Inspection on 15/06/05 for The Oaks

This inspection was carried out on 15th June 2005.

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

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

Other inspections for this house

The Oaks 26/10/06

The Oaks 21/10/05

The Oaks 12/01/05

The Oaks 11/10/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Oaks (The) 1a Spencer Way Redhill Surrey RH1 5LF Lead Inspector Penelope Calthrop Announced 15 June 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oaks (The) Address The Oaks, 1a Spencer Way, Redhill, Surrey, RH1 5LF 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) 01737 789404 01999 999999 www.the avenuestrust.co.uk The Avenues Trust Limited River House, 1 Maidstone Road, Sidcup, Kent, DA14 5TA To be confirmed Care home only (PC) 6 Category(ies) of Learning disability (LD), 6 registration, with number of places Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age/age range of the persons to be accommodated will be: 31- 55 YEARS Date of last inspection 12 January 2005 Brief Description of the Service: The Oaks is a care home providing personal care and accommodation for 6 adults with a learning disability. Previously, the individuals in the home lived in Earlswood long stay hospital. The home is run by The Avenues, who manage a number of similar homes in the area. The property is situated between Salfords and Redhill. Vehicle access is needed to reach either.The home occupies a detached building, benefiting from communal areas at either end and a sensory room at the rear. The staircase at each end of the ground floor accesses service user bedrooms at first floor level, a further two bathrooms and the staff sleeping in room.The home benefits from a good-sized secure garden, with patio seating and a barbecue area. There is a small amount of parking at the front, which is off the road, with opportunities to park in the local roads. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on one day, over a period of six and a half hours. The acting manager was on duty in the home and assisted with the inspection process, together with a newly appointed senior support worker. The service manager for the home was also present for part of the time. Five of the six service users were seen and were present during the time of the inspection, one was away on holiday. The service users in this home have limited verbal communication skills, although one individual was able to say that they were ‘Happy-very happy at the moment.’ They were also able to indicate that they liked the new flooring and furnishings in the home. Observations showed that service users were confident about approaching staff and that they could indicate when, for example, they wanted a drink by coming to fetch staff and taking them to the kitchen. The acting manager explained the importance of staff knowing each individuals way of communicating and also when they behave in a certain manner what this may mean. This was seen recorded in their care plan in a specific section about communication so that staff can refer to this if unsure. Three members of staff were interviewed during the course of the visit. A tour of the premises was undertaken and records were sampled. What the service does well: What has improved since the last inspection? There have been improvements to the environment since the last inspection took place, as noted in the section above. This has given a cleaner fresher feel to the home and the new furniture is more supportive for service uses using it. The appointment of a second senior is providing support to the acting manager. This will help ensure that the running of the home continues as smoothly as possible and with minimal disruption to service users, until a new manager is recruited and in post. Interviews for the post of permanent Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 6 manager are reported to be taking place imminently. The home has also moved further on in implementing the system of person centred planning (PCP), which will be referred to as care plans for the purpose of this report. This as a method of care planning to meet service users needs. This ensures that care planning begins with the individual concerned, rather than from the perspective of the professionals or others involved with their care. Ultimately, this system should better address service users needs as they see them. 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. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2. The home has the information needed about the service it offers, enabling prospective service users to make an informed decision about entering the home. An admission procedure that is in place for prospective service users, means that their needs would be fully assessed and admission take place only if their needs could be met by this home. EVIDENCE: The statement of purpose has been updated recently by the acting manager, who has made amendments where these were needed. Each service user has a copy of the service user guide, which is in pictorial format to be more accessible to them. A copy was viewed and contained pictures and photographs with a simplified version of the document to assist their understanding. The home has had no new admissions since it opened. However, The Avenues have an admissions procedure, which the acting manager was able to talk about. This demonstrated an awareness of the need for thorough assessment of an individual’s needs, before they are considered for admission to the home. A programme of visits and gathering of assessment documentation would take place; additionally the home would undertake their own assessment. It was stressed that the assessment period cannot be rushed, particularly with this service user group. There was some original pre admission assessment information on service Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 9 users currently living at the home in place. However, it is recommended that the acting manager check on whether there is any additional archived information at Avenues head office. This would ensure that as full a picture as possible is held on each individual living at the home. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9. Care plans were in place and risk assessments formed part of the care planning process. Improvements were needed in respect of the organisation of the information held about each service user and in ensuring formal care plan reviews take place. Decision-making is promoted, but individuals need help in this area at this home. EVIDENCE: The home has moved to the system of person centred planning (PCP) as a form of care planning. There was evidence that this change in system still has some work to be undertaken to complete it. This was reported by the service manager for the home as being planned by The Avenues across its’ homes. Currently there is information being held in a variety of places, as the home has retained some of the previous ways of storing service users information. This makes it difficult to find information, even for those staff that have worked at the home for some time. It is recommended that the full completion of moving to PCP’s be completed as soon as possible. Within the information held, there was obvious attention to areas such as goal action plans and communication. Skills building would benefit from being more clearly identified within the care plan and this was recommended. Risk assessments were also in place, with evidence of regular reviews occurring. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 11 Care plan reviews were happening on an annual basis, but there appeared to be some gaps where six monthly reviews were not always in place on the files. This again was difficult to ascertain, due to documents being in differing places according to which individual’s file was being viewed and in one case within the same file. A requirement was made regarding ensuring care plans are reviewed every six months as it was unclear whether this was occurring. Decision making by service users was reported to be encouraged by staff at the home. Due to the needs of the individuals living at the home, some require input from staff for making decisions such as where to go on holiday. However, daily decisions can be made that include what to drink, what to wear, when to buy new clothes and choosing these, with help where needed. Staff were observed encouraging decision-making during the inspection visit. Feedback from a relative of one of the service users indicated that they were not regularly consulted about decision-making, unless it was in ‘serious circumstances’ or during a formal review they were attending. It was unclear whether they were indicating they wished to be consulted more or not. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 & 13. Personal development is identified within care plans. Individuals participate in community-based activities and are recognised as being part of the community they live in. EVIDENCE: Areas of personal development such as skills building could be seen contained within the care plan information that was viewed. Goal action plans were also present. There were basic recording sheets to show when certain activities had been participated in by an individual. However, due to the need for completion of the move to the new care plan format, as discussed under the previous section of this report, these areas could be difficult to locate within the wealth of information held. As a result of this, the impression was that these important areas were becoming ‘lost’ amongst everything else. They were not always in the section indicated by the index, due to the need to decide how to store information and organise these files. It is envisaged that the planned completion of the new system of care plans as advised by the service manager for the home, will address these concerns. Service users make use of community facilities such as the leisure centre, local shops and pubs. People living locally are reported to be friendly and will say Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 13 ‘Hello’ when meeting individuals from the home. The home has a vehicle to assist in service users accessing areas that are some distance from the home. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20. The systems in place with regard to medication are good, ensuring service users medication needs are met. EVIDENCE: The home uses a system of blister packs as a way of dispensing medication. This is reported to work well by the acting manager at the home, who is responsible for the ordering and returns of medicines. The home has a system in place for recording all orders, deliveries to the home and returns to the pharmacy. Those medicines taken by individuals are listed with an explanation of what they are prescribed for and potential side affects to observe for. The home also has clearly written instructions on how each individual likes to take their medication, which was pleasing to see. Any medication that is ‘as required’ has written guidelines in place, which the GP has signed. The acting manager advised that no homely remedies are given by the home unless first checked with the GP and their agreement obtained. Before they can administer medication, staff must attend medication training and have a number of observed sessions by the home manager before being assessed as competent to give medication. No individuals living at this home are responsible for their own medication. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23. Generally, home staff have awareness and understanding of adult protection issues and arrangements for training in this area were in place. It was noted that the organisation are undertaking some further work to ensure all service users are adequately protected from abuse. EVIDENCE: The home has had no complaints since the last inspection in January 2005. There is a complaints procedure in place and a complaints book on site in the home. Home staff access annual training on protecting vulnerable adults. The acting manager was due to attend the multi agency training two days after this inspection visit. This was a previous requirement that had been made. Staff are due to attend training during June and July. It is recommended that senior support workers also attend the multi agency training. The organisation has robust systems in place to protect service users finances. All six individuals have appointeeship in place, which is held by The Avenues. Two staff check any monies held at the home daily. These are held separately for each service user, with each individual’s photograph on the front of their security bag. Each individual has a separate building society account. The balance of these with all transactions that have occurred, are forwarded for checking monthly by Avenues head office. There are also regular checks by an auditor who visits the home to carry out their checks. During the visit, the inspector was made aware of a staffing issue that The Avenues are addressing. This has involved a situation where service users were placed in a potentially vulnerable situation. Action has been taken to reduce the likelihood of this happening again. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28 & 30. Recent attention to the decor and furnishings has improved the environment in the home, making it a generally pleasant place to live in for the service users there. The standard of hygiene in the home was good. EVIDENCE: The home appeared fresh and clean on the day of this visit. Requirements made following the last inspection had been fully met. There was evidence of new furniture in some bedrooms and in communal areas. One service user said that they were happy and liked the new floors and furniture in the lounge and in their bedroom. The home has purchased two new sofas and had laminate wood flooring laid in the two lounge areas. These rooms and the dining room showed evidence of recent redecoration. This home benefits from the amount of communal space that it has. In addition to the two lounges and dining area, there is a sensory room with comfortable furnishings that is accessed from outside. This enables individuals to choose where to spend their time, apart from in their own bedrooms. The back garden is secure and was tidy, with an area for sitting out. There is a separate sleeping in room for staff, with it’s own washbasin. The kitchen still has the original units in place and these are now looking Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 17 somewhat tired and dated. The work surfaces are intact, which is good from a hygiene perspective. The service manager reported that as part of a planned audit by The Avenues, the home’s kitchen has been identified as needing replacement. It is not yet known when this might be. A requirement was made in relation to one of the taps in the ground floor toilet, which was found to be loose. The garden and outside of the house will be fully checked on the next inspection visit. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 & 35. The home has had an unsettled time with changes of acting managers and staffing issues, which will have had an impact on service users. The acting manager and staff team were judged to be competent, with access to regular training in order to meet service uses needs. However, work needs to occur to ensure that more staff obtain an NVQ, in line with minimum government targets for 2005. A procedure is being put in place to enable necessary checks by CSCI on staff recruitment records to occur, for the protection of service users. EVIDENCE: Staff spoken with reported that the past months had been ‘difficult’ without a permanent manager in post at the home. There have also been some issues amongst the staff, which give the impression of a lack of cohesion within the staff team at times. Recruitment to the vacant manager post is reported to be imminent and it is envisaged that this will assist in the home settling down into a period of stability, which will benefit service users living there. There are a core of experienced staff at the home, who know service users and their needs well. There is a vacant post at present, but interviews for this have been scheduled. Some permanent staff fill in when there are gaps in the staffing rota, or regular bank staff are used. A requirement was made that staff that have worked a night shift finishing in the morning, must not work a Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 19 day shift later that same day, as this was reported to occur on occasion. Although some staff at the home have achieved NVQ level 2 or above overall, the home is not yet meeting the government targets of 50 of the staff team being trained to this level. This will assist in those staff achieving a greater level of understanding of good practice and enable them to link theory with the practice that they already do on a daily basis. A requirement was made that the home must enrol more staff onto NVQ training. Original staff recruitment records are held at The Avenues head office, not on site at the home. Some staff recruitment records were supplied to CSCI following a requirement made at the time of the last inspection. Copies of references were available on site at the home for this inspection. A procedure is being agreed by CSCI and The Avenues to enable CSCI inspectors to make the necessary checks as part of their visit in the future. There was evidence of attention to training needs of staff, although one individual reported they ‘needed to address this’ with reference to mandatory training. Staff spoken with reported access to regular training from The Avenues and felt they were fortunate in this. Staff at this home access service specific training in management of aggression, managing challenging behaviours and autism. Some of this was reported to be updated each year. Staff are trained on breakaway techniques and there is a policy in place regarding restraint, as some of the individuals in this home can present with behaviours that challenge. The Service manager reported that the organisation has a procedure in place that a home must follow if restraint has to be used. This involves completing a form that would be sent to CSCI, but also to Avenues health and safety unit. The home will then receive a visit from their health and safety advisor to discuss and evaluate action taken. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40 &42. This home needs a period of stable and permanent management in place, for the benefit of both service users and staff. Staff knowledge and observations of individuals contribute toward ensuring their wishes are considered, with monthly key worker meetings offer time to discuss whether changes will be beneficial to individuals. More external surveying of interested parties views could be considered. Policies and procedures are reviewed annually by The Avenues and updated if required. This ensures service users interests are safeguarded by up to date information. The health, welfare and safety of service users is promoted, but the home must ensure that all aspects such as staff working hours are considered within this. This to ensure service users are not being cared for by staff that are over tired. EVIDENCE: The home has no permanent manager in place, although efforts are being made to recruit to this post and it is reported interviews were due within days of this visit. Please see comments made under the previous staffing section, regarding the need for a period of stability and team building in the home. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 21 The current acting manager is a senior support worker within the home and benefits from knowing the home and service users very well. Evidence seen was that the home is well organised by the acting manager, with priority given to ensuring service users needs are being met. However, both the person themselves and the staff know that this is only a temporary situation and the impression was of some anxiety amongst staff about who is and when their next manager will be in post. Prior to this, the home was being managed for some months by an acting manager who normally works in another Avenues home. This unsettled period is likely to have had an impact on service users, as they pick up on the comings and goings, concerns and role changes of staff. The acting manager reported that due to the limited use of verbal communication by most of the service users, the staff use other means to obtain service users views about things at the home. Individual key-workers are central to this and monthly meetings are held to discuss how a service user is and whether any changes are needed with them in order to meet their needs. A major part is played by staff knowledge and observation of an individual. An example was given of staff knowing when a service user might not be enjoying an activity any more by their behaviour. This would then be discussed and a decision might be made to stop that activity and try something different. Avenues as an organisation hold meetings annually for parents and also have events such as a barbecue and Xmas party. An open day has been planned for the change to person centred planning. Questionnaires are also sent out annually to parents by head office. The responses from these are reported to be for corporate use and are not held at the home. Any actions taken are therefore unable to be tracked through on site at the home. It is recommended that the results of these surveys should be held on site as a means of auditing a clear trail of any issues raised and actions taken. Policies and procedures are updated centrally by the organisation as required every year. Home managers are consulted with via a Policy Review Group and the organisation is reported to be responsive to their views. New or updated policies/procedures are distributed to the home centrally. They are then discussed at a staff meeting to ensure staff are aware of them. There was evidence of attention to matters of health, safety and welfare of service users at the home. The home has a designated member of staff who takes the lead responsibility for matters of health and safety. A monthly audit of the home is undertaken and findings recorded. There was evidence of the servicing of utilities, which are organised via head office. The home already has one qualified first aider amongst the staff and a second person is attending the four-day training in July. Oaks (The) H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 4 N/A 3 Standard No 11 12 13 14 15 16 17 3 x 3 x x x x Standard No 31 32 33 34 35 36 Score x 2 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oaks (The) Score x x 3 N/A Standard No 37 38 39 40 41 42 43 Score 2 x 3 x 3 3 x H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 23 NO 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. 2. 3. Standard 6 24 32 Regulation 15(2)(b) 23(2)(b) 18(c)(i&ii) Requirement The home must ensure that care plans are formally reviewed every six months. The loose tap in the ground floor toilet must be repaired. The home must ensure that a minimum of 50 of staff are qualified to, or enrolled on NVQ level two or above. Night staff must not work on the same day on which they have finished a night shift. Timescale for action 27/7/05 27/7/05 31/12/05 4. 33 19(5)(c) 27/7/05 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 2. 3. 6 6 Refer to Standard Good Practice Recommendations That the acting manager obtains any original assessment documents that may be archived at head office. That skills building is clearly identified within the care plans. The completion of the full change to person centred planning and organisation of information held on service users files should be completed as soon as possible. H58-H09 S13736 The Oaks V223346 150605 Stage 4.doc Version 1.30 Page 24 Oaks (The) 4. 5. 23 39 The senior support worker should attend the multi agency vulnerable adults training. That surveying other interested parties such as care managers, forms part of the system of quality audit at the home. 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