Care Home: Oak Manor Nursing Home

What the care home does well The manager carries out a pre-admission process that involves residents and their families or social worker. Prospective residents and their family are provided with information about the home to enable them to make an informed decision about moving in and are invited to visit and see there own room and facilities beforehand. Each resident is assessed on their personal, nursing, social care and mental health needs before moving in to give the manager time to put in place any specialist equipment they may need to help care for them. All of the residents have a named nurse who writes up the care plans and regularly reviews the care in place to ensure that they are comfortable and content regularly consulting residents or their family. Care staff assists residents with their personal care. Residents and their relatives can be confident that any concerns they have will be dealt with properly.Oak Manor Nursing HomeDS0000066644.V377086.R01.S.docVersion 5.2The manager makes every effort to protect residents from harm by making sure staff are properly vetted before they start work. Residents` healthcare needs are attended to well and their medication is managed and administered safely. What has improved since the last inspection? Care records have improved and now include more detail about how residents care needs should be met, although some further improvements are required by staff by completing the food and fluid charts coinciding with nutritional risk of those residents with dementia and require all care. Some of the bedrooms have been refurbished, although this is ongoing there are still some bedrooms that require redecorating and made more homely. Staff training is more constructive, with the manager recording training ratios, allocating time for staff to complete the required mandatory training. The manager is currently organising this year`s quality assurance survey by sending out questionnaires to relatives and visiting professionals to include their opinions of the care and support provided at the home. There have been some major improvements to the environment with the addition of a reception area; this area contains all the updated information about the home for visitors. The manager`s office is now situated at the front of the building making her more accessible for visitors to speak to her. The den lounge has improved lighting and has French doors out to the enclosed sensory garden for residents to walk outside without restriction. What the care home could do better: The care records show there are some inconsistencies with cross referencing between reviews and risk assessments. Food and fluid charts should be fully completed. The new activities co-ordinator requires updated activities training especially with reminiscence.Oak Manor Nursing HomeDS0000066644.V377086.R01.S.doc Version 5.2 Residents who stay in there rooms should have some form of social stimulation during the day and not just at mealtimes to reduce the risk of isolation. Residents would benefit from having a picture menu to help them make a choice for there meals. Staff numbers need to be increased who have achieved the recommended National Vocational Qualification (NVQ) in care to continue to improve care standards. Some areas of the environment still require redecorating such as residents bedrooms where wheelchairs have knocked against walls. Key inspection report CARE HOMES FOR OLDER PEOPLE Oak Manor Nursing Home Scarning Dereham Norfolk NR19 2PG Lead Inspector Hilda Stephenson Key Unannounced Inspection 17th August 2009 09:00 DS0000066644.V377086.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oak Manor Nursing Home Address Scarning Dereham Norfolk NR19 2PG 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) 01362 694978 shaun.morrissy67@btinternet.com www.caringhomes.org Caring Homes Healthcare Group Ltd Anne Gregory (undergoing registration) Care Home 64 Category(ies) of Dementia - over 65 years of age (64) registration, with number of places Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user under the age of 65 years, who is named in the Commission`s records, may be accommodated. 4th September 2008 Date of last inspection Brief Description of the Service: Oak Manor is a care home with nursing, providing care and accommodation for up to 63 older people who have dementia. Caring Homes Healthcare Group Ltd., whose head office is located in Essex, owns the home. Personal accommodation in 55 single bedrooms and 4 shared occupancy bedrooms. All bedrooms have their own en-suite facilities apart from 2 single bedrooms. The home is single storey, and level access, with some corridors with gentle gradients where a small change in level occurs. The home is located in the village of Scarning, which is close to the market town of East Dereham and all local amenities. Fees are currently between £536.00 - £900.00 per week. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well the provider delivers outcomes for people using the service. The unannounced key inspection of this service has been carried out using the information from previous inspections, written information provided by the manager, some residents and their relatives and others who work in or visit the home. This unannounced visit took place during the day of Monday 17th August 2009. The manager was on annual leave but came in to oversee the inspection. Prior to the inspection the manager provided a completed and detailed Annual Quality Assurance Assessment (AQAA) giving details of what the homes strengths and weakness were and how these could be adapted to improve care for residents who live there. During the inspection a tour of the building was undertaken, staff practice was observed, records and files were read, staff, residents and there relatives were consulted. Twelve surveys were received; two relatives and one professional were consulted over the telephone prior to the visit. The quality rating for this home is 2 star, meaning the outcomes are of a good quality. What the service does well: The manager carries out a pre-admission process that involves residents and their families or social worker. Prospective residents and their family are provided with information about the home to enable them to make an informed decision about moving in and are invited to visit and see there own room and facilities beforehand. Each resident is assessed on their personal, nursing, social care and mental health needs before moving in to give the manager time to put in place any specialist equipment they may need to help care for them. All of the residents have a named nurse who writes up the care plans and regularly reviews the care in place to ensure that they are comfortable and content regularly consulting residents or their family. Care staff assists residents with their personal care. Residents and their relatives can be confident that any concerns they have will be dealt with properly. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 6 The manager makes every effort to protect residents from harm by making sure staff are properly vetted before they start work. Residents’ healthcare needs are attended to well and their medication is managed and administered safely. What has improved since the last inspection? What they could do better: The care records show there are some inconsistencies with cross referencing between reviews and risk assessments. Food and fluid charts should be fully completed. The new activities co-ordinator requires updated activities training especially with reminiscence. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 7 Residents who stay in there rooms should have some form of social stimulation during the day and not just at mealtimes to reduce the risk of isolation. Residents would benefit from having a picture menu to help them make a choice for there meals. Staff numbers need to be increased who have achieved the recommended National Vocational Qualification (NVQ) in care to continue to improve care standards. Some areas of the environment still require redecorating such as residents bedrooms where wheelchairs have knocked against walls. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Oak Manor Nursing Home DS0000066644.V377086.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 Oak Manor Nursing Home DS0000066644.V377086.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prior to new residents moving into the home, written information is made available to them and they have a needs assessment undertaken before deciding to move in. EVIDENCE: The new reception area contains written information and the homes brochure informing new residents or their family about the facilities offered at Oak Manor. After an initial enquiry for a room, the manager or her deputy manager arranges for new residents or their family to visit the home to check the facilities that are offered. The manager then visits prospective residents with Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 10 their family or social worker in attendance to discuss and assess the residents care, social and mental health needs to ensure that Oak Manor is the right place for them. The manager arranges any specialist equipment to be in place before admission, and discusses the fees, extra charges, facilities offered so the admission goes smoothly for residents with dementia and memory impairment. The manager completes a pre-admission assessment and obtains this information from the resident, family member or health/social care professional. Three randomly selected care plans were checked and two of these showed that family assisted with the initial assessment, while the third showed that the resident managed to communicate themselves. The pre-assessment records showed an improvement in the detail of the information gathered since the last inspection, this contains both care and nursing needs, as well as social and mental health needs. One of the residents confirmed that they were consulted about there admission and actually visited the home beforehand. Oak Manor Nursing Home DS0000066644.V377086.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are person centred although, not all records are complete. Residents have there basic care and nursing needs met. Medication is managed and administered safely. EVIDENCE: Three care plans were read and checked alongside the care they receive. This method of collating evidence is called case tracking. The same residents were either spoken to, or there relatives and the staff who look after them, to check whether they are receiving the care that is recorded. Two of the residents were unable to express there view so there family was spoken to. All three care plans were written by the named nurse and contained individual personal care, nursing needs and risk assessments. All three of the records contained some gaps in the recording of food and fluid intake, Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 12 especially important for those who are vulnerable and require assistance with their meals. The care plans contained clear guidelines for staff to follow, and any specialist equipment that was used was regularly checked and used safely. The staff are allocated residents to care for on a daily basis and follow the instructions written in the care plan. Ongoing training for moving and handling is in place. It was observed that staff spoke to residents in a polite manner and treated each person with dignity and there privacy was respected at all times. Each resident is allocated a named nurse, who writes there care plans and reviews the care on a regular basis. In some instances a family member is consulted when this is compiled. There was evidence of nursing intervention, risk assessments, life history and likes and dislikes to help care staff to care for the individual needs and wishes. Some care plans contained more detailed information which is important when residents are unable to communicate themselves. Relatives who spoke to us said ‘I am happy about the care that my mother receives; I can trust the staff to look after her’. Another said ‘that she had some concerns, although this was being followed up with a meeting with the manager’. The majority of the residents appeared content, although occasionally some appeared agitated. Staff who spent time in the lounges tried distraction behaviour, playing games or going for a walk. There were residents who were cared for in there own rooms and did not use the lounges for various reasons. The risk of isolation was not recorded within the care plans and needs to be addressed by staff rather than only visiting when they were due for having there position changed. All the residents have some form of dementia with the majority having communication difficulties; these were being addressed by staff with several forms of communication skills being used. The nurses administer the medication to residents. There are always two nurses on duty and they care for half of the residents each. Medicines are dispensed from a portable lockable trolley and security was a high priority due to the number of residents walking through the home. The medicine charts were checked of the three case tracked residents and these were found to be accurate and completed. Oak Manor Nursing Home DS0000066644.V377086.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered a choice of wholesome nutritious meals. Activities have improved and residents are offered more meaningful activities to suit their needs. EVIDENCE: The manager has employed an Activities Co-ordinator to organise and arrange sociable events, group activities and reminiscence on a one to one basis. This has commenced and evidence of staff playing games with some residents in the lounges was seen during the day. When speaking to the activities coordinator there were plans in place to commence visits from various churches in the local community which has been lacking in the past. A recent summer fete had been a success with several visitors from the village and relatives assisting with their residents. Some of the residents spoken to appeared to enjoy the day, ‘especially because the weather was in their favour’. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 14 It was seen in the care plans that more details had been collected about residents past history, work life, family and hobbies and the Activities Coordinator was compiling some activities taking these details into consideration. There should be consideration for those residents who stay in there room so that they do not stay isolated. During the day some residents were enjoying doing exercises to music. The staff said ‘residents enjoy music and it’s a good opportunity to keep there limbs supple at the same time’. Due to the warm weather some residents were enjoying the enclosed garden which has several raised beds containing highly scented plants. The cook explained that residents have a choice from the menu, some may benefit from a picture menu to enable them to make a visual choice. The menu consisted of wholesome nutritious meals with plenty of seasonal fresh fruit and vegetables used and locally produced meat and fish. The cook explained that she serves a variety of different diets, although a high proportion of residents preferred a soft diet due to the high number requiring assistance with their meals. The dining room was nicely laid out for the lunch time meal, and several areas with table and chairs were situated so residents who required assistance could be offered a more private area. Food and fluids are recorded for each resident who has a nutritional risk, although there are some gaps in these records and this needs to be addressed. On the whole residents appeared to enjoy there meals and no-one was rushed with there lunch. The cook who has worked at the home for some time has achieved the ‘Good Food Hygiene Award’. Oak Manor Nursing Home DS0000066644.V377086.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and relatives concerns are acted upon and they are protected from harm. EVIDENCE: The manager said that there had been two complaints that she has had to deal with in the past two months. These were recorded in the complaints log with the action taken to rectify them. The complaints policy was displayed in reception and was also included in the residents guide. A relative who was spoken with during the inspection still had some concerns about the care of the resident and that they had found the call bell unattached just that morning, which had been dealt with straightaway. Due to the nature of some of the concerns the manager had arranged a meeting with the relatives to plan how standards could improve for the resident. Staff confirmed that they had received adult protection training, within the initial induction and ongoing updated training. All staff that was spoken to had an understanding of the whistle blowing policy and how it is a positive move to report bad practice. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 16 Evidence was seen within staff records of how disciplinary action and further training was put in place when someone did not follow the moving and handling instructions. Oak Manor Nursing Home DS0000066644.V377086.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered a homely, clean environment, although some areas still require decorating. EVIDENCE: There have been major improvements over the last few months to the environment with the addition of the spacious reception area containing a seating area and access to the manager’s office. The den lounge has improved the lighting and been redecorated. Throughout the corridors there is vinyl flooring to reduce trip hazards. The communal rooms had been repainted and appeared brighter, with a variety of chairs available. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 18 Several bedrooms were seen and these contained various amounts of personal possessions, pictures and family photographs. Some bedroom doors had pictures or the residents name or number on them to help them identify there own room when walking round the ground floor. There were areas in some of the bedrooms that would benefit from repainting where wheelchairs had knocked the paint off the wall. The enclosed garden is now complete containing raised sensory beds, and several residents were sitting outside in the warmer weather. Residents have access to the garden from the lounges. The home is contained on a large area of land, and staff confirmed that they accompany residents who like a walk. On the day of inspection the home was clean, tidy and free from offensive odour, although a relative said ‘it depends on what time you visit’. The residents laundry needs are undertaken at the home and dedicated staff takes care of the clothes to ensure they are delivered to the right person after washing. Oak Manor Nursing Home DS0000066644.V377086.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are cared for by sufficient numbers of trained staff. EVIDENCE: The rota was seen to confirm the residents are cared for by sufficient numbers of staff. Each day is divided into three shifts of staff; the morning is covered by two nurses, twelve care staff, two cleaning staff, laundry and housekeeper. Reducing to ten care staff for the evening shift with two nurses and overnight is covered by two nurses and four care staff. During the day the manager, administrator, maintenance man and activities co-ordinator are also on duty. The kitchen has a fulltime cook and two kitchen assistants who cover and serve all three main meals of the day. During breakfast, lunch and tea there are also two assistants who help residents with there meals. The AQAA states that there are thirty four care staff employed and only ten of them have achieved the recommended National Vocational Qualification in care (NVQ), this needs to be addressed to increase the number of care staff up to fifty per cent of the numbers. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 20 The manager has addressed the training issues that had arisen in the past resulting in numbers of staff undertaking the mandatory training, such as moving and handling, dementia care, infection control, continence, personal care and adult protection increasing. Speaking to staff they confirmed that they had received ‘quite a lot of training’ which had helped in improving standards of care in the home. Three staff files were checked on how staff had been recruited. They had been vetted before commencing work and for the first two weeks were supernumerary and supported by senior staff through the induction training which is good practice. Evidence of regular supervision was also seen within the records. The activities co-ordinator must be supported by the provider to carry out the role so he can meet the needs of the residents especially in arranging reminiscence activities. Oak Manor Nursing Home DS0000066644.V377086.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a home that is safe and managed by a competent manager. EVIDENCE: Inspections carried out previously showed the home had not been managed well, due to the high turnover of managers however, changes in management from May 2009 ensured improvements towards developing a home that was run in the best interests of the residents. The new manager is Anne Gregory who has management experience, has obtained the registered managers award and NVQ 4 in management and is a Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 22 qualified nurse. She is currently going through the process to become the registered manager, and is constantly supported by the operations manager. Staff said they found the manager approachable and would be happy to discuss any issues with her and felt confident their concerns would be addressed. Improvements with the induction training, regular staff supervisions, basic care training for staff, care planning and general care has improved in the past few months. Monies held in the home for residents was checked and found to be managed safely. The manager has started to implement formal quality monitoring using a format looking at all aspects of managing the home. Areas such as care planning reviews, accidents and staff supervision records were included. The manager completes audits of residents’ care plans outlining the action for the nurses to undertake to improve the written records, as stated previously there are still some gaps in the records. A formal survey had been sent to residents’ representatives and visiting professionals to obtain feedback about how the home is managed. The manager has made a very good start on monitoring the quality of the service provided to residents. One relative commented in a recent CQC survey that there was a residents/relatives meeting recently where everyone had the opportunity to state points of view. The manager advised that points raised at these meetings were being acted on. A selection of the health and safety records were checked with the maintenance staff, fire records, fire equipment, water temperatures, boiler maintenance, security, hoists and the insurance certificate. These appeared to be regularly maintained and up to date. Oak Manor Nursing Home DS0000066644.V377086.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 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 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 3 x 3 Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15.2 Requirement It is required that the care plan reviews must correspond with care need instructions. Records of food and fluid intake must be completed when a resident has a nutritional risk. Some bedrooms still require redecorating where wheelchairs have knocked against walls. It is required that all staff including the activities coordinator receives appropriate training to carry out their roles effectively. Timescale for action 17/11/09 2. 3. 4. OP7 OP19 OP30 15.2 16 18 (c) 17/11/09 17/11/09 17/11/09 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 OP12 Good Practice Recommendations Residents who are cared for in their own rooms should DS0000066644.V377086.R01.S.doc Version 5.2 Page 25 Oak Manor Nursing Home 2. 3. OP15 OP28 have some social stimulation during the day to reduce isolation. Residents would benefit from using a picture menu to assist them in their choice of meal. Care staff numbers achieving the NVQ level 2 should be increased. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Oak Manor Nursing Home DS0000066644.V377086.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!