Care Home: Five Oaks

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What the care home does well The home had a relaxed and friendly atmosphere. A regular visitor to the home told us, "It`s a very pleasant home". There is a good rapport between residents and staff. People who use the service are treated with respect and their dignity and privacy is valued and upheld. One resident commented, "They are very kind". Staff demonstrated a good knowledge of residents needs and consequently an individualised service is promoted. A resident we spoke with told us, "You have everything at hand". Residents have good access to health care professionals. The home makes sure that people`s needs are assessed before they move in so that people know the home will be able to meet their needs. Residents of the home feel that the staff are kind and polite and support them properly. There are a variety of activities available to residents and people have a say in how the home is run. The manager is professional and works in a transparent and open manner. One resident told us that the manager, "Has been very helpful". Staff receive the training they require to provide the care and support the people using the service need. What has improved since the last inspection? Eight requirements were made at the last inspection. The registered manager and the service manager have complied with six of these requirements. The registered manager is supported to manage the home through regular supervision. Up to date fire records are being maintained at the home. Night staff now undertake fire drills so that they are confident about what to do in the event of a fire occurring at night. Care plans have improved and are more detailed and are being reviewed regularly. This means that the resident`s assessed needs are recorded and up to date so that staff are aware of how best to support people at the home. Residents who like to have their bedroom door open now have self-closing devises fitted to their doors so that, if there was a fire, their door will close automatically and reduce the risk from possible smoke inhalation. What the care home could do better: Two requirements have been restated from the last inspection. Although a ramp was fitted to the garden room, it broke and will have to be replaced. The organisation carries out a quality review every year. As part of this review surveys are sent to all the residents and their representatives so they can indicate how satisfied they are with the service. The organisation must publish the results of these quality monitoring reviews so that people who use the service have information about how well the home is doing to meet its aims and objectives. This is a requirement under regulation 24 of the Care Homes Regulations 2001. A good practice recommendation was issued at the last inspection that people should be consulted about their care every time their care plan is reviewed. We saw some evidence that this is taking place but the recommendation remains in this report until all residents have an opportunity to say how well the home is meeting their needs. Two new requirements have been issued as a result of this inspection. The flooring in the laundry area needs to be repaired or replaced so it can be kept clean. Medication carried over from the previous month must be recorded so that the staff know how much medication is being stored at the home. Two good practice recommendations have been made relating to increasing the size of the laundry area and ensuring that records are maintained of the names of staff who have undertaken fire drills at the home. CARE HOMES FOR OLDER PEOPLE Five Oaks 377 Cockfosters Road Hadley Wood Hertfordshire EN4 0JT Lead Inspector Mr David Hastings Unannounced Inspection 22nd May 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Five Oaks DS0000010660.V364538.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. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Five Oaks Address 377 Cockfosters Road Hadley Wood Hertfordshire EN4 0JT 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) 020 8449 7000 020 8449 7311 FiveOaks@ScimitarCare.co.uk Scimitar Care Hotels Plc Ms Lynnsey Mitchell Care Home 44 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (44) of places Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th November 2007 Brief Description of the Service: Five Oaks is a private residential home owned by Scimitar Care Hotels PLC. The home is registered to provide personal care for 44 elderly people. Following an application by the owner to amend the category of registration, it has been agreed that six of the people accommodated at the home may have dementia. The home is purpose built; facilities include 42 single rooms and two double rooms on three floors; service users are never asked to share a room so the double rooms are used as single rooms. There is a large lounge with interconnecting doors to a dining room, a smaller lounge, the garden room, and a sitting area in the lobby, furnished with comfortable armchairs. The three floors are accessible via two shaft lifts. There is a well-maintained garden with patio, accessible, through French windows. The home is located in a quiet residential area. At front of the building there is a parking space for staff and visitors’ cars. The home is also accessible by public transport. The Cockfosters underground station on the Piccadilly line, is a few minutes’ car drive from the home. Weekly fees are between £682.50 (Residential) and £721 (Respite) This report is available through the internet. Copies may also be obtained from the provider of this service. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This Key Unannounced inspection took place on Thursday 22nd May 2008 and was completed on the same day. The inspection lasted seven hours. We spoke with seven staff on duty during the inspection. We spoke with fifteen residents of the home and four visitors. We observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. Prior to this inspection the service sent us their Annual Quality Assurance Assessment (AQQA) this document gives us information about how well the home is doing to provide a quality service to the people who use it. We have used this information as evidence in this report. Residents we spoke with said they were happy with care and support they received. One resident told us, “It’s very clean, friendly and homely”. Another resident told us, “I’m very happy here”. What the service does well: The home had a relaxed and friendly atmosphere. A regular visitor to the home told us, “It’s a very pleasant home”. There is a good rapport between residents and staff. People who use the service are treated with respect and their dignity and privacy is valued and upheld. One resident commented, “They are very kind”. Staff demonstrated a good knowledge of residents needs and consequently an individualised service is promoted. A resident we spoke with told us, “You have everything at hand”. Residents have good access to health care professionals. The home makes sure that people’s needs are assessed before they move in so that people know the home will be able to meet their needs. Residents of the home feel that the staff are kind and polite and support them properly. There are a variety of activities available to residents and people have a say in how the home is run. The manager is professional and works in a transparent and open manner. One resident told us that the manager, “Has been very helpful”. Staff receive the training they require to provide the care and support the people using the service need. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Two requirements have been restated from the last inspection. Although a ramp was fitted to the garden room, it broke and will have to be replaced. The organisation carries out a quality review every year. As part of this review surveys are sent to all the residents and their representatives so they can indicate how satisfied they are with the service. The organisation must publish the results of these quality monitoring reviews so that people who use the service have information about how well the home is doing to meet its aims and objectives. This is a requirement under regulation 24 of the Care Homes Regulations 2001. A good practice recommendation was issued at the last inspection that people should be consulted about their care every time their care plan is reviewed. We saw some evidence that this is taking place but the recommendation remains in this report until all residents have an opportunity to say how well the home is meeting their needs. Two new requirements have been issued as a result of this inspection. The flooring in the laundry area needs to be repaired or replaced so it can be kept clean. Medication carried over from the previous month must be recorded so that the staff know how much medication is being stored at the home. Two good practice recommendations have been made relating to increasing the size of the laundry area and ensuring that records are maintained of the names of staff who have undertaken fire drills at the home. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 7 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. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 not applicable) People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident that the home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. EVIDENCE: Two assessments were examined of people who had recently moved into the home. These assessments were detailed and covered all the elements required by this Standard including the assessment of peoples’ physical, emotional, social and cultural needs. We were informed that people’s cultural needs in relation to their religion would be assessed prior to them moving into the home. We found that the information from these assessments was being recorded on peoples’ care plans as well. There was evidence that people moving into the home have a review of their placement after four to six weeks to see if they are happy at Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 10 the home and whether they decide to move in on a permanent basis. People who use the service told us that they or their representative had visited the home before they moved in. All the residents we spoke with said they were happy with the care they received. One person commented, “They have been very decent”. Another resident said, “I like it”. The home has a condition on their registration that six people with a diagnosis of dementia can be supported at the home. We discussed this with the manager who told us that a number of people at the home have developed dementia since their admission. The manager told us that the organisation was considering applying to the Commission to increase the number of people who can be accommodated at the home with dementia. We also discussed the possibility of applying for a wider category of dementia so that the home would be able to admit people with dementia. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Six care plans were examined. Each plan had a summary of the person’s care needs including their physical, emotional and social needs. Each plan gave clear instructions to staff about how best to care for each person. Care plans were being reviewed on a regular basis and updated where needed. Each person’s plan of care included an assessment of the risk of falling and how staff are to reduce this risk, for example, having two staff to help with personal care tasks or by supervising the resident when they walk around the home. Other risk assessments had been undertaken in relation to pressure care and nutrition. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 12 Work has been undertaken to gain a social history of people at the home so that staff can have an insight into what the person was like before they moved into the home. There was some evidence that people had been consulted about their care plans and people told us that staff respected their wishes in relation to personal care and support. Visits by health care professionals such as doctors, district nurses, chiropodists, dentists and opticians were being recorded on plans we examined. These showed that people had good access to these professionals. This was confirmed by residents and visitors we spoke with. Satisfactory records were examined in relation to the receipt, administration and disposal of medication. Records indicated that staff have undertaken medication training and only qualified staff administer medication at the home. Each person’s medication chart has a picture of them attached to it so that staff can double check who is receiving the right medication. We found that one person’s medication was not being accurately recorded and three tablets were not accounted for. We were told that this was due to the medication being carried over from the previous month but this had not been recorded. A requirement has been issued that all medication carried over from the previous month must be recorded so that staff are aware of how much medication is being stored at the home. The administration chart for this person indicated that they were receiving the medication they were prescribed at the right times. We saw a number of examples of supportive staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful and kind towards them. Care plans also gave detailed instructions to staff on how to maintain people’s privacy. Five Oaks DS0000010660.V364538.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 People using the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides varied activities for people who use the service in order to keep them suitably occupied and engaged. Visitors to the home are encouraged and welcomed. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: The home has recently employed an activities coordinator. People who use the service were positive about the activities available at the home. One resident told us, “We have never had a dull moment”. The activities coordinator told us about the activities she organises at the home. These included cooking, games and gardening. We saw that the residents had made some hanging baskets for the home. The activities coordinator also told us that although she undertakes group activities it was also important to ensure that people who don’t usually join in are kept suitably engaged and occupied and she was able to give examples of one to one activities she carried out with residents. On the day of the inspection, after lunch, an entertainer came to the home to play music and residents were clearly enjoying singing along. Residents’ files contained records of their social interests and a record was being maintained about how Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 14 each resident spent their day at the home. Discussions with the manager confirmed that some people attend places of worship and others worship at the home. All residents have a telephone in their bedrooms. Visitors to the home told us that they could visit at any reasonable time and that they were made welcome by the management and staff. Residents we spoke with confirmed this. One visitor told us, “There is always someone visiting here” and another visitor commented, “We are always welcomed”. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. We saw examples of staff offering choice in relation to meals and activities during the inspection. One resident said, “They don’t take over. They let you do the things you can do”. Another person told us that they were never, “Bossed about” at the home. The kitchen was inspected. Fridge and freezer temperatures were being recorded and there were sufficient amounts of fresh fruit and vegetables available. The cook was interviewed and had a good knowledge of individual resident’s dietary needs and preferences. The cook was able to give examples of how residents have made decisions about the menu at the home. The cook also told us that although, at this time, no one has any cultural requirements in relation to food, culturally appropriate meals can be provided. The meals we saw on the day of the inspection looked and smelt appetising. People who use the service confirmed that the food was good at the home and that they always get enough to eat. One person commented, “The food is good, which is important”. Another person said, “You get a choice”. Five Oaks DS0000010660.V364538.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 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. People at the home are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. Since the last inspection eleven minor complaints have been received. Records examined indicated that these complaints had been dealt with appropriately and in line with the home’s complaints policy. It is good practice to record all complaints, however minor, so that people are confident that their concerns are taken seriously. All the residents we spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. One resident told us, “I’m very happy here. I ‘d soon complain if I’m not”. Staff were able to describe how vulnerable people could be at risk of abuse in a residential care setting. All staff interviewed were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that we spoke to said they felt safe and well supported at the home. One resident said, “They are very careful with me”. Records indicated that staff have undertaken training in the protection of vulnerable people. The manager also told us that the new staff will be Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 16 undertaking adult protection training as part of their induction programme. This is particularly important for senior staff, as they will be supervising staff and will need to be familiar with the types of abuse people can face in a residential setting. The home instigated an adult protection referral last year and this was dealt with appropriately and in line with the home’s policy and procedures in relation to protecting vulnerable adults. Five Oaks DS0000010660.V364538.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 and 26 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service live in a clean, safe and well-maintained environment. EVIDENCE: The manager showed us around the home and we met with some residents in their rooms. The home is decorated and maintained to a good standard. Communal areas were being fitted with new carpet and the home was clean and fresh. A requirement was restated at the last inspection that a ramp is fitted to the home so that the garden is accessible to people using wheelchairs. The manager told us that a ramp had been fitted but it broke so a new ramp will be fitted in the near future. The requirement has been restated. We spoke to a resident who uses a wheelchair and they told us that they could get into the garden unaided. Residents we spoke with said they were happy with their room and we could see that people are encouraged to bring in their own personal items as rooms were saw looked individual and comfortable. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 18 People we spoke to told us the home was always clean. One resident told us, “Every day the cleaner comes in”. The home employs domestic staff. The water temperatures of wash hand basins in peoples’ rooms were checked and found to be within safe limits so residents cannot accidentally scold themselves. Bathrooms and toilets were clean and contained anti bacterial soap. Staff have undertaken infection control training and told us how this has improved their work practice. The training contained practical learning such as effective hand washing. This should ensure that the risks associated with cross infection are minimised. The laundry area was inspected. The flooring in the laundry area is worn and may be difficult to keep clean properly. A requirement has been issued that the flooring in the laundry area is replaced. The laundry appeared quite small for the size of the home and it may be prudent to increase the size of the existing laundry or move the laundry to a larger site. A good practice recommendation has been issued relating to this. Five Oaks DS0000010660.V364538.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 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff at the home work very hard to meet the needs of the residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are sufficiently detailed in order to protect residents at the home. EVIDENCE: A satisfactory staff rota was examined which indicated that eight staff are working in the day, six staff are working in the evening and three waking night staff are on duty throughout the night. The manager told us that the staff turnover at the home is very low and this is having a positive effect on the care of residents. One person told us, “The staff here are lovely”. Another resident said, “They work very hard”. Both visitors and residents were very positive about the support they receive from the staff at the home. A resident told us, “There is always someone there if I get into difficulty”. Records of staff training we received from the home indicated that 10 of the 30 staff have obtained NVQ level 2 or equivalent. We also saw that 7 staff were currently undertaking this qualification to improve their knowledge and skills in caring and supporting people who use the service. Three staff files were examined from staff recently employed by the home. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 20 We checked these files to see if the home’s recruitment procedures were being followed so that residents are protected from unsuitable staff working at the home. The files examined contained all the information needed to protect residents including two written references, proof of identity and criminal record checks. Staff we interviewed were very positive about the training offered by the home and records and certificates seen indicated that staff are attending the appropriate training they need to support people properly and safely. This training included medication, moving and handling, adult protection and infection control. Five Oaks DS0000010660.V364538.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, 36 and 38 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager of the home knows the residents very well and understands their needs. Residents do have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are promoted and protected. EVIDENCE: The manager has been in post for about nine years and both residents and staff were very positive about her work at the home. Staff, residents and visitors said the manager was very approachable and professional. One person told us, “Whatever the manager says she is going to do she does”. A relative we spoke with said the manager was very transparent in her management approach and that this has led to an open atmosphere at the home. The Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 22 manager has completed the NVQ registered managers award and confirmed that she attends other training events as required. Quality monitoring questionnaires have been sent out to residents and their representatives and visitors confirmed that they had received them. The results of these questionnaires have still not been collated, analysed and published even though a requirement about this was made at the last key inspection. It is important that the results of any quality monitoring review are made available to all residents, their representatives and other interested parties so that people who use the service can see how well the home is doing to achieve the aims and objectives of the service. A requirement relating to this has been restated in the relevant section of this report. It is not acceptable to have restated requirements and the Commission may consider the need to take further action. However we have taken into account the introduction of regular residents meetings, which should ensure that people are able to have a say in how their home is run. The home does not usually hold money on behalf of residents. If residents need anything the manager told us that this is purchased by the home and an itemised monthly bill is sent to the resident or their representative. Phone bills sent to residents are also itemised so that they know exactly what they are being charged for. The manager told us that she now receives regular supervision and records of these supervision sessions are being recorded. This should ensure that both the service manager and the manager have a record of any actions that need to be taken. A requirement was made at the last key inspection that an automatic door closure devise is fitted to any bedroom door where the resident wishes to leave their door open. We also required that until this had been completed risk assessments must be undertaken for all residents concerned. We saw that some self-closing devises had been fitted and during the inspection a further three units were put on peoples’ doors. Risk assessments were seen for people who like to have their door open and changes had been made to the evacuation plan for the home. We were assured that everyone who likes to have their door open has now had a self-closing devise fitted. This should ensure that people are protected from smoke inhalation should a fire occur at the home. We examined fire records maintained at the home. These records indicated that all staff, including night staff, are undertaking regular fire drills. It is important to record the names of the staff who have undertaken these drills and a good practice recommendation has been issued relating to this. Records seen on the day of the inspection and information provided by the home prior to the inspection indicated that other health and safety matters were being properly managed at the home. These included electrical and water safety as well as appropriate risk assessments. Training records examined indicated that staff have undertaken the relevant health and safety training to make sure that residents are cared for in a safe way. Five Oaks DS0000010660.V364538.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 3 X 3 Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP19 Regulation 23(2) a Requirement The registered person must ensure that the garden is accessible to those residents who use wheelchairs. (Timescale of 01/01/08 not met) This requirement is restated. The registered person must ensure that the results of any quality assurance surveys are published and made available to all interested parties. This includes residents and potential residents to the home. (Timescale of 01/01/08 not met) This requirement is restated. The registered person must ensure that the flooring in the laundry area is either repaired or replaced so that the floor can be cleaned effectively. The registered person must ensure that any medication left over from the previous month is recorded as being carried over to the new month. This should ensure that an accurate record is maintained of how much DS0000010660.V364538.R01.S.doc Timescale for action 01/08/08 2. OP33 24(2) 01/07/08 3 OP26 23(2) b 01/10/08 4. OP9 13(2) 01/07/08 Five Oaks Version 5.2 Page 25 medication is being held by the home. 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. Refer to Standard OP33 OP26 OP38 Good Practice Recommendations The registered person should ensure that the views of residents are sought every time care plans are reviewed. The registered person should ensure that the site of the laundry area is reviewed and sited in a larger area. The registered person should ensure that the names of staff who have undertaken fire drills is recorded so that the manager knows which staff may require further fire drills. Five Oaks DS0000010660.V364538.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Five Oaks DS0000010660.V364538.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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