Inspection on 04/05/06 for The Oaks Care Home

This inspection was carried out on 4th May 2006.

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 14 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 31/05/07

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 Sharon Rosenfeld Key Unannounced Inspection 4th May 2006 09:00 The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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.V291346.R01.S.doc Version 5.1 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.V291346.R01.S.doc Version 5.1 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.V291346.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 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 Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during one day was carried out by one inspector as part of the statutory annual inspection programme. The inspection was unannounced. A partial tour of the building took place. Seven residents and four staff were spoken with. The registered manager was present during the majority of the inspection. The home has 22 registered beds, there were 21 beds occupied. The weekly charges range from £277.00 to £300.00 per week. There are no additional charges. What the service does well: What has improved since the last inspection? The residents are generally consulted with about their care plans particularly during Care Programme Approach (CPA) reviews. The care plans have been reviewed and updated where necessary and evidence was seen of systems in place to ensure that health care appointments are managed effectively. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 6 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 Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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.V291346.R01.S.doc Version 5.1 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): 2. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents needs are assessed. EVIDENCE: Two of the resident’s files were seen. They both contained a summary of the care management assessment and a copy of the single care plan generated through the care programme approach, (CPA). The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are generally consulted about how their assessed needs are going to be met by the home and other services. EVIDENCE: Two of the resident’s files were seen. The CPA assessment and care plans show that consultation has taken place with residents, and with other key people involved in their care. Where possible the residents’ representatives are also involved. The home produces an individual care plan on behalf of each resident. These are partly based on their CPA care plan and partly on the homes own assessment of need. The care plans have been reviewed and where necessary updated since the last inspection and evidence was seen of arrangements to meet personal health care needs. The care plans contain a lot of information and the registered manager should be mindful of ensuring that they are The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 10 produced in formats that will make them as easily accessible as possible for the residents and staff. The residents generally enjoy the freedom to manage their own time. The negative symptoms of mental illness have, however affected some people’s motivation and ability to look after themselves properly. The registered manager and staff gave examples of how they try to balance the right of individuals to make decisions about their lives with the need, as they see it, to impose restrictions on choice and freedom in the residents best interests. One example is the tendency of some people to stay in bed all day. The registered manager must ensure that any restrictions imposed are discussed and agreed with the consultant psychiatrist and community psychiatric nurse (CPN) at the residents care reviews. Some of the resident’s behaviours present a risk, particularly with regard to infection control. The care plans of these people must be updated to state how the risks are to be managed. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The residents take part in age appropriate activities both inside and outside of the home. The nutritional value of the meals provided could be improved upon. EVIDENCE: One resident said he had lived in a number of different residential care homes but preferred living at The Oaks because there were more opportunities for socialising and participating in leisure activities including day trips out and holidays. One person is employed to support and assist residents to engage in community activities and to attend appointments. The home has information about the various centres that operate to provide support and activities for people with mental health issues and people also use local community facilities if they wish. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 12 One resident said she generally decided herself how to spend her time. She said she decides when to go to bed and when to get up in the morning. One person chooses to spend all of time in his room and generally only socialises with others at meal times in the dining room. The staff were observed to knock on doors prior to entering them and interacting with the residents. One resident confirmed she had her own room key and could access all areas of the home as she pleased. The meal provided at lunchtime was processed fish, potatoes and frozen vegetables. It appeared appetising and well presented. Two residents said they enjoyed it. The food stores seen contained basic, low cost ingredients. There was no written, up to date information on how diabetic diets are met. A record of the food provided for residents is required, in sufficient detail to enable inspectors to determine whether the diet is satisfactory, in relation to nutrition for all residents, including those who have special dietary needs. The practice of serving from a large pot containing the tea, milk and sugar must be reviewed, as it is impersonal and institutional. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The resident’s physical health care needs are generally well met and they receive the support they need in the way they prefer. EVIDENCE: The residents personal support needs are written in detail in the care plans. Reminders were seen about follow up medical appointments, which meets the requirement made in the previous inspection. None of the residents require assistance with moving and handling however, some people do require support meeting personal care needs. One person said he was grateful of the support he received in this area, and was happy with the way that staff delivered this care. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 14 One person said the times for going to bed and getting up are flexible. The registered manager talked about the need to encourage one other person to get up and participate in daily life in the home and in the community. If this person was not encouraged the registered manager believes she would spend all of her time in bed. The restrictions placed upon her need to be agreed in her individual plan following consultation with her and her consultant psychiatrist and CPN. The administration of medication was observed. The appropriate checks were made to ensure medication was administered correctly and records seen were well maintained. One person has the responsibility for the management of his own medication however; his ability to do this is not assessed within a robust risk management framework. The registered manager is not altogether confident in his abilities and stated that the CPN does monitor this with the resident to a degree. The resident has a lockable facility in which to store his medicines however, he does not use this. He is however protective of his responsibilities and does not welcome too much interference from the staff. There is little risk to others as the resident lives in his room most of the time. A risk assessment is however required. The staff administering medication had undertaken a distance-learning course in the safe management and administration of medicines. The medication that requires cold storage is still kept in the kitchen fridge. The registered providers must provide more suitable, safe storage for these drugs The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Procedures are in place to ensure that resident’s views are listened to and to ensure that allegations of abuse are reported. EVIDENCE: There is a complaints policy that clearly describes the procedure for raising concerns about the home. One verbal complaint had been received from a neighbour that has subsequently been resolved. There are no current complaints, concerns or allegations. Some of the staff have received adult abuse awareness training. 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 taking place. The policy did not however make reference to the pivotal role that social services must play in the management of adult protection investigations. This must be added to the policy and procedure and all staff must be made aware of this. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The residents do not live in a homely, comfortable and safe environment. The current arrangements to keep the home clean and hygienic state are not effective. EVIDENCE: The planned improvements that were communicated to the CSCI in June 2005 have not taken place and the CSCI is now considering taking legal action. Photographs were taken both internally and externally as evidence of the homes poor state of repair and may be used should action be brought against the provider. The following observations were made: • • • • External rendering was falling off the walls to the front and rear. The front, side and rear drives were badly cracked and potholed. These areas are accessible and therefore present a significant hazard. The front garden is inaccessible as it is overgrown with weeds. Pallets and rubbish have been left at the side of the house outside the side entrance. DS0000002237.V291346.R01.S.doc Version 5.1 Page 17 The Oaks Care Home • • • • • • • • • • • • • • • • • The side porch has broken glass. There were disused bed bases and mattresses in the rear yard area. The guttering by the rear porch drains onto the yard and not down a gutter. This may cause a slip hazard in the winter months. The rear porch window frame was rotting. The visitors’ bathroom on the ground floor was in a poor state of repair. There was a significant damp patch with bubbling paintwork on internal walls above the rear porch entrance. The entrance hall carpet is badly worn. Redecoration was needed to a number of rooms following the fitting of new double glazed windows. The furniture in some rooms was in a poor state of repair with missing fitments such as handles. There was no soap or towels in any of the bathrooms and toilets. There was no toilet paper in some and no toilet roll holders in any seen. Room 19: There was a trip hazard from a rug between the bedrooms and dressing room areas. The carpet in the bedroom is badly fitted and badly soiled. There is a new window however the wallpaper around it has not been replaced. The mattress was badly worn and the registered managers attention was drawn to its prominent springs. The bed was pushed up against an unguarded radiator that does not have a low surface temperature. There was no hot water supply to the sink The sink waste cover came away when the plug was taken out. The bedroom lock was the type that prevented the door from being opened in emergencies by staff. Advice must be obtained as to the suitability of these locks from the fire service. The rug between presents a trip hazard. The registered manager said that the current occupant of the room prefers to have the rug situated as it is. The risks of this must be discussed with her. The bathroom opposite room 18 was in a poor state of decoration. The light bulb did not work and a section of the tiled wall had come away next to the sink. There was a very strong smell of urine outside one identified bedroom. The toilet on the ‘Magnolia Floor’ was not signed. There was a broken pane of glass. Outside the fire exit there was broken glass. The roof guttering was filled with cigarette butts. The plastic roof of the conservatory was cracked and broken in places. The drainage pipe outside this fire exit is fitted down the steps; it drains onto the bottom of the fire escape and not into a gutter. This may cause a slip hazard in the winter months. Many of the light bulbs throughout the house did not have shades. The bathroom by room 11 required a window covering. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 18 • • • • • • • • • • • • • Room 12 had a broken windowpane and the carpet was badly burned from cigarettes. There was a flex trailing across the room. The chair by room 11 required repair or replacement. The toilet by room 8 required redecoration and a window covering. Room 8 requires redecoration. There was no light shade and the beds had thread bare sheets. There was a poor quality mattress and carpet. The glass in the archway at the bottom of the stairs was broken. The window in room 6 was broken. The mattress in room 3 was in a poor condition. The windowpane of the bathroom outside bedroom 1 was rotten and had come away from the glass. The chair in the conservatory was in need of repair or replacement. The lounges have had replacement windows and radiators and require redecoration. The carpet was worn between the large and small lounges. The smoking room furniture fixtures and fittings and decor were in a very poor condition. The fire system has been condemned and requires replacement. This has not been tested on a weekly basis as required. A large number of quotes have been gathered over a period of almost a year to undertake some of the improvement work required, however, the lack of a planned maintenance and renewal programme that is acted upon has lead to the home falling into a poor state of repair. One person required personal care support from staff for a continence problem. Whilst the staff managed the situation appropriately, the bathroom and toilet were not thoroughly cleaned afterward and the sink and taps were still heavily soiled several hours later. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are receiving training to enable them to be competent in their role. The residents are protected by the homes recruitment procedures. EVIDENCE: The registered manager has accessed a range of training from a variety of sources. A record was seen of training that staff has attended, or are about to attend in a variety of subjects. The home employs thirteen carers. One person has achieved their NVQ 2 in care. A further four people have enrolled on the NVQ 2 and four on the NVQ 3. The registered manager stated there have been delays to the commencement of these courses due to a lack of appropriate assessors at the college. The manager is undertaking the registered managers award. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 20 A local training provider delivers the induction that meets the skills for care programme. The files of two staff were seen. They contained the majority of the information required. Photographs of staff were not available. The registered manager was not able to show records of criminal records bureau enhanced disclosures. He said they are generally destroyed. The files did contain a record of the disclosure reference number and date of receipt. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally well run and the staff seeks residents views on the quality of the service provided. Some practices put residents at risk of harm . 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. Minutes of staff meetings were seen and the staff spoken with confirmed that the registered manager is supportive, approachable, seeks their views and takes these into account. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 22 A quality assurance system was introduced and the first set of responses had been gathered prior to the last inspection. The registered provider should consider involving an independent person to facilitate quality monitoring to obtain an unbiased assessment. The registered provider must also re-instate the monthly, unannounced visits and forward a copy of each report to the CSCI. The staff records confirmed that mandatory training was planned and implemented. The registered manager has also obtained funding for additional training that is linked to the work staff perform. This is good practice. The staff’s induction is facilitated by a local training provider and covers the topics set out by Skills for Care. The records evidenced that appropriately qualified trades people had tested the equipment and supplies at the home. The fire alarm system had been assessed as needing to be replaced. The system was not being tested every week as required by fire safety protocols and the fire procedures had not been reviewed with the fire service to ensure they are appropriate given the current risks. The emergency lighting and fire doors had not been tested at appropriate intervals either. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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 3 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 2 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 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 1 X The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 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 YA17 Regulation 17(2) Requirement Timescale for action 19/05/06 2 YA20 13(2) 3 YA20 13(2) 4 YA23 13(6) The registered manager must ensure that the records of food provided are written in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. The registered manager must 31/05/06 ensure that appropriate records are maintained of risk assessments that determine a service users capacity to manage their own medication. Periodic checks must be made to ascertain if the individual is managing their medication appropriately. The registered provider and 31/05/06 manager must make suitable arrangements for the security of medicines that require refrigeration. The registered manager must 31/05/06 ensure that the safeguarding adults (adult protection) policy and procedure details the role that social services play in the DS0000002237.V291346.R01.S.doc Version 5.1 The Oaks Care Home Page 25 5 YA24 13 6 YA24 23 7 YA24 23(2)(o) 8 YA24 23 management of all allegations of abuse. The registered person must ensure that all parts of the home that service users have access are as far as reasonably practicable free from hazards to their safety. Where hazards have been identified such as damaged carpets these must be repaired or replaced. This remains unmet from the previous inspection; legal action is now being considered. 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. Where work has been identified this should be repaired or replaced. This remains unmet from the previous inspection; legal action is now being considered. The registered manager and provider must ensure that the external grounds of the home are kept free from rubbish, are suitable for and safe for use by service users and are appropriately maintained. The registered provider must ensure the following work to the building is prioritised and carried out (refer to list on NMS 24): • Replace broken and rotten windows. • Redecorate the rooms; which have torn wallpaper and where new windows have been fitted. (Refer to NMS • Make safe the potholes in the outside space. • Replace the worn DS0000002237.V291346.R01.S.doc 30/06/06 31/08/06 30/06/06 31/08/06 The Oaks Care Home Version 5.1 Page 26 • • carpets. Repair/replace the damaged chair in the conservatory. Replace the worn mattresses and bed linen. 31/05/06 9 YA30 13, 16 10 11 YA30 YA34 13, 16 19 schedule 2 12 YA42 23(4) 13 YA42 23(4) 14 YA42 13(4) The registered manager shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home and ensure that their satisfactory standards of hygiene. The home must be kept clean. This remains unmet from the previous inspection; legal action is now being considered. The registered manager must make arrangements to keep the care home free from mal-odours. Evidence that a relevant and up to date PoVA and Criminal Records Bureau enhanced disclosure check must be retained for examination by regulators. The registered provider and manager must ensure that the fire alarm system is maintained appropriately or replaced if necessary. Until the fire system has been replaced, the registered manager must liaise with the fire and rescue authority to produce a fire policy and procedure that will make adequate arrangements for detecting, containing and extinguishing fires, give warning of fires, and for the evacuation, in the event of a fire of all persons in the care home. The registered manager must undertake a full risk assessment DS0000002237.V291346.R01.S.doc 31/05/06 19/05/06 31/08/06 19/05/06 30/06/06 The Oaks Care Home Version 5.1 Page 27 of the property to identify any parts of the home to which service users have access to and make the home free from hazards to their safety. This should be done in consultation with the health and safety executive using the 5 step risk assessment or similar. 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 YA39 Good Practice Recommendations The registered provider should involve independent advocates in the review of the quality of the service provided. The Oaks Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000002237.V291346.R01.S.doc Version 5.1 Page 29 - 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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