Care Home: Oakhaven Care Home

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What the care home does well The service has developed good information about the care provided by the home. All prospective residents are appropriately assessed before they are provided with a place in the home. This helps them to ensure that they can meet each individuals needs. People are assured that their privacy and dignity will be respected. The staff are kind and helpful. The service provides a warm, homely and friendly environment. Residents and relatives were quick to praise the staff team and found them very helpful. Relatives and friends are very much encouraged to maintain relationships at all times. The home is quick to communicate any changes in residents` health to the appropriate health professionals and relatives. What has improved since the last inspection? The service user Guide and Statement of Purpose have been reviewed and now includes the necessary information to inform people about the service. Improvement has been made with involving people with their care plans and risk assessments. The majority of staff have now received training in `Safeguarding Adults.` They also have a good understanding of the procedure that should be followed if this issue is identified. The number of hours per week allocated to domestic work has been increased. More than 50% of the staff group are now trained to NVQ Level 2 or above. New employees are now recruited following a robust recruitment policy. They are now provided with a more structured induction pack. The manager has obtained the Registered managers award in care. What the care home could do better: The manager should ensure all people living in the home are provided with the Service User Guide at the point of admission. The care plans must contain more detail needed to ensure all care needs of individuals are met. They should be more person centred in their approach. This will be particularly helpful for those people with dementia living in the home. Any carer involved with the administration of medication must receive training at a level that is appropriate for that task. This will ensure the risk of harm to people in the home is minimised. Improvement is needed to show how people living in the home spend their days. This must involve recording any physical or social activities they are involved in. People who live in the home must be enabled to meet their religious and cultural needs. This will help to ensure holistic well-being. The environment of the home must be reviewed to ensure the needs of people with dementia and physical disabilities are met. A review of the staffing levels provided in the home must take place to ensure they are set correctly. This will ensure that all care needs can be met at all times.All breaches in fire regulations must be met to ensure people are protected at all times. The manager must ensure an environmental risk assessment is performed in all areas of the home. This will help minimise the risk of harm to individuals. CARE HOMES FOR OLDER PEOPLE Oakhaven Care Home 213 Oakwood Lane Oakwood Leeds West Yorkshire LS8 2PE Lead Inspector Sean Cassidy Key Unannounced Inspection 7th November 2007 09:00 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 Oakhaven Care Home DS0000066834.V354714.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. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakhaven Care Home Address 213 Oakwood Lane Oakwood Leeds West Yorkshire LS8 2PE 0113 2402894 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) Eldercare (Halifax) Ltd Mrs Barbara Ann Holdgate Care Home 24 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (24) of places Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2006 Brief Description of the Service: Oakhaven is a twenty-four bedded home for elderly people situated in the north of Leeds. The house was built in Edwardian times as a family home and still retains many of the original features. Over the years various alterations have been made to make the home more accessible. There is a tastefully built extension to the rear, offering single, ground floor, and en-suite accommodation. All other bedrooms are located on the first and second floors, the first floor being accessed via a chair lift or staircase. There is one shared room with separate lounge and bathroom where a couple may live a little more independently should they so choose. On 7/11/07 the fees charged by the home were £440 per week for all people living there Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence in this report has included: • • A review of the information held on the home’s file since the last inspection. Information obtained from service users, relatives and staff and other professionals. An unannounced visit to the home was conducted by one inspector and lasted one day. The majority of this time was spent speaking to residents, management, staff and relatives. The visit included a tour of the premises. A number of documents were examined which included care files, training files, recruitment files and health and safety details. The information required from the provider in the form of the Annual Quality Assurance Assessment was provided prior to the inspection and information from this is also included in the report. What the service does well: What has improved since the last inspection? Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 6 The service user Guide and Statement of Purpose have been reviewed and now includes the necessary information to inform people about the service. Improvement has been made with involving people with their care plans and risk assessments. The majority of staff have now received training in ‘Safeguarding Adults.’ They also have a good understanding of the procedure that should be followed if this issue is identified. The number of hours per week allocated to domestic work has been increased. More than 50 of the staff group are now trained to NVQ Level 2 or above. New employees are now recruited following a robust recruitment policy. They are now provided with a more structured induction pack. The manager has obtained the Registered managers award in care. What they could do better: The manager should ensure all people living in the home are provided with the Service User Guide at the point of admission. The care plans must contain more detail needed to ensure all care needs of individuals are met. They should be more person centred in their approach. This will be particularly helpful for those people with dementia living in the home. Any carer involved with the administration of medication must receive training at a level that is appropriate for that task. This will ensure the risk of harm to people in the home is minimised. Improvement is needed to show how people living in the home spend their days. This must involve recording any physical or social activities they are involved in. People who live in the home must be enabled to meet their religious and cultural needs. This will help to ensure holistic well-being. The environment of the home must be reviewed to ensure the needs of people with dementia and physical disabilities are met. A review of the staffing levels provided in the home must take place to ensure they are set correctly. This will ensure that all care needs can be met at all times. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 7 All breaches in fire regulations must be met to ensure people are protected at all times. The manager must ensure an environmental risk assessment is performed in all areas of the home. This will help minimise the risk of harm to individuals. 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. Oakhaven Care Home DS0000066834.V354714.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 Oakhaven Care Home DS0000066834.V354714.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): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information available helps prospective and existing residents make an informed choice about their care. Residents are assessed prior to admission so that the home can make sure they are able to meet their needs. EVIDENCE: The home has developed a new Statement of Purpose and Service User Guide that is informative and provides the reader with a clear understanding of the services that are offered within the home. Four people who live in the home were asked about these documents but they did not know what they are or whether they had been given them. The manager said that they are kept in the care files. It was recommended that people be provided with these documents so that they are kept fully informed of the services on offer. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 10 The files inspected showed evidence that people were assessed before they came to live in the home. People spoken to confirmed that this did happen before they moved in. Evidence was also obtained to show people were given the opportunity to visit and look around whenever possible. Oakhaven Care Home DS0000066834.V354714.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff work hard to ensure the health, personal and social care needs of the residents are met and maintained. Residents and relatives are confident that the home upholds their privacy and dignity. EVIDENCE: The care plan documentation of three people was closely inspected. Each plan showed that a full assessment of the individual is obtained and where a care need is identified a care plan was developed. Each person was risk assessed in a number of different areas that included nutrition, falls, pressure areas and continence. These were all reviewed monthly and changes were added when identified. This is good practice. Evidence was seen to show where people could get involved with agreeing to their care package they were. Regular letters are sent out to the relatives informing them that care plan reviews are taking place and they are invited. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 12 People said that the home was very responsive to their medical needs. “ I always see a doctor when I need to.” “They are very quick to see there is something wrong and get the doctor in straight away.” Evidence was seen to show dental treatment, optical treatment and foot care is provided regularly. One gentleman with obvious dental needs was questioned about his dental needs. He was a bit unsure as to whether he had received treatment or not. His file was looked at and there were clear records of dental treatment and the advised plan of care given by the dentist. This is good practice. One relative contacted said they were unhappy with the way in which the manager has responded to the care needs of her father. She said that his dependency needs had changed and requested that he move rooms to accommodate and support these changing needs. They were unsatisfied with the lack of action taken. The care plans used by the staff were reviewed and discussed with the manager. The manager agreed that the information contained within the care plans was often minimal and that there was an absence of a person centred care approach. The person centred care approach is very beneficial in ensuring carers are fully aware of the holistic care needs of the individual. This is particularly relevant to people with dementia. It was recommended that the care documentation be reviewed and this approach incorporated where possible. The files also showed clear evidence that people are weighed regularly. One persons weight records showed that a significant weight loss had been highlighted in the previous five months but no action was taken. It was recommended that a referral was made to a dietician for this individual. People who live in the home and relatives spoken to said that they were happy with the way the home ensured other professionals such as the optician, dentist and chiropodist were involved in their care when needed. The care records showed these visits were recorded when they took place. The medication charts kept in the home were randomly reviewed and they all appeared to be filled in correctly with no gaps shown. Documentation was seen to show staff are provided with medication training to assist them in this role. It was noted that staff working on nights are involved with administering medication but they have not received any training to assist them with this role. This is poor practice and places people living in the home at risk. The feedback from people living in the home was positive with regards to the way they were treated by the staff in the home. Comments made were, “They help me when they can. They are always very pleasant when they help me.” “They speak to me nicely which always helps.” Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 13 Carers were observed being supportive and helpful when they were involved with residents. One gentleman was observed being helped to mobilise with a Zimmer frame. He was encouraged to be as independent as possible and was given all the time that he needed. This was good practice. Four people highlighted that there were communication difficulties with the staff that worked in the home. They said that there has been an increase in the number of foreign workers in the home recently and this has posed communication problems. Although this was not evidenced at the inspection it is worth highlighting that good communication is essential in ensuring good care provision. This is an area that the management team need to be aware of for the future. It was pointed out to the manager that a clinical procedure was carried out in the lounge by a professional from outside the home. This was done in front of other residents when it should have been carried out in private. The manager agreed that this was poor practice and gave assurances that people would be seen in private in the future. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. People receive regular planned entertainment both in and outside the home. More evidence is needed to show how people spend their time on a day-to-day basis, especially those with dementia. EVIDENCE: When you walk into the home you are presented with a picture board that contains many pictures of recent events that the residents have been involved with. A new activities coordinator has been employed sixteen hours a week to devise and provide activities for residents. She has worked very hard and has been very successful with providing interesting activities in which all the residents can get involved with. Photographs were available that showed residents that preferred not to come out of their rooms were involved with the activities. Recent activities provided were, a summer party, Halloween party, bonfire party and visit to a Bradford theatre. The activities person also arranged for a ‘Zoo Lab’ to come into the home. They brought different types Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 15 of animals and residents were able to interact. There was good feedback from people about all the entertainment that has recently been provided. The activities person has plans for further entertainment including a Christmas pantomime to be presented in the home. Evidence to show local community groups are regularly invited to the entertainment was seen. More work is being developed in this area with the hope that local school children will also become regular visitors The activities coordinator recognises that she is very limited to the activities she is able to provide. The care documentation shows that when people are involved in activities this is recorded. However, long gaps were identified in between these recordings and there was no evidence available to show how each individual passes their day. Information obtained from staff, people who live in the home and relatives/ representatives provided evidence that more activity is needed on a day-to-day basis. This was further evidenced when sitting in the back dining room with a large group of residents, many with dementia. This group was left unattended for a period of half at least half an hour. The manager agreed that staff should be more actively involved in the provision of day-to-day activities but there are organisational difficulties that restrict this. This raises issues about staffing levels within the home, which are highlighted later. The organisation carried out a quality survey in April 07 that raised some negative responses. The manager will be carrying out another quality audit and hopes the responses will be more positive. People were very positive about the contacts they had with their families and friends. Visitors were seen to come in regularly through the day and those contacted said they were very happy with the open door policy of the home with regards to visiting. Two people did say they were not happy with the doorbell system for entry. They said it took along time for staff to answer the door when they called. This should be reviewed and altered if needed. Regular contact has been arranged for representatives for different religious groups to attend the home and provide services to the people who live here. There should be a greater awareness of the religious needs of those from minority religions that enter the home. One person spoken to said that no one had asked him about the possibility of meeting his religious/spiritual needs. The care plan did not show evidence that this had been explored even though he wished to explore this area. The internal quality audit sent to relatives regarding the food was overall positive. The cook works part time and only cooks the lunchtime meals. Staff prepare the tea for the residents. Feedback from residents and relatives regarding the food was mixed. Some said it was good when others thought it was not so good. Four people spoken to living in the home said they were fed Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 16 up with sandwiches for tea most nights. The food records kept in the kitchen showed sandwiches were given on most nights. This should be reviewed as part of the internal quality audit. Evidence should be provided that shows residents are involved with the menu planning. Evidence was found to show the religious needs of one resident with regards to food have not been met, even though evidence was provided to show it had been raised as a problem for that individual. This is poor practice. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The home provides clear information on how to make a complaint about the service. Staff are aware of the safeguarding policies in place and how to implement them. EVIDENCE: The complaints procedure is displayed in the home for all to view. People who live there and relatives said they were aware of how to complain and who to complain to. All were comfortable with being able to complain and were also confident that the complaint would be investigated correctly. It was recommended to the manager that she improve the recording system used for recording complaints. It was not clear from the information seen that the timescales were correctly met. It was also unclear who had made the complaints and whether they were happy with the investigation carried out by the home. The home has safeguarding adults policy in place that helps staff to be more aware of issues that are relevant to this subject. They are introduced to this topic at induction and it is included in the staff handbook. All staff spoken had a clear understanding of safeguarding issues and how to deal with an incident if it happened. The records seen showed that not all staff received appropriate adult protection training. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is homely, welcoming and clean. A review of the environment is needed to ensure it meets the needs of those people with dementia and those that have a physical disability. EVIDENCE: Certain areas of the home have been redecorated since the last inspection. Both lounges at the front of the house have been redecorated to a good standard and are well used by the people who live there. Five rooms have also been redecorated since the last inspection. A new wet room has been provided. The manager has identified all areas that are in need of redecoration and a budget is available to ensure this programme will be completed over the next financial year. All those spoken said the home was very welcoming and friendly. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 19 Five people said that the garden should be made more accessible to residents, especially during the warm weather. The manager agreed with this and said plans were in place to try and ensure this happens. A number of staff have recently undergone a distance-learning course in Dementia Awareness. Other carers are being enrolled onto this course. Some adaptations of the environment have been made since the last inspection. Toilet signs are now in place to help people with dementia identify these facilities more easily. More adaptation is needed to show evidence that the needs of people with a disability are catered for. Examples where this could be done are, the notice boards for residents are very high on the walls and difficult to read; the size of the print on menus and notices are very small and therefore difficult to read. The manager acknowledged that the environment could be more suitably adapted to assist the resident group with both physical and mental disability. People were very positive about the cleanliness of the home. Domestic staff were observed going about their duty. One was spoken to and confirmed she had the necessary training in infection control that helped her in her role. She has been provided with new equipment that helps differentiate between clean and dirty. This is an improvement from the last inspection. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Evidence was obtained to show there are concerns about the staffing levels and the ability of the staff to meet the holistic needs of the people living there. EVIDENCE: The staff were observed performing their roles over the course of the day. They were seen as very respectful when they were caring for individuals. The staff spoken to said they were very busy over the course of their shift and that they had little time to get involved with people with regards to activities due to the nature of their working day. Each member of staff was able to relate their day-to-day role that was very structured and routine. Some comments made by staff were, “We don’t have enough staff on duty. I think we manage to get all the physical work done over the day” “This is a good place to work but it is very busy. We need extra staff so that we can spend some quality time with the residents.” The staffing levels of the home were concerning to people who live there and there representatives. Some comments made were, “The staff are very hard worked and there are not enough of them.” “There aren’t enough people working here. They are always busy.” These are only examples of some of the comments received. The home has also carried out an audit of the staffing which also highlighted a number of Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 21 concerns from relatives/representatives. Some comments made to the home were, “Understaffed” “More personal contact needed” “No action taken on staffing level concerns.” “ Staff work hard but are very understaffed. Time was spent with a group of people sitting in the dining room at the back of the house. During this half hour period no of staff members appeared to either involve themselves with the group or monitor them to ensure they were ok. This was concerning as there were at least eight members of that group that showed signs of significant confusion. The recruitment process adopted by the manager was seen and the evidence showed that the manager recruits staff well. All the necessary information needed before an employee could work in the home was obtained. Staff were positive about the training provided and what was available to them. The manager provided good evidence to show staff are trained in different areas that are relevant to the care needs of the people living in the home. The training records are colour coded which help to identify when training is needed and what training a person can access. Regular appraisal and supervision is give and staff meetings also take place. Staff said that they found these helpful and informative. Visiting professionals to the home said that the staff were always polite and looked confident in their care provision. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 22 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. This judgement has been made using available evidence including a visit to this service. The people living in this home are assured that it is managed to a good standard. Although there are some health and safety issues, these are being urgently addressed. EVIDENCE: The manager has obtained the NVQ level 4 award in management and care. She has developed good management systems and processes that allow her to manage the home to a good standard. The manager has focussed on the issues highlighted at the last inspection and it is clear that there has been improvement. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 23 Good positive feedback about the way the home is managed was obtained from people who live there, their relatives, staff and visiting professionals. Regular quality assurance audits are carried out both internally and externally. Evidence was seen to show how the home obtains the views of the people living there and also their representatives. It should be made clear what the home does with this information so that evidence can be provided to show that action has been taken to improve the care provided. There was considerable feedback obtained regarding the numbers of staff on duty in the home. But there was no evidence to show what action was taken to review the staffing levels. The home manages the finances for some residents. The records were seen and were found in order. Receipts are kept for all transactions that are made. Staffs spoken to were aware of the fire procedures of the home and regular training is provided. A good manual handling awareness was also identified and training is also provided in this area. The health and safety records showed evidence that necessary checks are carried out to ensure people are safe. These included hot water checks, fire alarm checks, legionnella checks and electrical equipment checks. The environmental health department has recently visited the kitchen and awarded it four out of five possible stars for its cleanliness. The fire officer recently inspected the home and raised a few serious concerns that pose potential serious risks to the people who live there. The fire officer also identified concerns with regards to the number of staff on duty at night times. They said that they thought this was insufficient to ensure that all people living in the home would be made safe in the event of a fire occurring. The home is working closely with the fire officers to try and meet the fire regulations that are being breached at present. The fire officers are keeping the CSCI informed at all stages of this process. Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 24 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 x 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 2 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 2 Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 13(1)(b) Requirement Staff must refer people identified as having lost a significant amount of weight to the appropriate health professional. This will ensure the correct treatment is provided. The care plans must contain enough detail to ensure carers can meet the needs of the people they are providing care to. This will assist all staff with providing the correct care to individuals. All carers involved with the administration of medication must receive appropriate training. This will minimise the risk of harm. Evidence must be available to show how people have been involved in suitable activities over the course of each day. Particular attention must be given to residents who have dementia. The spiritual religious needs of people and their religious food needs must be provided for when identified. This will DS0000066834.V354714.R01.S.doc Timescale for action 31/01/08 2 OP7 15(1) 28/02/08 3 OP9 13(2) 28/02/08 4 OP12 16(2)(n) 28/02/08 5 OP15 12(4)(b) 31/12/07 Oakhaven Care Home Version 5.2 Page 26 6 OP19 12(4)(b) 7 OP27 18(1)(a) 8 OP38 13(4)(a) promote well being of the individuals. The environment of the home must be reviewed so that the needs of people with disabilities are provided for. This will ensure the home is responding to diverse needs of the people living there. The staffing levels of the home must be reviewed to ensure they are set correctly so that all the care needs of the people living there are fully met. Any breaches in fire regulations must be met. This will ensure the health and safety of all the residents living in the home. An environmental risk assessment must be carried out within the home to try and minimise potential harm to both residents and staff. 31/03/08 31/12/07 31/01/08 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 OP7 Good Practice Recommendations It is recommended that the care plans adopt a more person centred care approach so that carers have a better picture of the individual holistic needs of the people they provide care to. The manager should ensure evidence is available to show what action has been taken to deal with issues identified from the quality assurance audits that are carried out. 2 OP33 Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Oakhaven Care Home DS0000066834.V354714.R01.S.doc Version 5.2 Page 28 - 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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