 52 residents accommodated in the home 30 of which were in receipt of nursing care and 20 personal care. The staff on duty were made up of the Deputy Manager who was acting up as Manager. There were 2 trained first level nurses on duty from 8am to 8pm. There were 7 care staff working from 8 am until 2pm then 6 care staff from 2pm until 8pm. Through the night there was 1 first level nurse supported by 4 care staff. The kitchen was staffed by the head cook plus a kitchen assistant all day. There was a laundry assistant on duty plus domestic staff on each floor. There was a maintenance man working all day. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 21 There was an administrator working in the office all day. There was an activities co-ordinator employed on a apart time basis. Examination of the duty rota suggested that staffing levels were maintained on a daily basis. It was also observed that the overall dependency levels of residents in this home are high as there are several residents with poor mobility and physical limitations accommodated with residents who have challenging behaviours and advanced dementia. The dependency levels in this home must be reviewed and staffing levels adjusted accordingly so as to ensure that all the needs of the residents in this home are met on a continuous basis. The number of care staff who are trained to NVQ level 2 and above equates to 85 in this home according to the figures contained in the Pre Inspection Questionnaire. That is over and above the minimum standard required and the home is to be congratulated for achieving this number. Staff training is on going in this home. At the time of the inspection there was a training session on First Aid in progress and staff spoken to confirmed that they received all the required mandatory update training sessions. It is a requirement that all staff delivering care receive training in dementia awareness and managing challenging behaviours in order to be able to meet the needs of all the residents accommodated in this home. Three staff files were examined in order to assess the recruitment procedure. Most of the required information was contained in these files and the required checks had been carried out. However, there was no proof of identification (passport or driving licence) and no photograph in all three of the files examined. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 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 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, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There has been an unacceptable delay in application for Registered Manager at this home and although interim management arrangements are in place there is no manager accountable or responsible for the running of this home. EVIDENCE: At the time of the visit the Acting Manager was not on duty and the inspector liaised with the Deputy Manager. During the course of the visit, however, the Regional Manager telephoned the home and, following a discussion with her over the telephone, the inspector was able to identify that the Acting Manager for the home had now left Tall Oakes and was working in another of the Company’s Care Homes. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 23 The Regional Manager stated that a letter had been forwarded to the CSCI confirming this. This was of concern to the Inspector, as the Acting Manager was in the process of Registration with the CSCI after a long period of time where this home had been without a Registered Manager. It is a requirement of this report that a Registered Manager be appointed for this home within three months and that the Company inform the CSCI, in writing, of the arrangements for management of this home in the interim period. The Regional Manager stated that the Deputy Manager was currently taking over managerial responsibility for the home and that she had been appointed more managerial hours. Quality Assurance was undertaken at the home on a regular basis by the Company for all of the services provided and results of this were available for inspection. The CSCI receives Regulation 26 reports from the Regional Manager usually on a monthly basis. Care staff were receiving formal staff supervision and this was recorded. Staff spoken to confirmed this. The inspector chatted to the maintenance man who confirmed that he keeps records relating to the health, safety and maintenance of the home. Records were examined identifying that the servicing of equipment was on going. Fire detecting and fire fighting equipment had been regularly checked and serviced by an external Company. Labels were seen stuck on to fire extinguishers identifying that these had been checked within the last 12 months. The maintenance man is also responsible for the testing and recording of hot water temperatures around the home. Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 3 x x 3 x 3 Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 25 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 OP31 Regulation 8 Requirement Application must be urgently made to appoint a Registered Manager. PREVIOUS REQUIREMENT NOT MET Application must be made for variation of registration to reflect the needs of residents. PREVIOUS REQUIREMENT NOT MET The overall dependency of residents accommodated in this home must be reviewed and staff provided accordingly The home must evidence how personal preferences and autonomy are upheld for individual residents All staff delivering care must receive training in dementia awareness and managing challenging behaviour The Company must provide the CSCI with a letter outlining what arrangements are in place for management of the home in the interim period DS0000026969.V301610.R01.S.doc Timescale for action 28/09/07 2. OP4 14 28/07/06 3 OP27 18(1)(a) 28/07/06 4 OP14 12(2) 28/07/06 5 OP30 18(1)(c) (i) 8 28/09/06 6 OP31 28/07/06 Tall Oaks Nursing Home Version 5.2 Page 26 7 8 9 OP29 OP19 OP19 19 (4) schedule 2 23(2)(b) 23(2)(b) 10 OP19 23(2)(a) Staff files must contain proof of identification including a recent photograph The flooring in the corridor area outside room 22 must be made good. The Company must provide the CSCI with a redecoration/refurbishment programme for the home including timescales The providers must ensure that the environment is adapted to meet the needs of all residents including individuals with dementia and other related mental health conditions 28/07/06 28/08/06 28/08/06 28/08/06 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 Refer to Standard OP8 OP15 OP15 Good Practice Recommendations To review the working procedure so that there are available staff to answer call bells within an acceptable period of time To review and revise the menus ensuring that residents’ personal preferences are upheld To review the crockery used as some residents are finding these too heavy to use Tall Oaks Nursing Home DS0000026969.V301610.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office 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 DS0000026969.V301610.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!