Inspection on 09/10/06 for The Oaks

This inspection was carried out on 9th October 2006.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Oaks 26/09/07

The Oaks 15/08/05

The Oaks 14/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The Oaks Firs Road Kenley Surrey CR8 5LH Lead Inspector James O’Hara Key Unannounced Inspection 9th October 2006 09:00 The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 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 DS0000025852.V314417.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 Adults 18-65. 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 DS0000025852.V314417.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Oaks Address Firs Road Kenley Surrey CR8 5LH 020 8763 1719 020 8763 1719 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) Surrey and Borders Partnership NHS Trust Mrs Adelade Chibaiso Mallikaaratchi Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow five specified service users aged 65 or over to be accommodated until such times that the home is no longer able to provide the care they require 26th January 2006 Date of last inspection Brief Description of the Service: The Oaks is owned by Surrey and Borders NHS Trust and is registered with the Commission for Social Care Inspection to provide residential care for up to 12 adults with learning disabilities. The home offers accommodation to people who have a moderate to severe learning disability. The home is beautifully situated in a wooded area of Kenley. The home is not easily accessible by public transport being a 20 minute walk up a very steep hill from both bus and rail routes. The home has 2 vehicles one of which is adapted for wheelchair users. The property is a large, converted building with accommodation sited across 3 floors with access being provided by a lift. All bedrooms were noted to be of good size, communal accommodation is a large lounge and a smaller quiet lounge, a large dining room, 3 bathrooms and 5 toilets. The home has a large garden, which is frequented by squirrels and other wildlife. The home has a heated, in-door swimming pool. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 9.00am and 12.30pm on a Monday morning/afternoon. The registered manager, Mrs Adelade Mallikaaratchi, was not present in the early part of the morning; however a member of staff ably supported the inspection process until Mrs Mallikaaratchi came to the home a little later. Methods of inspection included a tour of the premises, observation of contact between staff and service users and discussion with one member of staff and Mrs Mallikaaratchi. Records examined included service users person centred plans, care plans, risk assessments, complaints, adult protection, staffing training and personnel records, medication, and health and safety records. Requirements and recommendations from the previous inspection were also discussed with Mrs Mallikaaratchi. What the service does well: What has improved since the last inspection? Service users person centred plans and risk assessments are regularly reviewed every six months and as recommended at the last inspection the service users needs and wishes in the person centred plans are recorded in the first person. All service users now have a health action plan. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 6 By boxing in the cooker the Mrs Mallikaaratchi has removed the risk to staff or service users catching their clothing or injuring themselves on the cooker. The practice of wedging bedroom doors open has been eliminated. Service users doors have now been fitted with automatic door release mechanisms connected to the fire alarm system in the home. 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. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 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 the following standard(s): 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home provides prospective service users and their representatives with all the information they need to make an informed decision about whether or not to use the service. EVIDENCE: On the day of the inspection Members of staff on shift could not locate the homes Statement of Purpose. The registered manager, Mrs Mallikaaratchi produced this when she arrived at the home. The Statement of Purpose includes almost all of the details as listed in Schedule 1 and Regulation 5 of the National Minimum Standards. The registered manager must ensure that the Statement of Purpose includes fire precaustions and associated emergency procedures in the care home. It is recommended that the registered manager ensure that all staff receives induction into the homes administration systems and structures including the location of the homes Statement of Purpose. The Surrey and Borders NHS Trust has its own assessment for admission to residential care, which is completed by the home. No new service user has moved to the home since the last inspection. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 9 All service users have contracts drawn up by the Surrey and Borders NHS Trust using Standard 5 of the National Minimum Standards as guidance. These contracts are located in the service users personal files. The current fee charged to service users at the home is £1,105.54 per week. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. All service users have service user plans with detailed information on their needs and personal goals and all service users have individual risk assessments and risk management strategies in place so that service users can participate in activities in the home and in the community in a safe manner. EVIDENCE: One service user file was examined at random and there was evidence of regular six monthly reviews of Person Centred Plans and risk assessments. As recommended at the last inspection the service users needs and wishes are recorded in the first person in the service users Person Centred Plans. The Person Centred Plan had been completed on the 15/02/06 and included reference to the service users qualities, dreams and how they preferred support with personal care. The services user file also included a Quality of Life review 16/01/06 and a review of assessed needs 17/01/06 attended by the service users care manager, Mrs Mallikaaratchi, the deputy manager and key worker. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 11 A review was also present from the service users day service 17/01/06. Risk assessments were in place and were reviewed on a regular ongoing basis. As recommended at the last inspection all corespendence sent on behalf of service users is located in their personal file. Mrs Mallikaaratchi provided evedence that service users hold regular monthly meetings. Copies of the most recent meeting minutes indicated that service users were able to express their wishes about holidays, outings, menu’s and plan for a Hallaween Party. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Provision is made so that all service users attend appropriate social activities and day centres. Arrangements are made so that service users have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and eaten by the service users. EVIDENCE: Service users attend classes either in the morning or afternoon at the Driscoll Centre at least four days per week. Previously service users would attend an in house day care room. Mrs Mallikaaratchi stated that the day care room is only used when the home does not have a driver to take service users to the Driscoll Centre. The home has a heated indoor swimming pool. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 13 The home is not easily accessible by public transport being a 20 minute walk up a very steep hill from both bus and rail routes. There is very little opportunity for service users to become part of the local community. Service users generally go into Purley, Caterham or Coulsden to go to hairdressers, cafes, restraunts, supermarkets and shop for their personal items. Mrs Mallikaaratchi stated that one service user does however attend the local Church each Sunday. Mrs Mallikaaratchi produced a rolling four weekly menu system. The menus are seasonal and reflect the dietary needs of some the service users that live at the home. The menus are have been checked by the Surrey and Borders NHS Trust dietician for balance and nutrition. The home has no visiting restrictions although it does ask that visitors telephone before a visit in case the service users are out. The home has a second, quiet lounge, which can be used, as a private visitor’s space. Throughout the inspection it was observed that staff treated service users with respect. A large number of comment cards were returned to the Commission For Social Care Inspection as feedback from service users and their relatives. In general service users indicated that they were happy with the home. Staff supported service users to complete the questionnaires. It was noted that many of the service users had little communications skills but that staff understood them because they are aware of how individual service users express themselves. It is recommended that the registered manager contact the Surrey and Borders NHS Trust Speech and Language Therapy Department for advice on Total Communication. Relative’s questionnaires too were very positive about the home. One relative stated that “I have always found the staff most welcoming and friendly”, another relatives states, “ we are so happy thanks to the carers and staff at the Oaks”. Another relative had some concerns about care of her relative and has contacted the home about the matter. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 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 the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. In general the arrangements for meeting the health care needs of the service users are good however more could be done to offer some service users support with their assessed needs. The homes policies and procedures for handling medicines in the home ensure the service users are so far as reasonably practicable protected from harm and/or abuse. EVIDENCE: All of the service users are registered with a local General Practitioners Surgery. A questionnaire returned by a General Practitioner to the Commission indicated that the overall care provided to service users in the home was satisfactory. The General Practitioner also stated that staff seems very caring. The Surrey and Borders NHS Trust supplies most of the Community Health Facilities that the service users require, this system offers the service users ready access to health facilities. Input from physiotherapists, dieticians and such professionals were regularly noted on service user’s files. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 15 All service users have annual health checks and flu vaccinations. It was noted that all service users now have a health action plan. One service users file included a report from the Speech and Language Therapist 03/03/06. In order to support the service user the report recommended that staff attend an eating and drinking basic awareness course. Mrs Mallikaaratchi stated that staff has yet to attend this course. The registered manager must ensure that all staff attends an eating and drinking basic awareness course. Mrs Mallikaaratchi stated that two service users have recently been diagnosed with epilepsy. She is currently arranging for staff to attend epilepsy training and some staff are booked to attend rectal diazepam training on the 17th of November 2006. An audiologist assessed the needs of some of the service users who have hearing impairments to find out if a loop system would be of benefit to them. A member of staff stated that one of the service users was provided with a loop system to watch television but stated that he chooses not to use it. It was noted when entering the home there was a smell of urine. Mrs Mallikaaratchi stated that one service user had continence problems. The registered manager must contact a continence advisor for guidance in order to support of the service user with continence problem. It is also recommended that a cleaning programme be drawn up for the home in order to eliminate the smell of urine. Person Centred Plans include details of how service users prefer support with personal care and guidance is also available on how specific tasks should be undertaken. Medication is stored in a locked cabinet in the dining room. Medication administration records were checked on the day of the inspection and were up to date and accurate. The home has the support of a local pharmacist for advice on medication. The pharmacist visited the home on the 20/09/05; Mrs Mallikaaratchi stated that he is due to visit the home at the end of October 2006. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home has appropriate complaints procedure in place. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure the service users are so far as reasonable practicable protected from abuse, neglect and/or harm. EVIDENCE: The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 17 The homes has an appropriate complaints procedure included in the service user guide, this includes details of the Commission for Social Care Inspection. A number of service users relative’s questionnaires were returned to the Commission from as feedback about the home, two relatives indicated that they are not aware of the homes complaints procedure. It is recommended that the registered manager send copies of the homes complaints procedure to all of the service users relatives, Mrs Mallikaaratchi produced the homes own service users relative’s questionnaires, one of the service users relatives raised concerns about communication with some staff in the home. It is recommended that the registered manager discuss how staff communicate with and are perceived by visitors to the home at the next team meeting. Mrs Mallikaaratchi stated that all of the staff team has attended adult protection training; records show that this was some time ago and some staff needs to have refresher training on the topic. It is recommended that all staff attend refresher training on adult protection. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The overall impression when visiting this home is that it is homely, comfortable clean and hygienic however some areas of the home would benefit from redecoration. EVIDENCE: By boxing in the cooker Mrs Mallikaaratchi has removed the risk to staff or service users catching their clothing or injuring themselves on the cooker. Mrs Mallikaaratchi stated that the practice of wedging bedroom doors open has been eliminated. Service users doors have now been fitted with automatic door release mechanisms connected to the fire alarm system in the home. Mrs Mallikaaratchi stated that the carpet outside the dining area had been flooded and removed; she has sent a quote for new carpet to the Surrey and Borders NHS Trust and is awaiting response. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 19 Mrs Mallikaaratchi has also obtained a quote for new seating for the living room but says that she is awaiting advice from the trusts moving and handling advisor. It was noted that some of the communal areas of the home were in need of redecoration. It is recommended that the registered manager contact the Surrey and Borders works department to consider redecoration of some of the communal areas in the home. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The homes procedures for the recruitment of staff appear to be robust and provide the necessary safeguards to ensure that so far as reasonably practicable service users are not placed at risk of harm or abuse. The registered manager needs to ensure that the staff team receives regular supervision so that the service users benefit from having a consistent approach to their needs. EVIDENCE: Criminal Records Bureau Checks have been inspected for all current members of staff. Staff personel files examined also included a recent photgraph, two written references, employment contracts and copies of passports. It was noted at the previous inspection that more that 50 of the staff team holds an NVQ level 2. One of the staffs training records was chosen at random and examined. Records indicated that the member of staff had completed training on food hygiene 23/03/05, fire safety 03/10/06, adult protection 23/11/04, first aid valid until 11/12/06, Person Centred Plan 07/12/04, health action planning The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 21 21/02/06, dementia 27/07/06 however there was no record of health and safety training. Mrs Mallikaaratchi stated that all staff was awaiting moving and handling training. Mrs Mallikaaratchi had difficulty locating details of some of the staff teams training. It is recommended that all staff attend health and safety and moving and handling training and that the registered manager develops a training record in the form of a matrix so that she can easier assess staff training completed and required. There was evidence that all staff received regular monthly supervision up until August 2006. Mrs Mallikaaratchi stated that due to the Surrey and Borders NHS Trusts implementation pf the Knowledge for Skills Framework she has not supervised staff at the required frequency. She stated that staff has completed appraisal questionnaires and attended regular team meetings in the months of September and October and is aware that regular supervision must be carried out. The registered manager must ensure that all members of staff receive supervision at least six times a year. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 22 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The overall impression when visiting the home is that it is well organised and well managed. Appropriate quality assurance and quality monitoring systems are in place so that the views of the service users and their representatives are considered about the running of the home. EVIDENCE: Mrs Mallikaaratchi started work at the home on the 01/09/05. She is a RNMH and is currently completing the Registered Managers Award and NVQ Level 4 in Care with the Surrey and Borders NHS Trust. Regulations 26 visits are carried out by the organisation in order to inspect the premises of the care home, its record of events and records of any complaints, form an opinion of the standard of care provided in the care home and prepare The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 23 a written report on the conduct of the care home. Mrs Mallikaaratchi has regularly sent monthly copies of the Care Homes Regulations 26 visit reports to the Commission. Mrs Mallikaaratchi provided evedence that service users hold regular monthly meetings. Copies of the most recent meeting minutes indicated that service users were able to express their wishes about holidays, outings, menu’s and plan for a Hallaween Party. Mrs Mallikaaratchi produced completed copies of the home own service users relative’s questionnaires. Mrs Mallikaaratchi stated that a finance audit was carried out at the home last month and she awaiting feedback. The home has the support of a local pharmacist for advice on medication. The pharmacist visited the home on the 20/09/05; Mrs Mallikaaratchi stated that he is due to visit the home at the end of October 2006. The Surrey and Borders NHS Trust health and safety advisor carried out a health and safety audit on the 19/06/06. A Landlords Gas Safety Certificate was seen for the 17/08/06, Portable Appliance Testing Certificate 03/05/06 and legionella testing was completed on the 01/06/06. Hot water testing is carried out weekly (Mondays). The fire alarm system is tested weekly. A full fire drill was carried out on the 17/08/06. The Surrey and Borders NHS Trust fire officer carries out quarterly audits at the home and a fire risk assessment was completed on the 11/01/05. The Oaks DS0000025852.V314417.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 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 Standard No Score 1 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X The Oaks DS0000025852.V314417.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 YA1 Regulation 4 (1) c. Requirement The registered manager must ensure that the Statement of Purpose includes fire precautions and associated emergency procedures in the care home. The registered manager must ensure that all staff attends an eating and drinking basic awareness course. The registered manager must ensure that all members of staff receive supervision at least six times a year. Timescale for action 31/12/06 2. YA19 18 (1) c. 31/12/06 3. YA36 18 (2). 31/12/06 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. Refer to Standard YA1 Good Practice Recommendations It is recommended that the registered manager ensure that all staff receives induction into the homes administration systems and structures including the location of the homes Statement of Purpose. It is recommended that the registered manager contact the Surrey and Borders NHS Trust Speech and Language DS0000025852.V314417.R01.S.doc Version 5.2 Page 26 2. YA19 The Oaks 3. 4. 5. YA22 YA23 YA32 6. YA24 Therapy Department for advice on Total Communication. It is recommended that the registered manager discuss how staff communicate with and are perceived by visitors to the home at the next team meeting. It is recommended that all staff attend refresher training on adult protection. It is recommended that all staff attend health and safety training and that the registered manager develop a training record in the form of a matrix so that she can easier assess staff training completed and required. It is recommended that a cleaning programme be drawn up for the home in order to eliminate the smell of urine. The Oaks DS0000025852.V314417.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 The Oaks DS0000025852.V314417.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. 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