Care Home: Oaklands

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What the care home does well The manager at Oaklands Rest Home makes sure that people have their needs assessed in depth before they move in. The manager makes sure that people have all their health needs met through good liaison with the health professionals in response to what people tell her and in keeping with assessed needs. People living at Oaklands enjoy their meals and the food, drinks and snacks that are offered, and are able to keep good contact with family and friends. People at Oakland`s feel that they are listened to and that staff are nice. People like living at Oaklands and commented: `I`m very pleased with this place, it has exceeded all my expectations, I wouldn`t have wished for anything better, am very pleased, satisfied and surprised by this place.` What has improved since the last inspection? Care plans and files are better organised. The prevention of pressure sores or wounds has improved and staff take action to prevent the development of these. The laundry room has been cleaned and the walls and floors are now washable. CARE HOMES FOR OLDER PEOPLE Oaklands Shaw Road Royton Oldham OL2 6DA Lead Inspector Michelle Haller Unannounced Inspection 16th June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oaklands DS0000005513.V363697.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. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaklands Address Shaw Road Royton Oldham OL2 6DA 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) 0161 627 1142 F/P 0161 627 1142 Oaklands Rest Home Limited Mrs Michelle Lorraine Shaw Care Home 18 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (10), Sensory Impairment over 65 years of age (2) Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to people of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP (maximum number of places: 10); Dementia over 65 years of age: Code DE(E) (maximum number of places: 8); Sensory Impairment over 65 years of age: SI(E) (maximum number of places: 2); Mental Disorder, excluding learning disability or dementia over 65 years of age: Code MD(E) (maximum number of places: 1). The maximum number of people who can be accommodated is: 18. 8th August 2007 Date of last inspection Brief Description of the Service: Oakland’s Rest Home is a privately owned care home with 18 registered places for people over 65 years of age and whose needs fall within the following categories: dementia; physical disability; mental disorder and old age. The building, which is a detached property, is situated on the main Shaw Road in the Royton area of Oldham. It is approximately two miles from the town centre and is in easy reach of public transport and community facilities. Accommodation comprises of three single en-suite bedrooms, three single and six double bedrooms with shared en-suite toilet facilities. Lounge/dining facilities are provided in three adjoining areas, which comprise two lounge areas and a dining area, the latter being situated to the rear of the building and next to the kitchen. The home charges £360.00 each week. The last inspection report from us was not on display. The manager was not advised that the CSCI report was to be kept on display and made readily available to prospective customers and their families. Oaklands DS0000005513.V363697.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 was a key inspection that included an unannounced visit to the service. This means the manager did not know in advance that we were coming to do an inspection. During the visit we looked around the building and talked to residents, relatives and staff, including the registered provider. We observed the interactions between people living at Oaklands Rest Home and examined care plans, files and other records concerned with the care and support provided to people in the home. We also looked at all the information that we have received or asked for since the last inspection. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. What the manager has told us about things that have happened in the home through ‘notifications.’ We also received 16 Commission for Social Care Inspection (CSCI) surveys returned to us by people using the service and other people with an interest in the service, such as staff and relatives. We have used their comments throughout this report. We have not received any complaints about the service since our last key inspection. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager needs to purchase equipment that will ensure that all medication is managed in keeping with pharmacy guidelines, so that people are protected from misuse of medication. The manager needs to introduce a programme of activities that will help to keep people motivated and interested in what is going on around them. People who were positive in all other aspects of living at Oaklands Rest Home, did say: ‘There’s nothing much to do - I can’t say anything else.’ The manager should make sure that all areas in the home are clean and that refurbishment includes replacing furniture (where necessary) in the home so that all areas of the home are pleasant to use. Oaklands DS0000005513.V363697.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. Oaklands DS0000005513.V363697.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 Oaklands DS0000005513.V363697.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 (standard 6 is not applicable.) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager ensures that people have their care needs fully assessed prior to, or soon after, becoming resident in the home so that the staff are fully aware of what needs the person has. EVIDENCE: Four assessments care plans were looked at. Each file contained an assessment that detailed the Social Services assessments that provided information about the health and psychological needs; medical diagnosis, moving and handling needs, dietary needs and self-help skills and communication. Pre-admission assessments that were dated prior to the day of admission showed that people had been visited by the manager either in hospital or their own homes prior to admission. This information included when routine health checks, such as eye test, dentist and podiatry, were last carried out. The manager made sure that, if needed, these were completed as soon after admission as possible. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 10 People described the admission process and said: ‘We chose it for the atmosphere, we visited here before – it’s nice and small. My (relative) visited for the afternoon - had tea here. They are nice.’ Everyone who returned CSCI surveys felt that the home had gathered sufficient information about them. Staff surveys also confirmed that they felt there was almost always enough information for them to provide the correct support. The assessment process would be further improved if information included an in-depth social history, life experiences and current and past interests of people receiving a service. Oaklands DS0000005513.V363697.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 health and personal care provided at Oaklands meets the needs of those living there, so that they are as healthy as possible and safe from unacceptable risk, this is done in manner that promotes dignity and shows respect. EVIDENCE: Each care file examined contained care plans that provided detailed information to staff about the actions they should carry out to meet people’s needs. When checking the instructions in the care plans with the assessment, they usually matched. Care plans instructed staff in relation to some aspects of dietary needs and preferences, moving and handling needs, as identified though risk assessment when necessary; communication, pressure area care and falls prevention. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 12 Care plan review notes were seen on each file and this provided a detailed description of people’s progress in the previous month and any changes that may be needed in their care plan. There were some instances where the care plan did not highlight some important aspects of care. This included diabetes care and specific mental health needs. Nevertheless, it was clear from other information, such as blood monitoring records, daily records, letters and other correspondence, that the support in these areas was effective. It is essential that risk assessments and information in the care plans contain all the information necessary to make staff fully aware of their responsibilities in relation to monitoring and meeting all assessed needs. Discussion with staff, however, confirmed that they fully understood the actions that were needed to support the individual needs of the people. The professional contact sheet for each person and letters, examination results and other correspondence confirmed that specialist and routine health care was provided. This included, district nurses, the falls team, speech and language therapist, psychiatrist, optician, dentist, podiatrist and general practitioners. Daily reports confirmed that instructions were followed and the general condition of people monitored and any changes were responded to. At the time of this inspection the manager stated that nobody in the home had pressure sores or wounds. Body charts and diagrams for recording the condition of the skin are in use and skin condition is assessed when people have a bath. Blemishes were recorded and steps taken to prevent further damage. Actions included moving regimes or provision of pressure relieving equipment, such as cushions. Reports and records clearly demonstrated that people are listened to in the home and that the manager will do whatever she can to support them in the choices they make. Daily reports were written in a manner that showed that people were treated with respect and supported in making choices about the care they received. The daily records also gave a picture of people’s experience of living in the home. The medication policy was read and assessed as being detailed enough to provide staff with guidance in relation to storing, administrating and recording medication. Certificates confirmed that staff responsible for administering medication had received update medication training in January 2007. The storage and recording of controlled medication was looked at. It was found that the home needs to purchase a cupboard and recording book that complies with the pharmacy legislation. This was discussed with the manager, who agreed to purchase these items as soon as possible. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 13 Staff were observed distributing medication and this was in keeping with the guidelines and service users were not put at any risk. The home has sit and weigh scales and weights are now measured accurately. Observations made during the day of inspection showed that staff were gentle and patient with people. Staff were discreet and made sure that all personal issues were dealt with in privacy. People had been supported to achieve a good level of personal care, in that, people wore clean clothes that were neat and ironed. The ladies wore tights or stockings and the gentleman wore socks. Slippers and shoes were clean. Glasses and hearing aids were worn. In response to guidance from the dental hygienist, each person has a mouth care checklist that staff sign when completed. People who returned CSCI surveys all felt that people were always provided with the health care that was needed. People were very pleased with the quality of health care at Oaklands and said: ‘If (relative) is poorly, a member of staff will phone me to let me know that they have got the doctor out, what the problem is and to let me know what medication is given’. ‘My (relative) is looked after exceptionally well, in fact in the last 21 months my (relative’s) condition has improved considerably due to the care and food she receives - … is so happy.’ A member of staff who returned a CSCI survey stated: ‘I regularly read the care plans’. People who were interviewed were also enthusiastic about the health care and said: ‘They’re nice ladies and they get the doctor if I need him.’ Oaklands DS0000005513.V363697.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 who live at Oaklands are encouraged and assisted to make choices about their life and experience in the home and food and meal times are a highlight of the day. EVIDENCE: Discussion with people living at Oaklands and information in records and provided in the CSCI surveys indicates that activities have diminished further since the previous inspection. There was very little record of activities, although people living at the home did speak of a game of bingo occurring recently. An activities calendar is no longer available. Each person spoken to said that no activities took place and the manager could not demonstrate otherwise. Comments included: They had a game of bingo - I’ve never played it before it’s not for me I need something more intelligent’ and ‘All I do is sit, sit, sit, sit!’ Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 15 ‘I like it here - it’s nice and comfortable - but there’s nothing to do - I can’t say anything else really.’ The manager, staff and relatives did say that staff came and took people out individually but this was not evidenced and did not make an impression on the people living in the home that commented. The lack of regular meaningful activities is of concern and was discussed at length with the manager, who agreed that remedying this problem would now become a priority. She also said that the home had organised a fund raising activity and that parties to commemorate birthdays and special festivals had occurred. An improvement in activities will be assisted if the manager makes sure that staff find out about people’s individual social histories, interests and wishes. Possible sources for training and additional information were also discussed. During the day of inspection it was noted that in one room the television was on a children’s channel for most of the day, the other was on a chat show and in the dining area music was played and people did sing along to this. Staff did sit and speak to people and were ready to provide drinks and snacks as requested. At present, people are not able to practice religious observance, as there has been a change of Vicar at the Parish Church. The manager said that she has approached the local Catholic Church without success. People said that an improvement would be ‘I feel that there could be more activities taking place, bingo, sing-alongs, etc., to enable people to keep their minds active.’ During the day of the inspection it was noted that people got on well with each other and staff. Staff who were interviewed indicated that routines in the home are flexible, with no set times concerning going to bed or getting up, receiving visitors and people could delay when they had their meals to suit their preference. The outcomes in this area could be improved if people were supported in recording their comprehensive social histories and current and past interests. Visitors were seen coming and going throughout the inspection period. People commented: ‘yes I have visitors … they can come when they like.’ People who returned surveys confirmed that they were helped to keep in contact with their friend or relative. One person wrote: ‘Any time (relative) needs to speak with me other than at visit, a member of staff will take (relative) to the phone, dial my number and let … speak to me in private.’ Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 16 Meals and mealtimes in the home remain good. The dining room is clean and furniture is clean and pleasant to use. The menus indicated that people are offered a variety of home prepared and ready made meals that they enjoy. On the day of inspection the menu for the breakfast included, porridge, eggs, cereal, fruit, jams and marmalade and toast; lunch was home made steak and kidney pie or egg and chips, followed by rhubarb and apple crumble. People were observed enjoying their meals and everyone commented that the food was plentiful and tasty. People were provided with equipment to maximise their independence and staff provided assistance in a dignified manner. The constancy of the meals were in keeping with what was required in the people’s care plans. The consistency of drinks for one person was discussed with the manager and she agreed to discuss this with the speech and language therapist, so that staff would be clear about what to do if the person refused thickened drinks. The record of blood sugars for people who were diabetic indicated that the medication and food provided kept them relatively stable. The larder and freezer were not examined on this occasion, as at previous inspections they have always been found to be well stocked with a varied selection of quality brand frozen foods that included vegetables, white and brown bread, pies and burgers and frozen joints of meat. Food and drink intake records were in place for the frailest person. People were observed to be supported to eat their meals in a dignified manner. Special utensils, such as adapted cups, bowls and spoons, were offered so that people could maintain their independence. During lunch staff also refilled drinks, such as tea, coffee or juice, as required. People were very complimentary about the meals and diet provided at Oaklands. They said ‘we get good food.’ ‘I am quite satisfied with the food, I’ve not come across anything I don’t like - they came and asked me if I liked kippers the other morning and I said no, so I chose bacon instead’ and ‘My … says he’s tried things he’s not eaten before since living here and that’s good.’ Oaklands DS0000005513.V363697.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. People feel safe to complain and arrangements are in place to ensure that people are protected from abuse. EVIDENCE: All the people who returned CSCI surveys confirmed that they knew how to complain and that they always felt listened to. People who were interviewed were confident that if they had any concerns, they could speak to the manager or any member of staff. They said: ‘The family feel listened to when we get anxious.’ We found there was a copy of the complaints procedure, signed as having been received, in people’s care files. The manager said that they had not received any complaints in the past year. No protection of vulnerable adults investigations have been undertaken in the home. The adult protection policy was examined and found to be in keeping with the guidelines provided by the local authority. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 18 The staff-training calendar confirmed that 12 members of staff have completed adult protection training. The manager stated that she is waiting for more places on the Protection of Vulnerable adults (POVA) training provided by Oldham Metropolitan Borough Council training unit. Two members of staff were interviewed - one said she had received POVA training and was very clear about the action she would take, the other person said she was due to commence the training, and said if she would always speak to senior staff. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence, including a visit to this service. People living at the home have a spacious and adapted environment suitable to their needs. EVIDENCE: The extension to the home and the refurbishment of the home has still not been completed. It is unfortunate that this work has continued since August 2007. The manager stated that she expects this work to continue for another six months. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 20 On the day of inspection some parts of the home were dirty and the middle lounge carpet was heavily stained and dirty. This was discussed with the manager who arranged for the area to be cleaned. It is important that a cleaning programme is put in place that makes sure that all areas of the home remain clean. Bedrooms that were seen had been personalised and people had brought in items from home. People were observed mobilising around the home independently. Everyone who returned surveys felt that the home was clean and fresh. Comments about the environment included: ‘It’s comfortable here.’ Relatives did also say ‘the home could do with decorating.’ The manager said that redecoration was part of the ongoing refurbishment process. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager promotes health and well being of people by ensuring that there are sufficient staff on duty, with the appropriate experience and attitude to meet the assessed needs. EVIDENCE: On the day of inspection the staffing included the manager, one senior care assistant, two care assistants, one domestic staff and the cook. There were 13 people living at Oaklands. Certificates and the training matrix confirmed that during the year staff have been encouraged to complete relevant training courses including: moving and handling, health and safety, medication administration, infection control, first aid, dementia awareness and fire safety. The manager continues to develop a training calendar that runs in conjunction with the training offered by Oldham Social Services. The training record that were seen confirmed that staff had received training and there were letters on file confirming the number of places offered for OMBC training; included the Core Skills Induction programme recommended by the Skills For Care organisation. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 22 Each staff file that was examined contained a copy of the application form, two references and a copy of the Criminal Record Bureau check. These were in order. Staff all felt that they received training that was relevant to their role and that prepared them for the work they had to do. They also felt that they were kept up to date with new ways of working. Those who returned surveys all felt that the staff were available in sufficient numbers to care for people in the home. They also felt that staff had the correct skills to provide this care to a good standard.’ Observation of staff interaction showed that staff were caring towards people and listened to what they said. People using the service were complimentary about the skills and conduct of the staff they said: ‘The carers and all staff at Oaklands not only provide care and comfort, they provide love and understanding, I cannot recommend them high enough.’ Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 23 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 manager runs the home in a manner that is safe and for the benefit of people using the service. EVIDENCE: The manager has written in the Annual Quality Assessment Audit that she has completed the Registered Manager’s award. Discussion with the manager confirmed that she was open about ideas in how to improve the service. The manager needs to be able to reflect this attitude in the information she provides in the AQAA. This is because, in a number of areas, she felt that no improvements were needed. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 24 The manager has commenced a quality monitoring system and one questionnaire had been returned at the time of the inspection, this questionnaire requests comments about the general atmosphere in the home, quality of care, the attitude of staff, and whether people found anything ‘offensive’ about the home, as well as their overall impression. The financial transactions and records for three people were examined and no concerns were noted. The manager confirmed in the information returned to CSCI that all services had been maintained and serviced in accordance with manufacturers’ instructions. The portable hoist was last serviced in March 2008. Fire safety equipment had been serviced in August 2007 and the fire records indicated that the manager undertook weekly fire checks. The safety officer inspected the home in February 2008 and no outstanding issues were identified. Certificates confirmed that staff have received health and safety training, appointed first training, infection control and control of substances hazardous to health (coshh) training. The accident records were examined and those logged were discussed and had been dealt with in keeping with prevention of accident guidelines. The manager has started to analyse accidents and incidents so that any patterns can be identified and steps taken to reduce accidents, where possible. Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 25 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 3 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 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP9 OP12 OP19 Good Practice Recommendations The manager should make sure that all medication is stored and recorded in keeping with pharmacy guidelines. People should be consulted on the types of activities they would like to see take place in the home so that they feel more occupied. The provider should extend the refurbishment of the home beyond replacing carpets and decorating bedrooms, to the replacement of stained bed bases and bed heads. This will further enhance the environment for the people living at the home. The manager needs to have a plan in place regarding the building works, which shows that she has considered the disruption that may be caused, and how she is going to address this for the people living at the home. 4 OP19 Oaklands DS0000005513.V363697.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Oaklands DS0000005513.V363697.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. 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