Inspection on 23/04/08 for The Oaks

This inspection was carried out on 23rd April 2008.

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 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 18/12/07

The Oaks 02/07/07

The Oaks 17/01/07

The Oaks 23/01/06

The Oaks 11/08/05

The Oaks 23/02/05

The Oaks 08/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Oaks Oak Avenue Hindley Green Wigan Greater Manchester WN2 4LZ Lead Inspector Unannounced Inspection 23rd April 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Oaks DS0000005755.V362763.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. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Oaks Address Oak Avenue Hindley Green Wigan Greater Manchester WN2 4LZ 01942 521485 01942 522141 hallkevin@f2s.com annegardnerrgn@hotmail.com Mr Kevin Hall 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) Mrs Denise Bostock Care Home 31 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (31), of places Physical disability (3), Physical disability over 65 years of age (8) The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 31 service users to include:up to 31 service users in the category of Older People (OP) up to 3 service users in the category of PD (Adults with Physical Disability) up to 8 service users in the category of PD(E) (Adults with Physical Disability over 65) up to 5 service users in the category of DE(E) (Adults with Dementia over 65) The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. The Home’s Manager, Senior Carers and Carers must be adequately trained to meet the specific needs of the individual service users with Dementia. The Statement of Purpose must be reviewed and updated to reflect the change to the registration. 18th December 2007 2. 3. 4. Date of last inspection Brief Description of the Service: The Oaks is a purpose built home located in a quiet residential area of Hindley, close to the main bus route, local shops and amenities. Car parking for visitors is provided at the front of the home and there is a safe garden area with seating for the residents. The home is registered to provide personal care services for up to 31 elderly residents both male and female. Accommodation is provided on two floors. There is a large combined lounge and dining room on the ground floor with a conservatory for the use of residents who smoke. Bedrooms, bathrooms and toilets are situated on both floors. The fees for the home are £322.65 for residents funded by the Local Authority to £393.00 for residents who pay for their own care. Additional charges are made for private chiropody, hairdressing and individual newspapers. This information was received on the 1st May 2008 A copy of the most recent inspection report is displayed in the entrance hall. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use the service experience poor quality outcomes. The home was not told that the inspection site visit was to take place. The site visit by an inspector and a pharmacy inspector took place over 2 days for a total of 13 hours. Several weeks before the inspection we (The Commission) asked the acting manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they did at present, what they felt they did well and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we do. During our time at the home we looked at care records and medicine records to check that the health and care needs of the residents were being met. We looked at the menus to check what the residents had for their breakfasts, lunches and evening meals. We also looked around the building at some of the bedrooms, bathrooms, toilets and sitting areas to check if they were clean, warm and well decorated We also checked how many staff were provided on each shift to make sure the residents’ needs were being met, and checked how the staff are trained to do their jobs properly. We also looked at how management check that the care and services that they provide is what the residents and their relatives want, or expect. How the home manages the residents’ spending money was also looked at. In order to get further information about the home we also spent time speaking to 2 residents, 2 relatives, the acting manager, 3 care assistants, the activities person and the cook. What the service does well: Management make sure that they assess the needs of people before they are admitted to the home. This is to ensure that staff only care for those people whose needs they can meet. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 6 Activities are considered to be an important part of the residents’ day. This brings enjoyment to lots of the residents. The meals provided are varied and nutritious and the residents have a good choice of menu. In order to protect the residents from harm, management make sure that they check people out properly and safely before offering them a job. What has improved since the last inspection? What they could do better: More attention must be given to ensuring that the care plans give enough information about the residents’ condition and then show how they are to be cared for. Care plans must be detailed for medicines prescribed as ‘when required’ or, as a ‘variable dose’ to help ensure they are given correctly. The decor in several parts of the home needs attention. Management must make sure that the staff are properly trained so that they have the knowledge and skills that they need to protect and meet the needs of the residents. To protect the residents from harm, management must ensure that risk assessments are in place in respect of the residents and the unguarded radiators. The manager must be registered with the Commission. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 8 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 The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are properly assessed before they are admitted to the home and this gives an assurance to everybody that a person is only admitted if the staff feel they can meet their needs. EVIDENCE: Before any resident was admitted to the home a senior member of staff from the home undertook an assessment of their needs. The assessment looks at what help and support the prospective resident needs in all aspects of daily life. The 1 assessment looked at was detailed and gave a clear indication of the residents’ needs and what he could and could not do for himself. Standard 6 does not apply. The home does not provide Intermediate Care. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the care plans are as up to date as they should be and do not always contain enough information about the residents’ condition or needs. This puts the residents’ health and well being at risk. EVIDENCE: Individual care plans were in place for each resident. The care plans of 3 of the residents were looked at. 1 of the care plans gave enough information to know how to care for the resident but the other 2 care plans did not give enough information about the residents’ conditions and how they should have been cared for. It was documented that one of the residents had been admitted to the home with pressure sores. Whilst it is the responsibility of the community nurses to provide pressure relieving equipment and treat the pressure sores the staff The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 11 within the home still have a responsibility to ensure there is a care plan in place to prevent further deterioration. There was no care plan for pressure sore prevention in place. The care plan of the other resident showed that she had developed a pressure sore. There was no care plan in place to prevent further deterioration. Her pressure sore risk assessment was also not up to date. There was also no evidence to show that the district nurse had actually been to the home to treat the pressure sore. This resident had a body map in place to show just where any wounds/sores were situated. They occurred on different dates but were all written on the one body map. Staff were advised to write a new body map for each new wound. This helps give a clearer picture of the residents’ condition at any one time. One of the care plans for a resident with dementia had a good care plan in place to show the actions the staff should take in response to the resident displaying certain behaviour. The care plans were reviewed regularly so that any change in their condition could be identified and appropriate action taken. The care plans detailed the religious and cultural needs of the residents. At the time of the inspection there were no residents of any ethnic minority. Neither were there any residents who required special diets to meet their religious or cultural needs. The staff looked at whether or not there was any risk in relation to the residents developing pressure sores, any risk of falling and also if they were at risk due to problems with their diet and fluid intake. They also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. Residents were weighed regularly. Inspection of the care files showed that the residents had access to health care professionals, such as dentists, opticians, district nurses and chiropodists. A Doctor was visiting a resident whilst we were at the home. The following were some of the comments made by relatives and residents: ‘They are all (staff) very good’. ‘Pleased with the care’. As part of the inspection a specialist pharmacist inspector looked at how medicines were handled. We looked at the medicines stock and records and found the majority of medicines were packaged in a blister system supplied by the pharmacy, this helped staff administer them in an organised way. We carried out checks on a random sample of medicines and found that these added up, this showed they had been given to residents correctly. We looked at how medicines were administered to residents. We observed part of the morning medicines round, which was carried out in an organised The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 12 and professional manner, and residents were treated with respect when staff were administering their medicines. We saw that most medicines were given at the correct time of day but the records showed that some residents were asleep when staff tried to give them their morning medicines. Although staff had acted correctly by not waking residents up they should have returned to give the medicines when the residents got up, this means that some residents had not received their medicines ‘as prescribed’. We spoke with acting manager about this, he agreed with our findings and said that he would develop a system that would ensure residents received their medicines correctly. We looked at the care plans of two residents that had been prescribed medicines to treat agitation and anxiety on a ‘when required’ basis. We found little information to support their use, care plans should say when and under what circumstances medicines should be administered but this information was missing. Having detailed written care plans is important to help ensure residents receive their medicines correctly. We saw evidence of regular monthly checks being carried out by the acting manager. These checks had identified some mistakes and action had been taken to help prevent them happening again. Checks on medicines handling are important because they help ensure medicines are administered as prescribed and help ensure staff are competent. We looked at how medicines were stored, a new room had been developed and this was clean, secure and well organised. This helps ensure medicines are not mishandled or misused. Staff were seen speaking to the residents in a quiet and respectful way. Staff confirmed that the importance of ensuring privacy, respect and dignity is part of their initial training. The residents looked clean and comfortable and were suitably dressed. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise choice and control over their lives and are given a choice of well-balanced and nutritional meals. EVIDENCE: The residents’ routines of daily living and their social interests were recorded in their care plans. The majority of residents had a Church of England or Roman Catholic religious faith and staff told us that the clergy visit the home on a regular basis and will also visit on request. The home employs an activities organiser who works 20 hours each week and organises a programme of activities for the residents. She seemed to be very aware of what each resident liked to do. A wide range of activities is offered at the home including card crafts, word games, memory /reminiscence games and at the residents request-bingo. We saw the residents enjoying an activity with a colourful parachute that involved ball games. Most of the residents were involved with this and were obviously having a lot of fun. The hairdresser visits every week and on alternate Fridays the residents have The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 14 manicures if they so wish. The activities person was in the process of making memory boxes for each resident. These little memory boxes were to be displayed outside each bedroom and contained things that reminded the residents of their past. The one that we saw was very good. It contained lots of memorabilia that dearly meant something to that resident. Relatives told us that visitors are always made welcome. We saw several relatives visiting at different times of the day. Staff told us that the residents are encouraged to bring personal possessions into the home. We saw that many of their bedrooms were personalised with pictures, photographs and ornaments. We were told that the residents may handle their own finances if they are able and wish to, although most are dealt with by their families. We did not eat with the residents but saw what they were having for lunch. The meal served looked appetising and nutritious. The residents have the lighter meal at lunchtime and the main meal in the evening. Inspection of the menus and a discussion with the cook showed that a choice of food is always offered. Any cultural or dietary needs, likes and dislikes were looked at when a resident is first admitted to the home. The dining room was a pleasant area although the tables looked very bare. There were no tablecloths or placemats on them. A discussion with the acting manager showed that he was aware of this and he told us that it would be addressed. Hot and cold drinks were served during the meal and throughout the day The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The inadequate lack of staff training puts the residents at risk of harm. EVIDENCE: A detailed complaints procedure was in place and was displayed in the reception area. The complaints procedure was also included in the Service User Guide. It is easy to understand and gives an assurance that complaints will be responded to within 28 days. A record is kept of any complaint made and includes details of the investigation and any action taken. We have received 2 complaints since the last inspection and are in the process of investigating them. During the 2 days at the home we looked at the training files for all staff members. On the first day it was very difficult to find out just what training had been provided for the staff. The Acting manager agreed to sort through the files and draw up a list of what training had been provided and what was needed for staff. What we did find on the first day at the home was that none of the staff had received training in the safeguarding of adults. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 16 During the visit a week later we found that the majority of staff had not received training in Dementia Care; despite the fact that the home is registered to care for 5 residents with dementia. We found that 8 staff members had received safeguarding training since our last visit. The records also showed that the majority of staff had not received training in infection control or first aid. Neither had there been regular updated training in moving and handling. We saw that the acting manager had requested training in safeguarding, induction and other important areas from The Wigan Training Partnership. To make sure that the residents are cared for properly and safely the staff must be properly trained. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 25 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in comfortable, suitably adapted surroundings that are in parts, in need of redecoration. The unguarded radiators throughout the home put the residents at risk of harm. EVIDENCE: Accommodation is provided on two floors and can be reached either by a lift or stairs. The corridors throughout the home were wide and well lit although there were no grab rails in place to help any resident with a mobility problem. There is a large combined dining room and lounge on the ground floor that has recently been redecorated and refurbished. It is a very pleasant room. Just off this room there is a spacious conservatory that is now the designated smoking room. It was noted that there was no call bell in this room. This is The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 18 essential, as a staff member does not always supervise the residents who smoke in this room. Toilets on each floor were close by to bedrooms and lounge areas. They had a lock on the door to ensure privacy and were suitably adapted for disabled use. Signs were on the doors showing they were toilets however thought should be given to improving the signage by the use of pictures. Several of the toilets and bathrooms were in need of redecorating as the walls and paintwork were badly marked. Also 1 shower was broken and the other shower did not provide disabled access. We looked at most of the bedrooms. Some are on the ground floor and some on the first floor. They were clean and warm, although some of the bedrooms were in need of redecorating. They had a safety overriding door lock and a lockable space to store anything that is of value or importance to the resident. Some of the bedrooms did not have a call bell lead in place. This could mean that a resident or staff member could not easily call for assistance. Some of the bedroom windows and some of the corridor windows had a top opening that did not have a window restrainer in place. We advised the owner to seek advice from the health and safety executive in relation to the risk presented. We felt that if a person was determined they could possibly climb out of the top window. The owner agreed to do this. All sinks, baths and showers have thermostatic control valves so that the water discharges at a safe temperature and therefore reduces the risk of accidental scalding. Throughout the home however, the radiators were unguarded. This poses a risk of accidental burning to the residents. As it was warm weather most of the radiators were either turned off or set at a low heat. Following a discussion with the owner he agreed to undertake risk assessments in relation to the radiator temperatures. We saw evidence of this during our second visit to the home. We emphasised however, that if a resident is at risk of falling, then action must be taken to ensure that the radiators in their bedroom and in the communal areas are suitably protected to prevent accidental burning. We did see issues of concern in relation to the control of infection. The bins for disposing of clinical waste did not have a foot pedal and this meant that staff were touching the surface of the bins. Communal toiletries such as blocks of soap and razors were in one of the bathrooms. The acting manager removed these during our visit. Staff hand washing facilities, such as liquid soap and paper towels were not available in bedrooms where personal care was being delivered. They were in place in bathrooms and toilets. During our second visit we saw that paper towels and liquid soap had been ordered. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 19 The laundry is situated in the boiler room and is very small but does contain sufficient equipment to provide a laundry service. However when the clothes have been laundered they are left under the stairwell ready to be delivered to the residents’ bedrooms. This makes the stairwell area very cluttered and also poses a fire risk. The owner was advised to contact the local fire officer for advice on this issue. The Oaks DS0000005755.V362763.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Failure to provide adequate training for all staff so that they are suitably trained and competent puts the residents at risk of harm. EVIDENCE: Inspection of the duty rotas showed that for the number of residents, the home was operating with the minimum amount of staff. 3 staff were on duty throughout the day to care for 22 residents. Staff told us that at present they felt that this was just adequate and they managed. The acting manager told us that the staffing numbers had been looked at and discussed and that it was being increased to ensure that there would be 4 staff on during the day time hours. The information from the AQAA document sent to us, and the information that we looked at in the training file, showed that 45 of the staff had obtained their NVQ level 2 in care and 3 staff were working towards it. The personnel files of 4 staff members were inspected. All were in order and these staff had been properly and safely employed. This helps protect residents from being cared for by unsuitable people. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 21 The information received from the AQAA document showed that the acting manager provided a staff induction programme for all newly employed staff. This is to make sure that they understand what is expected of them. On the second visit we were shown the training programme from Wigan Council and saw that the acting manager have requested The Skills for Care Induction training from The Wigan Training Partnership. As identified earlier in the report under Complaints and Protection it is essential for all staff to receive training in dementia care and the protection of vulnerable adults. Training in infection control, first aid and updates in Moving and handling are also required. Adequate training is required for all staff so that they are suitably trained and competent to do their jobs and do not put the residents at risk of harm. The Oaks DS0000005755.V362763.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To protect the health and wellbeing of the residents, the systems in place for ensuring that staff are suitably trained and competent need to be improved. EVIDENCE: There has been no registered manager in post since October 2007. An acting manager is in post and the management of the home has been overseen by the manager of a ‘sister home’ nearby. We were told that the acting manager is applying to be registered with The Commission and he will be starting the Registered Managers Award training during the month of June 2008. We spoke to 2 relatives who told us: The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 23 “Things are much better now. He is great. It has been a quantum leap since he took over” Information from the AQAA document sent to us showed that management do a monthly check of lots of things in the home. They check to make sure that there are no hazards around the building and also check the records about care, medicines, food and any accidents that have happened. They also send out surveys to residents and relatives asking for their views on the services provided. The system for the safekeeping of residents’ money was good. Management only handle any “spending money” brought in by relatives. Individual records are made of all transactions and balances. Receipts are held for any purchases made and receipts are given to relatives when they deposit any money for their relative. Information received from the AQAA sent to us and from random checking of servicing records showed that the homes’ fixtures, fitting and equipment are properly maintained and regularly serviced. We saw that regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. The health and safety issues of concern are in relation to infection control and the unprotected radiators. The acting manager was made aware of this and on the second visit we saw that they were putting some things right. Staff hand washing facilities in bedrooms had been ordered and the temperatures of the radiators were being monitored. The Oaks DS0000005755.V362763.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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 2 3 2 x x 3 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15(1) Requirement You must make sure that the care plans are up to date and give a clear picture of the residents’ condition and the care needed. Also when necessary, information on how medicines should be used should form part of the residents’ care plans to ensure they are administered correctly. 2 OP7 15(1) Care plans must be in place for any identified need. When it has been identified that a resident has, or is at risk of developing a pressure sore, a pressure sore prevention plan must be in place. You must make sure that residents are protected from avoidable risks to their health and safety. A call bell must be fitted in the conservatory and call bell leads must always be accessible to the residents in bedrooms, bathrooms and toilets. To protect the health and safety DS0000005755.V362763.R01.S.doc Timescale for action 30/06/08 02/05/08 3 OP19 13(4)(a) 30/06/08 4 The Oaks OP25 13(4)(a) 30/06/08 Page 26 Version 5.2 of the residents, individual risk assessments on the residents in relation to the unguarded radiators must be undertaken and appropriate action taken to reduce any risk identified. 5 OP26 13(3) To prevent the spread of infection, suitable containers for the disposal of clinical waste must be in place. You must provide the Commission with a detailed training programme showing that all staff have either been trained or have been allocated a training date for safeguarding training and dementia training. In addition all mandatory training in Moving and Handling and Fire Safety must be up to date. 7 OP31 CSA 2000 The manager must apply to be Section 11 registered with the Commission 30/06/08 30/06/08 30/06/08 6 OP30 13 (6) 18(1)(a) (c)(i) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 The Oaks Refer to Standard OP7 OP15 OP19 OP19 Good Practice Recommendations Staff should consider using a new body map for each new wound. This helps give a clearer picture of the residents’ condition at any one time. To make meal times a more pleasant experience tablecloths and/or placemats should be used. Thought should be given to improving the signage throughout the home by the use of pictures on bathrooms and toilets. A planned programme of decoration should be developed DS0000005755.V362763.R01.S.doc Version 5.2 Page 27 5 6 OP19 OP19 to ensure all areas are maintained to a good standard Advice should be sought from the Fire Officer with regards to the storage of laundry under the stairwell. Advice should be sought from the Health and Safety Executive in relation to any risk that the top opening windows might present. The Oaks DS0000005755.V362763.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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