Care Home: Oaklands

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What the care home does well The transitional beds provide people with a good alternative to remaining in hospital for long periods, allowing a period of time to regain self-care skills before returning home. The Manager of the home leads by example and imparts her high standards of care to the staff team. Staff know what they are doing and have the confidence to discuss their practice. During discussions, they demonstrated an excellent level of understanding about standards of care and how they are continually striving to improve on what they already do. Staff have very good levels of training. Care is very person-centred and the staff work flexibly to accommodate peoples` individual needs and wishes. The activities and leisure pursuits on offer are varied and interesting and there is still the flexibility to fit in with what individuals prefer to do themselves. People enjoy the meals, which are all freshly cooked, with home baking a popular feature. The accommodation is of an excellent standard, with very good attention to hygiene and cleanliness, without detracting from the homely and comfortable environment. Comments from people in the home included: "I am satisfied with Oaklands and have enjoyed my stay here," and: "Even though I can`t remember how I came to move in here, I`m happy being here and happy with the people who work and live here." What has improved since the last inspection? The owners are continually looking to improve on the facilities and services provided. This year the main sitting-room has been re-furbished and this room, the hall and main staircase has been re-carpeted. The installation of new assisted bathing facilities has meant that people have re-gained some independence. Policies are being re-written and linked to the National Minimum Standards for Care Homes for Older People, which is improving staff knowledge. What the care home could do better: There are sometimes difficulties in managing the behaviour of people with dementia. When incidents arise, they should be reported to CSCI as safeguarding issues, in the same way that accidents and other untoward events are reported. The older part of the building has some bedroom doors that are not connected to the automatic fire alarm system. If these doors are wedged open due to the absence of magnetic hold-back devices, they could present a risk if a fire occurred. The Manager must look at alternative, safer, methods of keeping these doors open if people in those rooms request it. Better recording of which staff have had fire practice, and when, would provide the Manager with up to date and accurate records. CARE HOMES FOR OLDER PEOPLE Oaklands 14 Pinfold Lane Methley Leeds West Yorkshire LS26 9AB Lead Inspector Stevie Allerton Key Unannounced Inspection 5th February 2009 12:00 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 Oaklands DS0000001487.V374143.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 DS0000001487.V374143.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaklands Address 14 Pinfold Lane Methley Leeds West Yorkshire LS26 9AB 01977 515451 01977 667644 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) Oaklands Residential Home Limited Mrs Kathleen Foley Care Home 21 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (21) of places Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd March 2007 Brief Description of the Service: Oaklands Residential Home provides care for 21 older people, with up to 4 people with Dementia. The day-to-day care is supervised by the owner/manager, who is a registered nurse; however, the home provides personal care only and is not able to care for people with long term nursing needs. The home has a contract with the local authority to provide 2 transitional care beds, for people leaving hospital that are not yet ready to return home. The older part of the house has been extended in recent years and provides 21 single bedrooms, all of which have en-suite facilities. The house stands in private landscaped gardens and is situated close to the local amenities in the village of Methley, part way between Leeds and Castleford; many of the people who live there, and their families, are from the local area, hence the home has a lot of visitors on a daily basis. Current fees are £417.00 - £455.00 per week. Oaklands DS0000001487.V374143.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 3 star. This means the people who use this service experience excellent quality outcomes. This inspection was carried out without prior notification and was conducted by one inspector over the course of an afternoon, starting at 12:00 noon and finishing at 6:30pm. The Registered Manager was not present at this visit; the Deputy Manager and other staff team members assisted throughout the inspection. Survey forms were sent out to a sample of people prior to the visit and six were returned, one from a Health Care Professional and five from people living at the home. Before the visit, information about the home since the last inspection was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI. This information was used to plan this inspection visit. We case tracked four people living at the home, either on a Transitional Care basis or a permanent residency. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of people and staff were considered. Using this method, we assessed all twenty-two key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. We spent time with people at the home and spoke to relevant members of the staff team who provide support to them. Records and policies were looked at and a brief tour of the building was carried out. We would like to thank everyone who took the time to talk and express their views. What the service does well: The transitional beds provide people with a good alternative to remaining in hospital for long periods, allowing a period of time to regain self-care skills before returning home. The Manager of the home leads by example and imparts her high standards of care to the staff team. Staff know what they are doing and have the confidence to discuss their practice. During discussions, they demonstrated an Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 6 excellent level of understanding about standards of care and how they are continually striving to improve on what they already do. Staff have very good levels of training. Care is very person-centred and the staff work flexibly to accommodate peoples individual needs and wishes. The activities and leisure pursuits on offer are varied and interesting and there is still the flexibility to fit in with what individuals prefer to do themselves. People enjoy the meals, which are all freshly cooked, with home baking a popular feature. The accommodation is of an excellent standard, with very good attention to hygiene and cleanliness, without detracting from the homely and comfortable environment. Comments from people in the home included: I am satisfied with Oaklands and have enjoyed my stay here, and: Even though I cant remember how I came to move in here, Im happy being here and happy with the people who work and live here. What has improved since the last inspection? What they could do better: There are sometimes difficulties in managing the behaviour of people with dementia. When incidents arise, they should be reported to CSCI as safeguarding issues, in the same way that accidents and other untoward events are reported. The older part of the building has some bedroom doors that are not connected to the automatic fire alarm system. If these doors are wedged open due to the absence of magnetic hold-back devices, they could present a risk if a fire occurred. The Manager must look at alternative, safer, methods of keeping these doors open if people in those rooms request it. Better recording of which staff have had fire practice, and when, would provide the Manager with up to date and accurate records. Oaklands DS0000001487.V374143.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 DS0000001487.V374143.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 DS0000001487.V374143.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, 5 & 6 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. No-one moves into the home without being properly assessed and being assured that their needs can be met. People have the opportunity to visit and see if the home will be suitable for their needs. The transitional beds provide people with a good alternative to remaining in hospital for long periods, allowing a period of time to regain self-care skills before returning home. EVIDENCE: A person recently admitted was selected for case-tracking. There was evidence in their care notes that they came for a day initially, from hospital, with their comment that they wouldnt be staying if they didnt like it. They did like it and had been at the home for 5 days. Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 10 Another persons care records showed that their Social Worker had been involved in a meeting to discuss whether they would like to stay or return home.(They had initially been admitted for Transitional Care). Everyone has a full care needs assessment and a care plan is drawn up from that. The person recently admitted had the beginnings of their care plan in place, around personal care & mobility. There was also a risk assessment in place for manual handling. The home has 2 Transitional Care beds, which are accommodated amongst the mainstream services at the home. The care plans detail how independence is being encouraged by the staff, promoting mobility, continence and self-care, so that they can return home after a few weeks. Comments from people in the home included: I am satisfied with Oaklands and have enjoyed my stay here, and: Even though I cant remember how I came to move in here, Im happy being here and happy with the people who work and live here. Oaklands DS0000001487.V374143.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 & 10 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Peoples personal and health care needs are met to a good standard. Medication is managed correctly, by staff that have been trained, which ensures that people get the treatment they need at the right time. EVIDENCE: Four people were case-tracked, their care plans looked at in depth and followed up by observation of their care, speaking to them and/or the staff looking after them. The start of the care planning process was seen for a person newly admitted, with assessments & corresponding plans for personal care. These written instructions for staff included encouragement for the person to increase selfcare skills, look after their own dentures, etc., and mobility (when staff should use the wheelchair & when the person should practice walking). No other care plan areas were identified yet. A risk assessment was in place for manual handling. Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 12 Another person had been admitted initially on Transitional Care, but remained as a permanent resident. A long-term needs assessment and associated care plans were in place. There was a named key worker. The care plans initially reflected the person being encouraged in the skills they would need to return home, including managing stairs. However, they had a fall on the stairs and were admitted to hospital via Accident & Emergency (the accident records were checked, all recorded correctly). The risk assessment for using the stairs was re-done the following day, identifying the risk as too great. One person who was case-tracked was currently having investigations into a physical problem. There was evidence of lots of communication with and referrals to appropriate health professionals, eg, Speech & Language Therapist, Physiotherapist & Occupational Therapist. This person was spoken to and confirmed the levels of support they felt they needed and said that these were being met. Staff are supporting them through a lot of hospital appointments for tests, etc. One mans care plan states that he prefers a male carer or an experienced female for personal care and bathing. A male key worker was named on the plan. This person expressed strong views about how he wishes to be cared for and felt the staff were very flexible and good at what they do. Peoples personal care plans were good, referring to Self-care Abilities and Self-Care Limitations. Moving & Handling aids are in use where needed, including: handling belt, turntable, recliner chair and hoist, as are pressurerelieving mattresses and cushions. There was good attention to privacy, dignity and the encouragement of independence seen in the care plans. The installation of new assisted bathing facilities has meant that people have regained some independence. There was evidence in care plans that, where peoples desire to be self-caring extends to washing their own underwear in their room, this was respected by the staff. Some people handle all their own finances and administer their own eye drops. Where able to, people have signed their own care plans. Comments from surveys of people living at the home included: I sometimes wonder where the staff are – its difficult if theyre doing other jobs at the time. From a district nurse: They are always considerate towards clients. The staff are respectful, and helpful when staff from the community team visit. Regarding clients hygiene needs, standards are high. From a relative: The care my mother receives is well suited to her needs. We observed the Senior Care giving out lunchtime medication in the dining room. She was knowledgeable about what she was doing and confident about explaining the procedures. She was very organised and methodical about administering and recording what had been given. A pre-dispensed system Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 13 supplied by the local pharmacist is in use, which she said works well. We discussed the difficulties presented when Transitional Care clients come from hospital with a bag full of medication in boxes. Home remedies that people prefer to use are noted on individuals care plans, eg, one person likes a particular homoeopathic cream on their knees. There is a specific fridge for medicines, the temperature of which is recorded every night. The medication records and the procedures seen did not highlight any issues for concern. Oaklands DS0000001487.V374143.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 & 15 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People have the choice of whether or not they wish to take part in the range of activities on offer. These activities are varied, fulfilling and interesting. People are provided with good food, which they enjoy. EVIDENCE: Care plans identify the interests and activities that people have expressed a wish to continue or take part in, including contact with visitors. The care plan for one of the people who was selected for case-tracking concurred with what this gentleman told us about his interests: he likes watching horse racing and having a bet. He gets a daily newspaper and likes doing the National Lottery. A male carer takes him to the pub and out to the shops & betting office, but he would like to be able to do this more often (every day). One ladys care plan notes that she does not like to join in activities or entertainment. She prefers one to one time and really enjoys the Reiki/Massage Therapists visits. Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 15 The activities programme for February was on display, both in the communal areas and in peoples bedrooms. It showed an activity happening every weekday. Staff are designated to lead particular activities, so that all staff are involved. An outside entertainer is a regular fixture. Quiz sheets had been handed out before lunch on the day of the site visit – a nostalgia quiz. They were collected in and marked after lunch, the winner getting 9/10 answers correct. The Deputy Manager said she had some more resources on the computer ready to be printed off and laminated and put into use. Most of the staff live in the local area and have contacts with the Community Centre, library, pubs, etc., so people are invited to any local events that are put on. The menus showed a good range of food, which is all home-cooked. The lunchtime meal was stew & dumplings, which looked and smelt very appetising. People said they enjoyed the meals, many of them saying they had put weight on since coming to live at the home. Care plans show that people are able to take meals in their bedrooms, according to their preference. Comments on surveys: There are not enough amenities (shopping) in the area. It depends on what activities are happening as to whether I join in or not. Food is freshly cooked. Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 16 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 & 18 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. There are good policies and procedures in place that protect people from possible abuse. However, the service could make better use of the Local Authoritys safeguarding procedure, in order to manage violent behaviour. People are confident about raising concerns or making a complaint and feel they will be listened to EVIDENCE: We looked at staff training on the Protection of Vulnerable Adults (POVA). Two of the staff are accredited trainers who cascade training to the rest of the staff team. At the time of the site visit nearly all of the staff had received this training, and the remainder were booked to complete it in February. One of the people who was case tracked was asked if he knew how to make a complaint and he said that he would go directly to the Manager. Complaints records were looked at and showed issues recorded and resolved, eg, clothing going missing or dentures not being cleaned properly. A comment from the survey forms said: I know how to make a complaint as there is a notice on the wall in my bedroom. An issue was noted when looking at the accident book, regarding some incidents of a resident with dementia becoming aggressive and violent on Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 17 occasion, striking other residents as well as staff. The Deputy was advised that these incidents should be reported to CSCI as a Regulation 37 notification, and referred to the Local Authoritys Safeguarding Adults Unit, in order to protect the people being hit and increase the opportunity for the person to be re-assessed for a more suitable placement. Oaklands DS0000001487.V374143.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, 21, 22 & 26 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People live in a comfortable and homely environment, with the equipment they need to maximise their independence. The high standards of cleanliness ensure that people live in a pleasant and hygienic home. General fire safety is maintained, but could be improved in one area of the building, to ensure that people are better protected from the risk of fire. EVIDENCE: A new flat screen TV has been provided for the main sitting room, and a new computer is on order with a large keyboard, for ease of use by people with diminished manual dexterity. The hall & stairs have been recarpeted recently, and the main sitting room has been refurbished. The biggest change has been the refurbishment of the bathrooms and shower room and the installation of new baths and equipment to aid independence, Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 19 such as a battery operated shower chair. Risk assessments showed which people could be left to bathe themselves in privacy once the staff had helped them into the new baths. The sitting and dining areas are well-furnished, comfortable and decorated to a good standard. The floorcovering in the dining room is showing signs of damage, but does not constitute a trip hazard. An excellent level of cleanliness was seen throughout the home. All bedrooms have en-suite facilities. The garden continues to provide interesting and pleasant surroundings. A comment from the surveys said: The sitting rooms are always clean & welcoming. Fire extinguishers showed that they had been serviced the previous month. Three bedrooms in the older part of the building had wedges in their doors to hold them open, as they are not connected to the magnetic system like the rest of the home. In the event of a fire, these wedged doors would not close and could place people at risk. If doors need to be held open, a Dorguard or similar device should be used. This was explained to the Deputy at the time of inspection. Oaklands DS0000001487.V374143.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 & 30 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People are looked after by a staff team that are well trained, which enables them to provide high standards of care. People are protected by the recruitment processes in place. EVIDENCE: We spoke to staff about their training towards National Vocational Qualifications (NVQs). 60 of care team are now qualified to NVQ level 2 or above, the 2 seniors spoken to have already got level 3 and the remaining seniors are working towards level 3. Training in Dementia Care, Infection Control & Medication has also been undertaken recently. The Manager is looking to get some training for staff about long-term conditions, such as Stroke, Diabetes & Parkinsons Disease. A notice was up advertising forthcoming training sessions in April, including Palliative Care. In discussion with the staff they demonstrated an excellent level of understanding about standards of care and how they are continually striving to improve on what they already do. They were very enthusiastic about the training they receive and said that they enjoyed it. Induction training is now provided externally, with moving & handling training being provided in-house by the manager, who is an accredited trainer. New Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 21 carers are assigned a mentor, who ensures that their external and in-house induction is translated into practice. The staff records for a fairly recent recruit were looked at, along with 4 other staff members. The new worker had been assigned a named mentor and was shadowing the seniors for one month. Their first appraisal was coming up. The staff member had completed their part of the appraisal form and the Deputy (the mentor) would arrange to see them individually to discuss their performance. They had already started doing NVQ level 2. Staff records showed that robust recruitment procedures were in operation. Each file seen contained a completed application form, 2 written references, evidence of identity checks and permission to work in Great Britain, Criminal Records Bureau and associated checks, and their training record. Staff rotas show sufficient numbers, with a good skill mix, across the shifts. On the day of inspection, apart from the Deputy in charge, the morning shift had been led by a Senior with 2 care assistants, and the afternoon was led by a Senior with 1 care assistant and 1 person doing domestic and care tasks. There was also a cook on duty. District Nurses comments from the surveys: As a community team we have a good relationship with all the carers. Peoples comments about the staff caring for them: Very good, theyre caring and friendly, The staff are excellent and always try their best for you, Brilliant staff. Relatives comments: The home is always well staffed and the manager is very helpful and approachable. Oaklands DS0000001487.V374143.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, 36, 37 & 38 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The service is managed well and runs in the best interests of the people who live there. The policies, procedures and record-keeping in place protect peoples rights and best interests. People are involved in and consulted about the home they live in. EVIDENCE: The home continues to be managed on a daily basis by the owner, Kate Foley. She was away at the time of the site visit, and the home was being managed in her absence by Dawn Jacques, the Deputy, who has worked at the home for 19 years. Mr Foley (joint Registered Provider) came in during the visit in case we required access to documents not readily avaialble to staff. He provided the information on fees on request. Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 23 We looked at the policy file, which is in the process of being updated. New policies are being cross-referenced to the appropriate National Minimum Standards, good practice. We sampled regulatory and operational records, including: care plans, accident records, medication records, complaints records, fire safety records, staff personnel & training records, staff rotas, policies & procedures. All were readily accessible and up to date, with one exception: it was noticed that, although the fire safety book showed that the alarm system was tested weekly, there was no record of how often staff had fire practices. The arrangements for storing and recording peoples finances held for safekeeping have not changed and continue to meet the standards. The homes own Client Surveys had been distributed the week prior to the site visit. These are done annually, to check quality. People spoken to felt that they had a say in how their home runs and find the owner and the staff approachable. They expressed confidence in the Manager and her Deputy in particular. Staff supervision takes the form of an annual appraisal, small group supervision sessions to talk about care planning issues, and individual supervision to discuss work performance. Oaklands DS0000001487.V374143.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 X X 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 4 X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 4 2 Oaklands DS0000001487.V374143.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 OP19 Regulation 13(4)(c) Requirement The use of wedges to hold doors open must not continue. If doors need to be held open , they should be fitted with an automatic closing device. This is so that people are protected in the event of fire. All staff must receive suitable training in fire prevention at regular intervals and these drills/practices must be recorded. This is so that there is an up to date record showing that all staff know what action to take, day or night, in the event of fire. Timescale for action 01/06/09 2 OP38 23(4)(d) 01/06/09 Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 26 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 OP18 Good Practice Recommendations The home should notify CSCI of all untoward incidents that occur to people living in the home, including incidents of physical aggression between them, and consider whether safeguarding procedures should be implemented. Oaklands DS0000001487.V374143.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000001487.V374143.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. 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. 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