Inspection on 31/05/07 for The Oaks Care Home

This inspection was carried out on 31st May 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Oaks Care Home 01/07/09

The Oaks Care Home 04/06/08

The Oaks Care Home 03/12/07

The Oaks Care Home 04/05/06

The Oaks Care Home 13/10/05

The Oaks Care Home 26/07/05

The Oaks Care Home 17/02/05

The Oaks Care Home 17/11/04

The Oaks Care Home 20/07/04

The Oaks Care Home 26/03/04

The Oaks Care Home 20/01/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 The Oaks Care Home 26-28 Corporation Oaks Woodborough Road Nottingham Nottinghamshire NG3 4JY Lead Inspector Karmon Hawley Unannounced Inspection 31st May 2007 10:45 The Oaks Care Home DS0000002237.V336040.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 Care Home DS0000002237.V336040.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 Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Oaks Care Home Address 26-28 Corporation Oaks Woodborough Road Nottingham Nottinghamshire NG3 4JY 0115 962 1075 0115 950 9996 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) Dr Prem Tiwari Dr Shobhi Tiwari Mr Lee Stuart Hackett Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29/11/06 Brief Description of the Service: The Oaks is a large converted Victorian house situated close to Nottingham city centre. The home is on a quiet road with no through traffic, it has an open aspect, with a garden to the front of the property and a hard standing area to the side and rear. The home provides care for younger adults with mental health issues. The accommodation comprises of two lounges, a conservatory area, a dining room and a separate smoke room. The home is not fitted with a lift and has several flights of stairs, making it unsuitable for people with mobility problems. The current weekly fees for the service range from £290 - £350. Hairdressing is not included in these fees. Chiropody services and ophthalmic services are delivered via the National Health Service. This information is made available to prospective service users at the point of enquiry. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken by an inspector reviewing all the previous inspection records available, looking at information provided by the manager about The Oaks and by undertaking a visit to the service with the inspector using a method called “case tracking.” “Case tracking” involves identifying individual service users who currently live at the home and tracking the experience of the care and support they have received during the time they have lived there. The inspector also checked that information provided by the manager matched individual experiences of service users living at the home by talking with them and observing the care received. Five service users were spoken with, all of them expressed that care was at a good standard and staff were very kind and attentive. General records maintained by the service and staff records were also looked at to ensure these were maintained and provided positive outcomes for service users. Three members of staff were spoken with and were able to discuss service users needs and support required. Two relative surveys and ten service users surveys were returned to the Commission for Social Care Inspection, comments are recorded in the relevant section of the report. What the service does well: What has improved since the last inspection? Risk assessments for medication administration are now in place ensuring service users capacity to self-administer are assessed and therefore service users are protected. Records of food provided and special diets are maintained demonstrating that service users receive a wholesome and appropriate diet according to their needs. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 6 The protection of vulnerable adults policy has been updated to include the role of the social services, thus ensuring service users are further protected. A new fire alarm system has been installed and regular checks are now carried out ensuring service users are further protected. Redecoration of bedrooms and several bathrooms has taken place; new carpets and items of furniture have been purchased offering a more comfortable environment for service users. 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 DS0000002237.V336040.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 Care Home DS0000002237.V336040.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users individual aspirations and needs are not always fully assessed prior to admission therefore their needs may not be fully met. EVIDENCE: Prior to admission the manager and deputy manager visit prospective service users in the community to carry out a preadmission assessment. Within two service users files these assessments were available, there were also referral assessments that supplemented the homes assessment. In the other case file seen there was a referral assessment but the homes assessment was not available. Information from the referral assessment had not been used to form a plan of care. Service users may visit the home and spend time there prior to making a decision to move in. One service user spoken with discussed how they had stayed at the home several times before deciding to move in on a permanent basis. Staff spoken with were able to discuss the preadmission procedure. Comments from the surveys were as follows: six service users stated that they received all the information required before moving into the home whereas four said they did not. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. As service users assessed needs, changing needs and personal goals are not fully reflected in an individual plan of care there is a risk that these will not be fully met. Service users are not fully supported to take risks as part of an independent life style. EVIDENCE: Each service user has a key worker, who assists them in the coordination, planning and reviewing of their care. Within two case files seen plans of care were personalised and were relevant to service users needs. Plans of care for possible aggressive behaviour or possible harm were in depth and stated support needed however did not fully cover how staff were to deal with the behaviour should it occur. Within another file seen where the service user had moved into the home a month ago there was no preadmission assessment, assessment of daily activities, risk assessment or plan of care in place. Within the referral information for this person it stated that they suffered with aggression and delusions, which affect their daily lives. Staff stated that this The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 10 person had stayed at the home before on respite care and they were waiting for further referral information. They were able to discuss this service users basic care and support required. The home has a flexible routine and service users may enjoy the freedom to manage their own time. Some service users motivation and ability to look after themselves properly. Staff discussed how they support service users in living a quality life and interacting in meaningful activity. Two service users attend a day centre and others are supported to be involved in the local community as they wish. Service users, if able, manage their own finances, support is offered to those who require it. Within two plans of care seen risk assessments were in place for highlighted risks, evidence that the risks had been discussed with service users was apparent. Several service users within the home smoke, there have been two fires at the home in service users bedrooms recently. There was evidence that this had been discussed with service users and service users had been informed that they may only smoke in designated areas. A risk assessment within one pan of care had not been updated since November 2005 or following the fire in their room. During the tour of the home cigarette ends were found in the bathroom near room eleven and several service users rooms smelt of cigarette smoke. This was discussed with the administrator who stated that despite the fact that service users had been informed they may not smoke there are occasions where they are still doing so. One service user was seen smoking in the conservatory during the visit, however they did move outside when a staff member entered the room. Risk assessments were in place with regard to aggressive behaviour, however did not fully state how staff were to deal with the behaviour should it occur. One staff member spoken with was able to discuss the action they would take in the event of this. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 11 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. 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 available evidence including a visit to this service. Staff ensure service users rights are respected and that they are supported as required to take responsibility in their daily lives. Service users are able to access services and facilities in the local community. EVIDENCE: One person is employed to support and assist service users to engage in inhouse activities, community activities and to attend appointments as required. Activities such as board games are on offer should service users wish to partake. Service users may visit local facilities and amenities should they wish. One service user spoken with said that there was not really anything on offer that they would like to do but expressed an interest in magazines, which are provided for them. Another service user discussed how they regularly visit the shops and they enjoyed being able to do this. The home has information about the various centres that operate to provide support and activities for people with mental health issues, two service users visit day centres. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 12 All service users spoken with said that the routine of the home was flexible and they may spend the day as they wish. Service users were observed to walk freely around the home and occupy themselves as they wished. One service user said they generally decided themselves how to spend their time and often have a rest in their room during periods of the day, they also discussed that they sometimes make their own bed but not all the time. There is a small kitchen available for service users to make their own drinks and snacks should they wish, several service users were seen using this throughout the visit. Comments received in the surveys were as follows: six service users and they usually can make decisions about what they do each day, whereas 4 said they usually can make their own decisions. There are no restrictions on visiting and visitors may be received in private. Staff were able to discuss how relationships would be managed and one service user is at present receiving support from their social worker with regard to their relationship. One service user spoken with said that they often receive visitors and staff always made them welcome. The staff were observed to knock on doors prior to entering them and interacted well with service users. Service users, if they wish have their own room key and during the tour of the home several service users rooms were locked. Service users, if able can control their own personal finances; if safe holding is required there is a facility for this within the home. Four accounts were checked and these corresponded with the accounting sheets. Receipts were available and both staff and service users sign for transactions. Service users may access money at any time. A wholesome and appealing diet is on offer. Home cooking and fresh vegetables are available. Choices are available at each meal; service users spoken with confirmed this. Service users felt that meals were at a good standard and were plentiful. Staff were able to discuss diabetic diets and records were available to show the meals that service users had had. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 13 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. 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 available evidence including a visit to this service. There are comprehensive arrangements in place to ensure that service users have their personal and health care needs met. EVIDENCE: Service users personal support needs are written in detail in the plans of care, these were personalised and reflected the service users likes, dislikes and preferences. Where service users have a specific need such as hair and skin care due to their ethnic origin this was incorporated into the plan of care. One service spoken with said they were grateful of the support they received and staff attended to their needs appropriately. Another discussed the help they received from staff in obtaining products for their hair and skin. Service users plans showed that the doctor, district nurse, community psychiatric nurse and other specialist services are accessed as required. One service user was seen returning to the home with a care assistant following a health care appointment; another service user discussed their routine health check and the well woman clinic they had attended. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 14 Medication polices and procedures were observed. Service users medication charts were clear and medication checked corresponded with the prescription. Two members of staff did not sign hand written entries on all occasions. Within service users plans of care all had undergone a medication risk assessment. There were records available to show medication received into the building and that returned to pharmacy. Staff who administer medication had undergone medication training. One member of staff spoken with was able to confirm this. A new fridge has been purchased for medication. A thermometer was attached to the fridge; however there were no records to show that these were being monitored to ensure medication was kept at the correct temperature. One service user spoken with said that staff looked after all their medication for them and they are given it, as they need it. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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 available evidence including a visit to this service. Service users have the necessary information needed to make a complaint should they need to and they are assured that this will be dealt with appropriately. Service users are protected by the policies and procedures in place and a knowledgeable staff team. EVIDENCE: There is a complaints policy that clearly describes the procedure for raising concerns about the home. Clear and easy complaint forms that service users may use are available outside the main office. No complaints had been received since the previous inspection. Staff spoken with were able to discuss how they would deal with a complaint should it be received. Service users spoken with said that they were happy with care received and life within the home. The comments received in the surveys were as follows: nine out of ten service users knew who they could talk to if they were unhappy and 7 said they knew how to make a complaint. Comments received in the relatives surveys were that they knew how to make a compliant should they need. Seven members of staff have received adult abuse awareness training. Staff spoken with were able to discuss these issues and the action they would take should they suspect abuse was occurring. The homes procedure to manage adult protection alerts was seen. It contained very useful information on the definitions of abuse and the action staff must take if they suspected abuse was The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 16 taking place. The policy has been updated to make reference to the role that social services must play in the management of adult protection investigations. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users live in a home that in places is in a poor state of repair, which does not offer comfort. The home in general is not kept clean and hygienic and malodour is present. EVIDENCE: Improvements in the home have taken place both internally and externally, such as redecoration and replacement of some carpets. However there are still a number of issues outstanding such as the clearance of rubbish in the garden and driveway and the replacement of additional carpets as this detracts from a safe and homely environment. One bedroom was being completely renovated on the day of the visit due to the recent fire. The administrator stated that an advert is being placed for a maintenance person. A number of areas throughout the home smelt musty; there was a very strong smell of urine outside two identified bedrooms and stale cigarette smoke in two identified bedrooms. The dining room chairs were dirty as was the sofa in the The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 18 conservatory. Communal areas were clean and tidy, however some service users bedrooms and bathrooms were untidy and had an air of despair, which detracts from service users living in a clean and comfortable environment. Both cleaners were off sick on the day of the visit, therefore housekeeping tasks and the laundry duties fell to the care assistants on duty. Comments received from the surveys were as follows: four service users said that the home was kept fresh and clean whereas three said usually and three said sometimes. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by knowledgeable and well trained staff. EVIDENCE: Each member of staff has an individual training plan in place, which shows that they continue to undertake compulsory training such as manual handling and food hygiene. Various courses on managing violent, aggressive and challenging behaviour have also been accessed. Staff spoken with were able to discuss the action they would take should they encounter this. Five members of staff have undertaken training in equality and diversity and staff spoken with were able to show knowledge in this area and discuss individual service users needs. Staff were knowledgeable with regard to hair and skin care one service user of an ethnic origin required and how they were supported in meeting this need. Five members of staff are currently undertaking the National Vocational Qualification (a nationally recognised work and theory based qualification) level 2 and two are undertaking level three. Two cleaners have attained the National Vocational Qualification in cleaning. Comments form the surveys received were as follows: five service users felt that staff always treated them well, whereas The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 20 two said usually and three said sometimes. Relative surveys stated that staff were an excellent hard working team who meet service users needs. A local training provider delivers the induction that meets the skills for care programme. There was evidence of staff undertaking an induction in the training file. One member of staff spoken with confirmed that had undertaken an induction. Service users spoken with said that staff were kind and caring and they felt that they were very good at their jobs. The manager was not at the home on the day of the visit; therefore staff files were not available for inspection. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not confident that their views underpin self-monitoring, reviews and development by the home. Service users are at risk due to the lack of up to date risk assessments in place and hot surface temperatures on radiators. EVIDENCE: The registered manager and deputy manager are both undertaking the Registered Mangers Award. The registered manager is trained to NVQ level 4 in management. Staff spoken with confirmed that the registered manager is supportive, approachable, seeks their views and takes these into account. Service users spoken with said that they felt that the home was well run. One relative survey returned stated that the manager always finds the time to discuss concerns and helps in anyway he can. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 22 Staff on duty on the day of the visit were unable to access information in regard to quality assurance and staff personnel details. Appropriate maintenance certificates such as the gas, electrics and fire systems were seen. The fire logbook showed that fire alarm systems are tested on a weekly basis. Emergency lights are tested on a monthly basis. There was evidence of only four staff attending fire drills; staff had not signed to confirm they had undertaken the drill. Appropriate information and action taken was recorded on accident records. A risk assessment for legionellosis was in place, staff stated that they check the water temperatures before assisting service users to bath, records of this taking place was available. No other water outlets were tested. A trip hazard in room 19 was identified, as the carpet did not join between the bedroom and living area. The administrator made a temporary repair with tape to ensure the immediate risk was reduced. During the tour of the home a radiator in room 19 was extremely hot to touch and leaking water. The administrator turned this off and reported the fault. The radiator in the conservatory area was also extremely hot to touch. The Oaks Care Home DS0000002237.V336040.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 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 X 2 2 3 X 4 X 5 X 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 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 1 X X 2 X The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14(1) Requirement The registered person shall not provide accommodation to a service user unless the needs of the service user have been assessed to ensure the home can fully meet the identified needs. Individualised plans of care are required to be in place following the initial assessment to ensure service users needs are fully met. Measures must be put into place to ensure service users are protected from identified risks. These measures must be reviewed on a regular basis. The registered person shall ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. This remains outstanding from the last three inspections and must be addressed. The registered manager must make arrangements to keep the care home free from mal-odours. Remains outstanding from DS0000002237.V336040.R01.S.doc Timescale for action 30/07/07 2 YA6 15(1) 30/07/07 3 YA9 YA42 13(4,c) 20/06/07 4 YA24 23 30/06/07 5 YA30 13, 16 30/06/07 The Oaks Care Home Version 5.2 Page 25 6 YA34 7 YA39 8 YA41 the last inspection 4th May 2006. 7, 9, 17, Ensure staff personal files 19 contain all the specified information as required by schedule 2 and 4 of the regulations. This remains outstanding from 29/11/06 and must be addressed. 12(1) Measures must be in place to monitor the standards delivered by the home to ensure that the home is run in the best interests of service users. 17(1,2,3b) Records as listed in schedules 3 and 4 are to be made available for inspection to ensure that service users are protected. 30/06/07 30/07/07 30/06/07 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 Refer to Standard YA20 YA20 YA42 YA42 Good Practice Recommendations Handwritten entries on service users medication charts are signed by two members of staff to show these have been checked as correct. Fridge temperatures are recorded to show that medication is stored at the correct temperature. Staff undertake regular fire drills and sign to state they have attended these to ensure service users are protected. Additional water temperatures are tested and recorded to ensure service users are protected. The Oaks Care Home DS0000002237.V336040.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 DS0000002237.V336040.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. 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