Inspection on 24/07/07 for West Oak

This inspection was carried out on 24th July 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

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE West Oaks Murray Road Wokingham Berkshire RG41 2TA Lead Inspector Amanda Longman Unannounced Inspection 24th July 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address West Oaks DS0000069273.V343097.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. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Oaks Address Murray Road Wokingham Berkshire RG41 2TA 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) 0118 9795100 westoak@barchester.com Barchester Healthcare Homes Ltd Ms Sara Frances Baker Care Home 55 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0) West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with Nursing - (N) to service users of the following gender: Either Whose primary care on admission to the home are within the following categories: Old age, not falling within any other category - (OP) Dementia - over 65 years of age (DE(E)) 26 Dementia - (DE) 26 The maximum number of service users to be accommodated is 55. 2. Date of last inspection Not applicable Brief Description of the Service: West Oak is a purpose built two-storey home in a residential road not far from the centre of Wokingham. It caters for up to 55 service users, up to 26 of whom live in the ground floor part of the home, known as Memory Lane, which offers specialist dementia care. The home has existed for several years but has recently been bought by a different provider - Barchester Healthcare Homes. This is West Oak’s first inspection since it has been owned by Barchester. The home has in place appropriate policies and procedures related to equal opportunities and diversity. Fees for the home are £920 per week. This is an all-inclusive fee for care and activities. Extra charges are applied for hairdressing and chiropody services. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. It was a thorough look at how well the service is doing. It took in to account information received from the manager prior prior to the site visit which took place on 24 July 2007. During this site visit the inspector toured the home, observed care practices. spoke with service users, relatives and staff and examined care records. The manager was on leave the day of the site visit and the inspector was ably assisted by the deputy manager. During the course of the inspection questionnaires were received from ten service users and a local GP used by the home. What the service does well: What has improved since the last inspection? West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 6 This is the first inspection since West Oak has been taken over by Barchester Healthcare Homes. 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. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 7 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 West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 8 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): 1, 2, and 3. Quality in this outcome area is Excellent. Prospective service users receive appropriate information about the home. Service users have a written statement of terms and conditions and service users’ needs are fully assessed before they enter the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection West Oak has changed ownership so it is now assessed as a new service. It has in place a Service User Guide and Statement of Purpose. The Service User Guide, containing a summary of the Statement of Purpose, and a brochure are sent to all prospective service users. Information received from the manager also indicated that a copy of the previous inspection report is also sent. The manager needs to explain to prospective service users that this previous report relates to a different registered service. All ten questionnaires received from service users stated they had received enough information from the home to help decide whether or not it was right for them. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 9 Prospective service users are visited by the manager or the deputy manager who will assess their needs and advise whether or not the home can meet them. Prospective service users may visit the home with friends or relatives, view rooms and activities and have a meal. If it is appropriate, and the service user wishes to move in to the home, they are placed on a waiting list. If their needs change before a place becomes available, their needs are re-assessed to ensure the home is still able to meet them. All new service users receive a notice of the terms and conditions of the home and these are different for self funding individuals. All admissions to the home are initially on a one month trial basis. Service users files for seven service users were examined. All had very detailed assessments in place. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Service users have appropriate, extensive, individual care plans and their health care needs are met. The are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five service user files were examined in detail. All were found to have detailed care plans in place. These address all aspects of the assessed needs and include a daily living profile and a life story section. This is very informative and contains details of their life history, significant events, hobbies and interests. Personal preferences for how each individual likes to be supported are recorded. For example preferences for assisting with toileting, continence and bathing, the service user’s preferred form of address, who should open mail, and whether the service user minds being assisted by a male or female worker in personal care. All service users who replied to the questionnaire stated they received the care they needed always (70 ) or usually (30 ). This was confirmed on the day of the site visit when service users and relatives spoken with stated they received good quality care. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 11 The care plan contains a section relating to death and service users can sign to say they do not want to be resuscitated. Of the five files examined this section was blank for the most recent admission, as it had not yet been discussed. It was blank for another service user (the deputy manager explained it was the family and service user’s choice not to discuss this). One was signed to say the service user did want to be resuscitated and two stated the service user did not want to be resuscitated. However one of these was not signed. This was pointed out to the deputy manager who agreed to sort it out urgently. Each file has a separate section on health care where contact with healthcare professionals, for example GPs, physiotherapists and chiropodists, is recorded and monitored. There are also a selection of monitoring charts, which are used as required in relation to each individual’s health. These include blood pressure, bowel movements and food and hydration. All ten service users who replied to the questionnaire stated they always or usually received the health care they required. Care plans refer to maintaining privacy and dignity and are written to enable and record choice. Staff spoken with all expressed the importance of choice, privacy and dignity and observations throughout the visit confirmed that service users at West Oak are treated with dignity and respect. Staff spoke to service users in a respectful manner, explained anything they were doing and why and where inclusive. For example the inspector observed a poetry group facilitated by the activities organiser. Service users who wished to join this group were welcomed and included whether or not they were actively participating in reading poetry to the group. The attitude of the management and staff at West Oak is to value people as individuals. This was illustrated on the day of the site visit by two particular instances. A private lunch was prepared and served for a service user whose wife was visiting. This was done in a private dining room where the table was laid up with flowers and napkins. Secondly, one service user whose birthday it was had several relatives of all ages visiting. They were made very welcome and were obviously at ease chatting and laughing in the home. Service users who replied to the questionnaire made comments such as “the majority of staff are wonderful and interactive” and that they were treated as “an individual”. The vast majority of comments made were very positive. However, one comment was made about a minority of staff not having a good enough command of the English language to understand and communicate. Also, during the visit one member of staff was observed not interacting with a service user when they were together in a communal room. Both these issues were raised with the deputy manager on the day of the site visit who addressed both of them. For information relating to language see the section on staffing below. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 12 Daily notes are maintained twice per day on each person’s care. Care plans are signed monthly by the relevant member of staff to confirm they are still appropriate and changes are made as necessary. A full review of each aspect of the care plan is undertaken on a six monthly basis to ascertain if needs have changed and whether or not the current care plan is still meeting those needs. These records were present on all the files checked. The home has policies on equal opportunities and strives to meet service users individual diverse needs through its person centred planning. The deputy manager was confident that the home can meet the needs of people from a diverse range of cultural or religious backgrounds. The home has an appropriate medication procedure in place and medication is administered by nurses. The home does not carry any bulk items and all medicines are individually prescribed. Medication is securely stored and medication administration records have photographs of the relevant service user on to double check medication is administered to the correct individual. Medication and administration records were examined and were seen to be correct. However there was bad practice in one area. Medicines such as paracetamol, which is prescribed for many service users in the home, are not dispensed from the correct individual’s prescribed packet. One or two packets, individually prescribed, are kept on the trolley and everyone requiring paracetamol is given it from those packets. Their individual doses are recorded on their individual MARS sheets but there is no double check against the individually dispensed packets. The inspector spoke with the nurse in charge and the deputy manager about this practice and they explained it was because the medicine trolleys were not big enough to carry all the individually prescribed packets. However, they agreed to change the practice from the following medication round so that people are dispensed medicines from their own individual packets. Since the site visit, the inspector has spoken with CSCI’s pharmacy inspector who has advised that there is a system called “bulk prescribing” which would cut down the number of packets of medicines. This system can only be used with the GP’s approval and there are clear rules about when this system can and cannot be used. The home should discuss this approach with the GP. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is Excellent. The service users enjoy the lifestyle afforded by the home. They are assisted to maintain contact with family and friends, encouraged to exercise choice and enjoy their meals and meal times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a happy atmosphere and this was confirmed in feedback from service users. The home has an activities co-ordinator and two assistants. A wide variety of activities are organised within the home. These have included a chocolate making demonstration, an ice-cream tea party in the garden, concerts, arts and crafts, an easter egg hunt and crowning of the May Queen. Residents participate in maintaining the gardens and planting pots of indoor and outdoor bulbs. Hairdressing and nail manicures take place weekly. On the morning of the site visit a poetry reading group was observed. This was popular and inclusive of those who wanted to read out poems and those who just wanted to listen. On the afternoon of the visit Memory Lane one to one activities were taking place. Individual files are prepared by the activities organiser, with the help of service users and their relatives, which consist of photographs and memorabilia to assist with reminiscence. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 14 A Christian religious service is held at the home once per week for those that wish to attend. The home does not currently have any service users from other religions, but the deputy manager was confident that any such needs or requests would be addressed through care planning, and information received from the home confirmed that ministers from other faiths will visit on request. The home does not currently have any transport but use is made of taxis and service users are assisted to visit local shops if they wish. Many of the service users have family contact and it was obvious on the day of the site visit that families and friends are welcomed in to the home and enjoy visiting there. The home is in touch with the local community. The mayor has visited on important occasions and the home enjoys visits from the local church choir. There is a school opposite the home whose choir also visit the home. Feed back from service users indicated that most service users enjoyed the activities available. However one commented they wished there were more activities and time to talk and another commented that they would like the RNID to be contacted to assist individuals with hearing problems. Access to transport such as a mini bus would also be of benefit. Service users are encouraged to make choices. They can choose when they get up or go to bed, what they wear and what they do with their day. Service users with dementia are assisted by being offered focussed choices such as a choice between two items of clothing or the show meals choice described below. The home has suitable menus in place and can cater for special diets. Two meal times were observed in the home. The food was freshly prepared and choices were offered. For those service users with dementia a “show meal” scheme is being used to assist in making choices. Those service users choosing to eat in the dining rooms are presented with attractive rooms where tables are laid with clothes, napkins and flowers. Staff were observed appropriately assisting those service users who needed assistance to eat. Service users wishing to eat privately with visitors can be served in a pleasant room on the ground floor and this was being used on the day of the visit by a husband who was being visited by his wife, who fed back to the inspector how kind and considerate the management and staff were at the home. The home has recently introduced the role of Hostess, who serves meals and beverages, sets tables and assists service users to take meals and drinks. All ten service users who responded to the questionnaire stated that the food served was usually or always good. Comments were made that food has improved following the introduction of a residents committee and that further steps were being taken to improve choice. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is Excellent. Service users’ complaints will be listened to and acted upon and service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an appropriate complaints procedure in place. The complaints policy is available to all service users and their representatives and is clearly displayed in the entrance hall and in The Service Users Guide in the Rosewood Lounge. All prospective residents and their representatives are sent copies of the Service Users Guide prior to admission to the home. All ten service users who responded to the questionnaire stated they usually or always knew who to speak to if they were not happy about something and all ten sated that they or their relative knew how to make a complaint. The Commission has not received any information relating to any complaints made and the complaints log, which was examined on the day of the site visit, had no complaints. One service user commented that they had never had cause to complain and one relative spoken with stated that when they had raised anything minor it was always dealt with quickly. The home has introduced a program of customer care training and plan to train 90 of their staff. They also plan to ensure that 50 of their staff are trained in managing difficult situations and challenging behaviour by the end of May 2008. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 16 The home has appropriate safeguarding procedures in place. Its policy is in line with the local multi-agency policy and it has a whistle-blowing procedure. Information for staff is displayed in the staff room. All staff receive induction training in the protection of vulnerable adults and attend a yearly update. This was seen in training records and confirmed by staff spoken with. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26. Quality in this outcome area is Excellent. Service users line in a safe, well-maintained environment, which is clean, pleasant and hygienic. They enjoy access to safe and comfortable indoor and outdoor facilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home confirmed that it is well maintained, decorated and furnished to a high standard. Communal rooms are comfortable and homely. The inspector spok with the maintenance manager who confirmed the home has a rolling programme of refurbishment and replacement of furniture. Bathrooms in the home have domestic style touches of décor to improve the homely feel. The corridors in the part of the home which accomodates service users with dementia is dotted with objects to aid and assist reminisince such as hats and sports equipment. Externally the building and gardens were seen to be well maintained.The gardens are accessible to service users. Service users spoken with, and those who replied to the questionnaire, confirmed that West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 18 good use was usually made of the gardens. At the present time the home is having an extension built. The home has been made safe from the building area. Several service users rooms were viewed. They were seen to be clean and confortable. Service users are encouraged to personalise their rooms with ornaments, pictures and small items of furniture. The deputy manager informed the inspector that staff will assist service users to do this. Once the building work is complete, the home is planning to personalise the bedroom doors along the corridor which is occupied by people with dementia, to assist in recognition. 90 of service users who replied to the questionnaire said the home was always clean and pleasant. On the day of the site visit the home was seen to be clean, pleasant and hygeinic throughout. West Oaks DS0000069273.V343097.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): 27, 28, 29 and 30. Quality in this outcome area is good. Service users’ needs are generally met by the numbers and skill mix of staff, who are well trained and competent, and have been recruited in such a way so as to protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received from the manager prior to the site visit stated that the staffing levels and skill mix of the staff at the home are more than sufficient to meet the needs of the service users and that for any residents assessed as having very high dependency extra staffing, e.g. one to one care would be deployed. This was confirmed by the deputy manager on the day of the site visit who provided an example of one to one care being provided for a service user for two days and nights when they were particularly poorly. All then service users who replied to the questionnaire stated staff were usually or always available when needed and comments included staff being very helpful and competent, just occasionally there is no one immediately available, and that a large number of the staff are very well qualified which gives the service user a sense of security. The home is staffed by a mixture of nurses and care assistants. At any time there is a minimum of two nurses on duty and this rises to three between 8.00am and 2.00pm. They are supported by 11 care assistants form 8.00am till 2.00pm, by eight care assistants untill 8.00pm and by four care assistants through the night. In addition there are hostess and housekeeping staff as West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 20 well as activity staff, maintenance and administration staff and the manager and deputy manager. The home offers NVQ training in Care, Dementia Care, Hostessing, Housekeeping, Activities and Catering. 17 out of 31 care assistants have NVQ level 2 or above. The home has an appropriate recruitment procedure in place and records examined on the day showed appropriate checks, including the receipt of two references and a CRB check, had been undertaken prior to staff commencing employment. The deputy manager informed the inspector that Barchester head office undertakes some recruitment in Poland. One service user had commented that some staff do not have sufficient command of English to understand and communicate. The deputy manager confirmed that, where necessary, staff do attend English lessons, but the home must ensure that staff deployed in the home are able to chat and communicate effectively with service users. The home provides induction training in line with Skills For Care and evidence of this was seen. In addition there is a structured program of training for the year, which covers all mandatory training including Moving and Handling, Protection of Vulnerable Adults, Fire, Food Hygiene and Health and Safety. Planned training is on display in the staff room. Other specialist training is also provided. For example, Customer Care and dementia training. Information received from the manager stated five staff have completed the Alzheimers Society “Yesterday, Today, Tomorrow” training, and are using their new skills and knowledge as a result. A further nine staff are near to completing the course. Staff spoken with felt the level of training provided by the home was good. Staff appeared competent and service users and relatives spoken with said staff were well trained and competent. . West Oaks DS0000069273.V343097.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): 31, 33, 35 and 38. Quality in this outcome area is good. Service users benefit from the style and approach of the manager, who is registered with the Commission, who runs the home in the best interests of its service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an RGN qualified manager who is registered with the Commission and is undertaking the Registered Managers Award. In the information sent to the Commission by the manager prior to the site visit, the manager stated that she operates an open door policy, and welcomes comments and suggestions from service users, their relatives, or any other interested party. This was confirmed by staff, service users and relatives spoken with during the site visit who spoke highly of the manager and her approachability. The home has several qaulity assurance measures in place. Residents and Relatives meetings are held three monthly to provide West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 22 information updates, explain new events or policies and invite comments. Evidence of the most recent meeting was seen during the site visit. The home carries out monthly audits including kitchen, nutrition, pressure sores and care planning. There is also a variable monthly audit tool which is used to look closely at areas such as infection control, documentation or health and safety. These were examined during the site visit and also contain any necessary action to be undertaken, when and by whom. The home does not look after or manage money on behalf of any service users. If a service user is unable to look after their own finances and does not have or does not wish a relative to do so, the manager stated she would involve an organisation such as Age Concern to arrange an advocate, or similar. The home has in place appropriate health and safety policies, procedures and training. Health and safety information is on display in the staff room. The maintainance manager undertakes all regular checks, such as water temperatures and ensures that all equipment, such as electrical equipment or fire safety equipment, checks are up to date. The home has fire safety procedures and provides training in fire safety to all its staff. West Oaks DS0000069273.V343097.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 3 4 X X X 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 4 17 X 18 3 4 4 X X X X X 3 STAFFING Standard No Score 27 3 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 X 3 West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 24 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 OP30 Regulation 19 (5) (b) Requirement The registered manager must ensure that all staff have sufficient skills to ensure they are fit to work at the home. (This refers to the need for all staff to be sufficiently skilled in spoken English to ensure they can chat and communicate with the majority of service users.) Timescale for action 24/11/07 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. Refer to Standard OP9 Good Practice Recommendations It is recommended that the manager discuss with the GP how best to manage the need for large amounts of identical medication in the home. It is recommended that the registered manager involves the RNID or other similar body, to ensure people who are deaf are given every opportunity to be fully involved with appropriate activities. It is recommended that the registered manager explores DS0000069273.V343097.R01.S.doc Version 5.2 Page 25 2. OP12 3. OP13 West Oaks the possibility of accessing transport to take more service users out. West Oaks DS0000069273.V343097.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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