Inspection on 23/08/07 for The Oaks Care Home

This inspection was carried out on 23rd August 2007.

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

The inspector 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 Care Home 05/08/09

The Oaks Care Home 28/02/06

The Oaks Care Home 28/10/05

The Oaks Care Home 21/03/05

The Oaks Care Home 27/04/04

The Oaks Care Home 18/12/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Oaks Care Home 15 - 25 Oaks Drive Lexden Colchester Essex CO3 3PR Lead Inspector Diana Green Unannounced Inspection 23rd August 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Oaks Care Home DS0000015338.V349473.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 Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Oaks Care Home Address 15 - 25 Oaks Drive Lexden Colchester Essex CO3 3PR 01206 764469 01206 764468 theoaks@new-meronden.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) New Century Care (Colchester) Limited Manager post vacant Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability (4), Physical disability of places over 65 years of age (61) The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 61 persons) Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 34 persons) One person, aged 56 years of age, who requires care by reason of a physical disability, whose name was provided to the Commission in August 2006 Persons of either sex, aged 60 years and over, who require nursing care by reason of a physical disability (not to exceed 3 persons) The total number of service users accommodated in the home must not exceed 61 persons All new staff to undertake training in palliative care by a recognised authority within three months of appointment. Details of training must be recorded on their individual training and development profile 26th September 2006 Date of last inspection Brief Description of the Service: The Oaks Care Home provides nursing and personal care with accommodation for up to 61 older people, including 3 service users aged 60 years and over with a terminal illness. The Oaks is owned by a private organisation named New Century Care (Colchester) Limited. The home is located in a residential area within walking distance from the centre of Colchester. The home is a single -storey building that was purpose built and has been extended to accommodate a small second storey. There are 57 single en-suite bedrooms on the ground floor and a further 4 single en-suite bedrooms on the second floor that are accessible by stairs and a lift. The home offers large communal areas. The home has surrounding wellmaintained gardens that are partially accessible to wheelchairs. The home is accessible by car and the nearest railway station is in Colchester a short bus drive away. Parking is available for staff and visitors in the adjacent car park. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 5 The fees range from £367.15-£800.00 weekly. Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 23/08/07. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 23/08/07, lasting 7 hours. The inspection process included: discussions with the area manager, the administrator, nine staff, the chef, laundry assistant, five residents and five relatives/visitors; a partial tour of the premises including a number of residents’ rooms, bathrooms, communal areas, the clinical room, the kitchen and the laundry; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Surveys were distributed to residents, relatives, care managers and health care professionals and the views from those completed and returned to CSCI have been included in the report. Information from the home’s Annual Quality Assurance Assessment has also been included in this report. Twenty-four standards were inspected and three requirements and two recommendations made. Staff and management were welcoming and helpful throughout the inspection. What the service does well: The Oaks premises are clean, well furnished and well maintained. There is access to the well maintained gardens surrounding the premises. The standard of health and personal care are good and there is good monitoring of care needs with appropriate and prompt referral to health and social care professionals. Residents are able to participate in daily social activities and regular entertainment is provided. There is good communication with relatives and residents said that care staff were friendly towards them. Visitors said that staff were welcoming when they visited the home. Staff are robustly recruited, supervised and receive training through a planned programme that meets requirements and is appropriate for a care home for older people. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 7 The manager is well supported by senior management. What has improved since the last inspection? 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 summary of this inspection report can be made available in other formats on request. The Oaks Care Home DS0000015338.V349473.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 Care Home DS0000015338.V349473.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): Quality in this outcome area is good based upon sampled inspected standards 1, 3,. Residents were well informed and had their needs assessed prior to moving in to the home. The service does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose and service user guide that met regulatory requirements. Both documents were under review to reflect the recent change of manager. Copies were displayed in the entrance of the home for visitors’ information and a copy was provided in each resident’s room. Residents were encouraged to visit prior to making decision on admission to the home. For those who were unable to view the home, photographs were The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 10 provided of the key areas including the bedroom. Feedback from residents and their representatives confirmed they were provided with sufficient information prior to admission. Prospective residents had a pre admission assessment in their own home or hospital undertaken by the manager or deputy manager prior to admission. This ensures that the home are able to meet the indivdual’s needs. Care plans viewed included a pre-admission assessment that was used to develop a full assessment and care plan. A written letter of confirmation is then sent to confirm assessment and ability to meet assessed needs. The home does not provide intermediate care The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good based upon sampled standards 7, 8, 9, 10. The health and personal care needs of residents are well met through care planning that is closely monitored and regularly reviewed. Residents’ privacy and dignity is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of six residents’ files were viewed. All files contained a pre admission assessment form that was used to inform the assessment and care plans. The assessments detailed the residents’ wishes for funeral arrangements and additional individual assessments had been completed in regard to specific needs (e.g. risk of falls, moving and handling, functional assessment, oral assessment, continence, nutrition risk, pressure areas, etc.) that had been regularly reviewed. Care plans were agreed with the resident and/or their representative and confirmed by signature in those care plans sampled. Care The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 12 plans included nutritional assessments with regular weight monitoring and appropriate action had been taken, i.e. referral to dietician, specialist diets, supplements provided. The records confirmed that residents had access to GPs, nurse practitioners, district nurses, specialist nurses, dentists, chiropody and opticians and attended outpatients as necessary. The home had medication policy and procedures that were available for staff guidance. Medicines were stored in a designated medication/clinical room located on the main/ground floor of the home. Three medicine trolleys were used for drug administration. A drug fridge was available but needed cleaning and defrosting. Monitoring of temperatures was undertaken and recorded with appropriate action taken as necessary. Registered nurses administered medication to residents with nursing needs and senior care staff with appropriate training, to the remaining residents. A list of authorised staff names with signatures and initials was available but needed review to remove staff who were no longer employed at the home. Medication was supplied through a local pharmacy in pre-dispensed packs and individual containers. Appropriate ordering and disposal procedures were in place. Five residents records were inspected. All residents supplies were checked and confirmed that the prescribed medication was available. Medication administration records (MAR) were generally well recorded. However two new entries and the dosage of another medicine that had been changed on the MAR sheet were not confirmed by date or signature. An individual medicine with a limited shelf life did not have the date of opening recorded on the container. Creams held in a residents’ room were confirmed to have been given by a tick rather than a signature. Daily records viewed stated that a cream had been applied but there was no name of the cream recorded. Positive comments were received from residents regarding healthcare. Comments received from one resident stated that “medication was always given on time” and another spoken with said that they had run out of their medication and it was several days before they received it. Care files contained clear information and indicated each person’s preferred name. Staff were observed to treat residents with courtesy and dignity. All residents’ rooms had locks and residents were able to have a key should they wish. Feedback from relatives confirmed that staff treated residents with respect and upheld their p[privacy and dignity when providing personal care. The Oaks Care Home DS0000015338.V349473.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): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15 The social and therapeutic activities provided enhanced residents’ daily lives and met their cultural expectations. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The resident’ files inspected contained a life history and choice of lifestyle assessment, providing a good profile on the person, and information on their past interests. Care files also contained care plans relating to activities. The home employs a part-time activities coordinator, who arranged a variety of activities during the week (e.g. games, art and crafts, bingo, etc.) and who was supported by a part-time volunteer. Evidence of an activities programme was seen displayed in the home, and individual records were maintained of residents’ involvement in the activities. Some outings had been provided but these could be further developed. All residents and their representatives who The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 14 completed surveys were positive about the activities at the home. Comments included “ lots of activities and entertainment “; activities on most days”; the activities are there if I want to take part”; activities are very good”. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. Arrangement could be made where visitors were able to stay for a meal and cups of tea were also seen being offered. Staff stated that a communion service was arranged each month in the garden lounge and representatives of various faiths attended the home as needed. From previous knowledge of the home it was evident that local community groups visited the home but this was mainly during the festive period. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them subject to space. Residents spoken with said they had they had choices about their daily life in the home for example what clothes they wore, taking part in activities, where they spent their day, what they had for meals, etc. Choices offered to residents were also confirmed from the care plans viewed and from discussion with residents. Information on advocacy services was included in the statement of purpose. The home operates a varied and seasonal menu with choices accommodated. The menu was displayed for residents’ information and had recently been reviewed following consultation with residents and their representatives. Contradictory feedback was received from residents and their relatives spoken with and who completed surveys. Comments made were “the cake is good but food could be improved”; “I have liquidised food & sometimes have the same for dinner & tea”; “meals are lukewarm and also tea & coffee”; “ I never like the food, it is the way the food is cooked and presented”. Food was served from a hot trolley and feedback from residents spoken with was that it was hot. One resident stated, “it was beautiful and it is always hot”. The main meal served on the day of the inspection looked appetising and comprised roast chicken, boiled and mashed potato, sprouts and carrots. Liquidised food was provided for residents who had difficulty swallowing/chewing and was served attractively. Other residents spoken with said they enjoyed the meal. Hot and cold drinks were seen being served during the day. The kitchen was clean and well organised. The Oaks Care Home DS0000015338.V349473.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): Quality in this outcome area is good based upon sampled standards 16 & 18 Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff supervision, training and recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that was displayed in the reception area of the home. Feedback received from residents and relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. The homes’ record of complaints detailed the investigation and action taken as a result. A record of all compliments was also maintained. Twelve complaints had been received since the previous key inspection regarding concerns with delays in call bells being answered, personal care, laundry, lack of equipment, moving and handling techniques, medication. All had been investigated and appropriate action taken where relevant. Feedback from residents confirmed that most issues were sorted out quickly. The home had comprehensive policy and procedures for safeguarding vulnerable adults and a whistle blowing policy. The records confirmed that most care staff had received training in protection of vulnerable adults and The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 16 regular updated sessions were planned. From discussion with the area manager it was evident that any allegations of abuse made would be appropriately referred and relevant procedures followed. A manager was always on call for advice in the event that an allegation of abuse is made. There had been no allegation of abuse made since the previous key inspection. The Oaks Care Home DS0000015338.V349473.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): Quality in this outcome area is good based upon sampled standards 19, 22 & 26 The Oaks Care Home is clean and hygienic and aims to provide a safe, wellmaintained and homely environment but some health and safety risks prevent this always being achieved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, several bathrooms, a number of residents’ rooms, the kitchen, the clinical room, the sluice and the laundry. The home was in a good state of decoration, maintenance and repair. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 18 The main home was on the ground floor. Stairs and a passenger lift enabled access to the first floor of the premises. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided. Call systems were provided throughout all individual and communal rooms. Pressure relief equipment was provided to meet the needs of residents. All equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. Ramps were provided to enable access to the gardens. The home had infection control policy and procedures in place to ensure that infections are minimised. Clinical waste is properly managed and stored. The home was clean and odour free. The home employs full time laundry staff. The laundry is large and comprises two separate rooms that are linked. There were two washing machines, two driers and a steam press. All equipment was in good working order. Systems were in place to minimise risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines; washing machines had the capacity to carry out sluice wash cycles. Linen was observed to be well laundered and sorted for residents before being returned. Appropriate staff hand washing facilities were in place. However disposable gloves were observed to be disposed in an open bin rather than a clinical waste bin. Sluice facilities were located on each floor of the home. Both were equipped with a mechanical sluice that was in working order and racking was available for storage of equipment. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is based upon sampled standards 27, 28, 29 & 30. The staffing levels (skill mix, number and competence) were appropriate to the needs of residents. Recruitment practices were thorough and promoted the protection of service users. Staff benefit from a supportive management team that develops skills and qualifications through an established training programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were fifty-eight residents at the home and staffing levels comprised: AM- 2 registered nurses 11 care assistants PM- 2 registered nurses 8 care assistants. The manager was on annual leave and the deputy manager was off duty. Staffing (numbers and skill mix) met the levels agreed with CSCI. However feedback was received from residents and their representatives that there were times during the day when they had to wait to receive assistance with personal care. Comments received were : “I have had to wait 15minutes for care staff to take me to the toilet”; “staff do not always answer the buzzer”; “it is a long time to wait for the hoist”; “staff are kind & friendly but have a lot to The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 20 do”; “the home is large & not enough staff”. Staffing levels must therefore be kept under review to ensure the dependency needs of residents are met and they do not have to wait unduly to receive assistance. Ancillary staff were employed in sufficient numbers to ensure the cleanliness and smooth operation of the home. The home had 8 care staff with NVQ level 2 training and a further 21 staff were undertaking NVQ level 2 training. This comprised 60 of care staff employed at the home. The recruitment files of three recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards (records were not inspected). The home had an established training programme. The records confirmed that training had been provided on Protection of Vulnerable Adults, health and safety, fire safety, food hygiene, COSHH (Control of Substances Hazardous to Health) and moving and handling and this was also confirmed from the records inspected. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 21 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 good based upon sampled standards 31, 33, 35, 36 & 38 The manager is supported well by senior staff in providing clear leadership throughout the home with most staff demonstrating a good understanding of their roles and responsibilities. The manager aimed to ensure good health and safety standards but some practices were evident that pose risks to service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a registered nurse (learning disabilities) with more than twenty years experience of working within the health and social care setting as a The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 22 nurse, manager and senior manager. He has additional qualifications in advanced counselling, teaching and assessing in clinical practice, a diploma in management studies and a certificate in managing safety. An application for registration is currently being progressed with CSCI. The manager is supported by a deputy manager who also has considerable experience in the care sector, both in care and as a deputy manager. The home had a quality assurance framework in place that included an annual residents’ questionnaire. Internal audits were regularly undertaken and reported on to develop an annual plan. The home monitored all complaints and compliments to identify trends and improve practice. Relatives meetings are held regularly. Visits required under regulation 26 had been undertaken by an operational manager and reported. Policies and procedures inspected were regularly reviewed and adherence monitored. All service users had an advocate/representative to manage their finances on their behalf. The home has secure facilities for the storage of any personal allowances looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held in individual zipped ‘pouches’. Four residents’ records were inspected, and records, receipts and cash all balanced. Records held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included: care plans, activity records, medication records, nutritional records and menus, complaints, statement of purpose, service user guide, staff recruitment and training records, maintenance and fire safety records. The home had a health and safety policy and procedures for staff guidance. All staff received regular training updates in health and safety. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. gas, electricity certificates, lift, hoists, annual PAT testing etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment fire alarms and emergency lighting, hot tap water temperatures, etc.). Risks identified at inspection included a cleaning trolley left unsupervised on two occasions and a recently employed member of care staff who had not received instruction on the fire safety procedures during induction. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 23 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13(2) Requirement Timescale for action 31/10/07 2. OP27 18(1)(a) 3. OP38 13(4) To ensure the safe administration and storage of medication: 1. Individual containers of medicines with a limited shelf life must have the date of opening recorded. 2. New entries/changes to the MAR sheet must be confirmed by the date and signature. 3. Where care plans/daily records and charts are used to record application of creams, the name of the cream must be stated. To ensure the dependency needs 31/10/07 of residents are met and they do not have to wait unduly to receive personal care, staffing levels must be kept under review and additional staff employed as needed. To prevent the risks to the 31/10/07 health and safety of residents and staff, trolleys with COSHH items must not be left unsupervised. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 25 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. Refer to Standard OP26 OP38 Good Practice Recommendations The registered person should ensure that staff adhere to procedures for the safe disposal of gloves. The registered person should ensure that all staff receive instruction on fire safety procedures at induction. The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. Extracts may not be used or reproduced without the express permission of CSCI The Oaks Care Home DS0000015338.V349473.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!