Care Home: Omega Oak Barn

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What has improved since the last inspection? Staff now receive regular formal supervision which gives them the opportunity to have their work discussed and any concerns looked into. All people who live at the home now have information about fees and terms and conditions of occupancy, so that they are informed about the terms of their stay. Any mistakes in medication records are left showing against subsequent correction, which leaves evidence if issues need to be followed up. All incidents and accidents are now reported to CQC according to regulation. All care plans are now reviewed regularly, to make sure staff understand people`s changing needs. What the care home could do better: The manager has only been in post a short time and her appointment shortly followed the opening of an extended wing specialising in the care of people with a dementia. The manager needs to access specialist training in dementia care to give a strong lead to staff. All staff who work with people who have a dementia, but do not yet have dementia training must gain this as soon as possible, to protect the people at the home with this specialist need. Medication recording errors must cease and staff must have refresher training so that they are aware of the correct procedure for recording medication, to make sure people are protected from administration errors. Care plans shouldOmega Oak BarnDS0000066075.V375575.R01.S.doc Version 5.2 Page 8contain more information about the social and recreational needs of people at the home to make sure these needs can be met. Key inspection report CARE HOMES FOR OLDER PEOPLE Omega Oak Barn High Lane Beadlam York North Yorkshire YO62 7SY Lead Inspector Karen Ritson Key Unannounced Inspection 26th May 2009 9:30 DS0000066075.V375575.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Omega Oak Barn Address High Lane Beadlam York North Yorkshire YO62 7SY 01439 771254 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) omega.oakbarn@btinternet.com Mr Timothy John Bower Mrs Susan Katharine Bower Manager post vacant Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (28) of places Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of srvice only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following catories: Old age, not falling within any other category - Code OP, maximum number of places, 28 Dementia - Code DE, maximum number of places, 28 The maximum number of service users who can be accommodated is 28 31st May 2007 2. Date of last inspection Brief Description of the Service: Omega Oak Barn is registered to provide residential accommodation and care to 28 older people, some of who may have a dementia. It is owned by Mr and Mrs Bower and managed by Mrs Corinne Jeffs, who has been in post for a short time. Omega Oak Barn is in part adapted building with a new single storey purposebuilt extension, (Acorns) that provides care to those people who have a dementia. The original building, (Oaks) provides care to people whose main need is physical care. The home has gardens to all sides. The main entrance doors give level access. The home is situated in the village of Beadlam. Public transport passes the end of the lane and gives access to the nearby towns of Helmsley, Kirkbymoorside and Pickering. Part of the original building is on two levels but with all bedrooms, communal areas and services on the ground floor. The upper floor provides office and staff accommodation. A number of bedrooms have en-suite facilities. Sufficient communal facilities are available. Information about the service offered is in the format of a Service User Guide that is made available to people in the home. A copy of this report will be included when published. These documents are kept in communal areas of the home. The fee level advised on 26th May 2009 was from £395 to £475 per week depending on assessed needs. The fee does not cover private items, Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 5 hairdressing, chiropody, or any external activities. Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection for this service took twelve hours. This includes time spent gathering information, examining documentation before and after a site visit. It also includes the time taken to write the report. The site visit took place on 26th May 2009 between 9:30 and 15:30. Information for this inspection was gathered from the following: 1. A visit to the home. 2. Speaking with people living at the home. 3. Speaking with staff. 4. Case tracking three people on the day of the site visit. 5. Reading survey forms from people living at the home and staff. 6. Looking at information provided by the manager prior to the site visit. 7. Notifications sent to the commission from the home since the last inspection. 8. Examining policies, procedures and records kept at the home. 9. Examining information regarding the home on the file kept by CQC. All key standards were looked at during this inspection. The manager was available throughout the day of the site visit. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations -but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: The home provides a pleasant, well maintained environment for people. People receive a good assessment of their needs and the manager writes down what is required in a plan of care for staff to follow. This plan is kept up to date and is reviewed with advice from health care professionals. People are well treated and their privacy and dignity is respected. Visitors are welcome. People have a Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 7 good, varied and nourishing diet. One person said: ‘The food is always good.’ Staff have training in abuse awareness and people are kept as safe as possible from risks to their wellbeing. Complaints are listened to and acted on. One person said: ‘The staff always have time to have a chat and listen if I have any grumbles.’ The home is well maintained and decorated and there are plans to complete gardens and outdoor areas. There are enough staff on duty to meet the needs for people living at the home. Staff are well trained and recruited. Corinne Jeffs, the manager, has been recently recruited. She has worked well to improve the quality of care in the time she has been in post. People are protected by the health and safety procedure in the home. What has improved since the last inspection? What they could do better: The manager has only been in post a short time and her appointment shortly followed the opening of an extended wing specialising in the care of people with a dementia. The manager needs to access specialist training in dementia care to give a strong lead to staff. All staff who work with people who have a dementia, but do not yet have dementia training must gain this as soon as possible, to protect the people at the home with this specialist need. Medication recording errors must cease and staff must have refresher training so that they are aware of the correct procedure for recording medication, to make sure people are protected from administration errors. Care plans should Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 8 contain more information about the social and recreational needs of people at the home to make sure these needs can be met. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 9 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 Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs well assessed, so that staff know what care is required. EVIDENCE: The manager has recently taken up post and most assessments were carried out before she was employed. Previous assessments give sufficient information to ensure staff understand the needs of people living at the home. The new assessments carried out by the manager cover all areas of care in detail. This includes a life history so that staff can begin to understand the person and Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 11 their interests. A photograph of each person will be kept on file, (one finished file was seen), and there is an admission sheet, which lists information such as GP and next of kin. This is useful, easily accessible information for staff to use. The assessment includes all areas of physical, social and recreational needs. All risks are assessed and these are specific to the individual. The emphasis for each assessment is upon retaining as much independence as possible. This ensures people’s individual needs are well assessed, and that there is detailed information for developing a care plan. The home does not offer intermediate care. Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have most of their care needs met. However, medication handling does not fully protect the people living at the home. People are treated with regard to their privacy and dignity. EVIDENCE: A care plan is drawn up, which gives detailed instructions on how to offer the correct care for each person. The emphasis in each case is upon capacity and includes an up to date record of all medication and includes such areas as mental capacity, weight, pressure areas, continence and nutrition as routine. Risk assessments are included in all areas which give concern, to ensure Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 13 people can carry out their daily routines whilst being protected from harm. Daily notes give useful and relevant information about each person and this information is passed across at each new shift. Each care plan is regularly reviewed with involvement from the person living at the home and health care professionals where necessary. This ensures that staff are given information about each person’s changing care needs and know what care is needed. The review notes should show how the care plan is to be changed as a result of new information. Each care plan includes advice from health care professionals where necessary and a separate record of health care professional visits gives clear information about each person’s health and how this is being monitored. At the last inspection there were some gaps in recording medication. It was unclear whether medication had been given or refused in these instances. In one section of the home, (Oaks) medication is kept locked in each individual room, in the other, (Acorns) the medication is kept centrally. For this reason it has been impractical to adopt a MDS type system, although the manager has plans to introduce this central storage for all medicines. Medication is kept in packets and recorded on the home’s own recording sheet, which is similar to a Medical Administration Record (MAR). The same codes are used as on MAR sheets, which make it easy to understand. Although there is a coding system in place and staff usually adhere to this, staff left a blank on two occasions in recent records, which could place people at risk of not getting the medication they need or getting the wrong medication. Staff have had training in the safe handling of medication, however, they must have an updated briefing on the importance of not leaving gaps in records to ensure medicines are handled safely at all times and that people get the medication they have been prescribed. Throughout the day of the site visit, the staff were observed treating people with care and courtesy. The home has a policy and procedure on privacy and dignity which staff cover in their induction. People said they liked the staff and it was clear from observing interactions between staff and people living at the home that there was a friendly and open atmosphere. One person said: ‘The staff are all lovely I can’t fault any of them. They are very kind.’ Omega Oak Barn DS0000066075.V375575.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people do not have their social and recreational needs fully met. Visitors are made welcome. People receive a varied diet they enjoy. EVIDENCE: The care plans contained some detail about people’s social and recreational needs, but in some cases this was not sufficiently developed. Details of people’s interests, and activities which would help to stimulate them and offer them a challenge were sometimes missing. The manager has plans to rewrite all care plans and assessments to include these areas. People have the opportunity to become involved in activities such as dominoes, bingo, pamper sessions, quoits, quizzes, card making, china painting, bird watching, Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 15 patchwork quilting and film afternoons. One person is receiving physiotherapy exercises. Another person visits a club twice a week. This means that people’s recreational needs are taken into consideration. However, the manager is planning more activities which are person centred and has employed an activities coordinator four afternoons a week to help achieve this. People have been consulted about trips they might like to go on and these are being organised for the coming months. The manager organises open days where friends and relatives of people living at the home are invited for a buffet lunch or a barbeque. This means people and their families are made to feel a part of the home and that the home is welcoming to them. The home has a visiting policy and procedure. The manager said she would amend the policy to include the rights of the person not to see a visitor if they wished, as this had been mentioned at the last inspection. Some people go out with their friends and people are welcome to visit at any reasonable hour. Menus are changes regularly and reflect seasonal preferences. Each person is offered breakfast, lunch, mid -afternoon tea, tea and if they wish, supper too. The home has a policy of offering seven drinks a day as routine and people are always encouraged to ask for a drink in between if they wish or if they have visitors. People are consulted about the menus at residents meetings and their preferences are recorded so that these can be incorporated into menu changes. The home does not cater for any specialist diets at the moment but these would be catered for when the need arose. The manager has recently implemented a new regime for organising the way people are assisted at meal times. Staff do not enter the kitchen during meal times and there are staff on duty in the dining room to assist with those people who require help with feeding. Other staff take trays to people who wish to dine in their rooms. This was arranged to avoid the risk of cross contamination at meal times so that staff and cooks do not regularly come from rooms into the kitchen. After an adjustment period this now seems to be working well. The cook said she missed the contact with people and made a point of visiting a number of people in their rooms before she went off duty to get feedback at first hand. This ensures people receive the diet they require and enjoy and that they are protected from risk of cross infection. Omega Oak Barn DS0000066075.V375575.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their complaints properly dealt with and they are protected from abuse. EVIDENCE: The home has a good complaints procedure and policy with updated contact details for other agencies people may wish to complain to. A complaints leaflet is given to each person on admission, and the policy is displayed on notice boards around the home. People said that staff would listen if they had a complaint and they believed something would be done about it. Staff have had training in the Deprivation of Liberty and Alerter 1 training for Safeguarding Adults. Staff said they understood what they would need to do if they suspected abuse and had learned techniques in how to deal with challenging behaviour. Only some staff have received training in dementia awareness. This must be provided so that all those who are responsible for the care of people with a dementia have insight into the way in which this may affect a person and the best way of approaching certain behaviours, to keep people safe and as free from distress as possible. Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 17 Omega Oak Barn DS0000066075.V375575.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe well maintained environment. EVIDENCE: An extension has been built since the last inspection which has increased the number of people the home can accommodate from 19 to 28. The new wing is specifically for the care of people with a dementia and has nine en suite rooms. The expansion has included an assisted bathroom, two assisted shower rooms, a second dining room, small lounge and a conservatory, to provide a good quality environment for people living at the home. All bedrooms in the home Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 19 are for single occupancy and people said they enjoyed having a room to themselves. The home was clean, well maintained, decorated and was free from any unpleasant odour. Rooms were personalised and there were pictures, flowers and plants around the home to give a homely atmosphere. The manager said she had employed more cleaning staff to ensure the home was kept clean at all times, as she felt there had been an issue with this recently. The laundry is suitable for the size of the home, with a non slip floor, a good sized sluice washer and tumble drier. The home has a contract for the disposal of clinical waste in line with infection control policy. The garden areas are accessible and there is a summerhouse for use in warm weather. An enclosed garden area has been created which is due to be planted with aromatic herbs and other shrubs in raised beds so that people have something pleasant to look out on and to spend time in. There is also an outdoor area called the quad, where people can go to smoke or to sit out. People said they were looking forward to the gardens being finished and said they had been kept well informed of the progress with the building in meetings and through posters pinned up in the home. Staff said the home was always clean and presented to a high standard. The home complies with the fire authority and the environmental health department, which ensures people are kept safe from risk associated with these areas. Omega Oak Barn DS0000066075.V375575.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by well trained and recruited staff in sufficient numbers to support the smooth running of the service. EVIDENCE: The home has sufficient staff on duty to ensure people receive the care they need at all times of the day. Extra staff are on duty at peak times to meet fluctuating needs. Staff have been well recruited according to policy and procedure, with two references and Criminal Records Bureau checks in place. This ensures people are cared for by staff suitable to work with vulnerable adults. Over 50 of staff have achieved NVQ in care at level 2 or higher. All staff have received an induction and from now onwards will receive this to the Skills for Care guidelines. All have completed foundation training in all required areas and updated infection control training is planned in the near future. Some have also carried out training in specialist areas such as dementia care, to ensure they have an understanding of the particular needs of individuals Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 21 who have a dementia. Although all staff who care for people with a dementia should have specialist training in this area of care, the standard of general training in care is good. This ensures people receive appropriate care from well trained staff. Omega Oak Barn DS0000066075.V375575.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a well managed service. Their opinions inform the service they receive. They are kept safe by robust health and safety procedures. EVIDENCE: The manager has been in post since the end of March. She is a Registered Nurse and also has the Registered Manager’s Award. Both staff and manager said there had been a period of adjustment to the new manager’s style, and Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 23 that there had been some initial resistance to some of her ideas. Both the manager and staff agreed that it was still early days to make any judgement, although in the main this seems to have settled down. The manager said she was pacing the introduction of any new ideas so that staff had time to get used to different ways of working. The new wing opened shortly before the new manager took up post, so this meant there had to be some changes in order to work effectively in a larger capacity home which is also catering for the needs of people with a dementia. The specialisation in dementia care is a new departure for the home and it is important that all staff have the training they require to give the best support to this group of people. At present only some of the staff have training in this area. The manager has a background in caring for people with a learning disability and must gain training in dementia care as a matter of urgency so that she can give a strong lead to staff in this area. Staff meetings and seniors meeting have started and staff said these gave them a good opportunity to discuss their work and any concerns. They also said they were encouraged to go to the manager with concerns at any time. The manager has been examining returned surveys. Some of the people living at the home and others with an interest in the home had made comments and suggestions. Although there has been informal feedback from some health care professionals and visitors, a wider formal survey would give a broader response and would help to inform an improvement plan for the service. The manager said she was thinking of ways she could encourage more people to respond to surveys. She also plans to use feedback from staff meetings, seniors meetings, reviews of care and contact with health care professionals and internal auditing to plan improvements. All staff receive regular supervision and this is documented. This was not taking place at the last inspection and ensures staff now have the opportunity for their work to be appraised and to discuss any professional development issues. The personal allowances for several people living at the home are managed. Money is kept in separate wallets and all transactions are recorded. Records were examined and the records were up to date and accurate. This protects people’s money. Several health and safety documents were examined. The home had up to date records for gas safety, electrical safety, fire alarms and fire equipment checks, portable appliance testing and environmental health. The home also has an up to date fire risk assessment. The manager keeps a maintenance calendar so that is easy for her see what work is required each month. This ensures people’s safety is promoted and protected. Omega Oak Barn DS0000066075.V375575.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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 3 X 3 Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13(2) Requirement Where medication is not given then the record must be coded correctly, spaces must not be left in the records. Timescale for action 26/05/09 2. OP31 9 (2) (i),12(1)( b) Outstanding requirement. The manager must gain a 31/07/09 qualification in the care of people with a dementia to ensure service users receive care from staff who receive guidance from a well trained manager. 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 All care plans should contain sufficient information about the recreational and social needs of people and how these are to be met. The manager is reminded that she must be registered with DS0000066075.V375575.R01.S.doc Version 5.2 Page 26 2. OP31 Omega Oak Barn 3. 4. OP33 OP7 the Care Quality Commission. A wider survey of interested people would give better information on which to base plans for improvement. Internal auditing should feed into this process also. Monthly review notes about care plans should refer back to the care plan and how this is to change as a result of new information, so that changing needs can be met. Omega Oak Barn DS0000066075.V375575.R01.S.doc Version 5.2 Page 27 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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