Care Home: Oxford Grange

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What the care home does well The CSCI invited relatives to comment on what they feel the home does well. People wrote, "My mother is a poor eater and the staff at Oxford Grange are always willing to try and get her to eat. The staff also make sure that my mother is always clean and well dressed. Her hair is always kept tidy for her as she forgets at times whether she has done her hair or not. I am very pleased so far with the way my mother has been looked after." "At times my wife will go to the main door of the home and ask or demand to be let out so that she can come home to me. The care workers on duty are always able to talk her into changing her mind and she will then settle down."A good start has been made towards improving the standard of furnishings and fittings and the building. A number of communal areas have been redecorated and new carpets have been fitted. A maintenance plan has been implemented which gives timescales of when areas within the home will be redecorated; these include bedrooms as well as communal lounges. Although the majority of people were not able to comment directly about their life at the home it was clear from observing care practice throughout the day that people are well cared for. Staff were seen interacting well with people showing them respect whilst providing care to them in a non-intrusive manner. Those people who did speak with the inspector said they feel well cared for and they are able to make their own decisions about everyday matters. The atmosphere at the home is warm and friendly and there is a good rapport between people living at the home and the staff. The home is well managed and staff morale is good. This is reflected in the low turnover of staff and the fact that staff feel valued. What has improved since the last inspection? There has been a number of improvements since the last inspection especially in terms of the accommodation. Care plans have improved and now take into consideration people`s health, personal and social care needs. This enables staff to deliver the right level of care each person needs. The home has implemented an activities programme in order to stimulate and occupy people during the afternoon and one evening a week. A number of staff have undertaken a six months dementia care training course, which they say has given them a better understanding of the needs of people with dementia. The home has introduced a quality assurance system that seeks the views of people living at the home and those associated with it. Results from satisfaction surveys are taken into consideration and action is taken to address shortfalls in the service. CARE HOMES FOR OLDER PEOPLE Oxford Grange 30 Oxford Road Dewsbury West Yorkshire WF13 4LL Lead Inspector Tracey South Key Unannounced Inspection 28th January 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 Oxford Grange DS0000045070.V358426.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. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oxford Grange Address 30 Oxford Road Dewsbury West Yorkshire WF13 4LL 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) 01924 463336 01924 455442 hayleyglover@tiscali.co.uk Northfields Care Homes Ltd Rachel H Bedford Care Home 43 Category(ies) of Dementia - over 65 years of age (43), Old age, registration, with number not falling within any other category (10) of places Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2007 Brief Description of the Service: Oxford Grange is owned by Northfield Care Homes Ltd and provides care and accommodation for up to 43 older people. The home is situated in a Victorian detached house in its own grounds. There are three floors of accommodation and the main office for Northfields Care Homes Ltd is situated in the basement. There are two car parks and gardens to the front and rear side of the building. Oxford Grange is situated on Oxford Road, approximately one mile from the local town of Dewsbury and two miles from the town of Batley. The current charges at the home range from £347.02 to £358.80 per week. Additional charges are made for hairdressing, chiropody and toiletries. The service provider ensures that information about the service is available to people by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Oxford Grange DS0000045070.V358426.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 star. This means the people who use this service experience good quality outcomes. This inspection included an unannounced visit carried out to the home by the inspector on the 28th January 2008. The visit began at 09.30am and the inspector had left the home by 4.30pm. During the visit the inspector spoke with some of the people who live at the home, care staff, the company’s operations manager and the home’s registered manager Rachel Bedford. Care records were examined and the inspector audited a sample of medications, reviewed staff recruitment records, and looked around the home. The manager at the home also completed an annual quality assurance assessment that was requested by CSCI (Commission for Social Care Inspection), which includes information about people who live at the home, the staff that work there, the service provided and any incidents or accidents that have occurred. Prior to this visit, surveys were sent out to obtain the views of people who live at the home, their relatives and doctors. Twelve surveys were sent out to people living at the home, three were returned. Twelve surveys were sent out to relatives, four were returned. Surveys were also sent to people’s doctors and staff who work at the home, none were returned. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. What the service does well: The CSCI invited relatives to comment on what they feel the home does well. People wrote, “My mother is a poor eater and the staff at Oxford Grange are always willing to try and get her to eat. The staff also make sure that my mother is always clean and well dressed. Her hair is always kept tidy for her as she forgets at times whether she has done her hair or not. I am very pleased so far with the way my mother has been looked after.” “At times my wife will go to the main door of the home and ask or demand to be let out so that she can come home to me. The care workers on duty are always able to talk her into changing her mind and she will then settle down.” Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 6 A good start has been made towards improving the standard of furnishings and fittings and the building. A number of communal areas have been redecorated and new carpets have been fitted. A maintenance plan has been implemented which gives timescales of when areas within the home will be redecorated; these include bedrooms as well as communal lounges. Although the majority of people were not able to comment directly about their life at the home it was clear from observing care practice throughout the day that people are well cared for. Staff were seen interacting well with people showing them respect whilst providing care to them in a non-intrusive manner. Those people who did speak with the inspector said they feel well cared for and they are able to make their own decisions about everyday matters. The atmosphere at the home is warm and friendly and there is a good rapport between people living at the home and the staff. The home is well managed and staff morale is good. This is reflected in the low turnover of staff and the fact that staff feel valued. What has improved since the last inspection? What they could do better: Care plans should be updated, as people’s needs change. This will ensure they receive the right level of care they need. Daily reports should describe how people have spent their day and show evidence that their needs have been met. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 7 Relatives who completed the CSCI’s survey made comments about what they felt the home could do better. “I would like to see that the residents get their own clothes back from the wash and not going to anybody else.” “Improvements could be made with the laundry service. Clothes going missing, clothes creased, clothes ruined dryer too hot, in dryer too long.” 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. Oxford Grange DS0000045070.V358426.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 Oxford Grange DS0000045070.V358426.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are properly assessed prior to moving into the home to ensure that their needs can be met. EVIDENCE: New people wishing to move into the home are invited to visit to help them reach a decision as to whether Oxford Grange is the right place for them. The manager explained that due to people’s frailty it is usually relatives who visit so they can see the accommodation for themselves and speak with the staff. Relatives who completed the CSCI’s survey feel that they receive enough information about the care home to help make decisions. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 10 Three people’s care records were examined and this included pre-admission documentation completed by the home and the funding authority when applicable. There was good evidence to confirm that people are properly assessed before they are offered a place at the home. This means that the home only admits people whose needs can be met. Oxford Grange DS0000045070.V358426.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ care plans are detailed and outline the level of support and care each person requires in ensuring their health and welfare needs will be met. Medication systems are well managed and people are treated with respect. EVIDENCE: Surveys sent to relatives asked if they feel the care home meets the needs or their relative. Two responded ‘always’ and two responded, ‘usually’. It was not possible to get direct feedback from many people due to their frailty, but those who were able said that they feel well cared for and that their needs are met by caring staff. Three peoples’ care records were examined and this included their individual care plan. All three care plans were of a good standard and described the level of care and support each person requires. Care plans are reviewed every Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 12 month although one person’s plan had not been updated in accordance with changes noted at the review. This person had been identified as losing weight and staff had been instructed to monitor the person’s dietary intake and encourage them to eat their meals. There was no reference of this on the care plan. The manager was asked to update the care plan immediately so that this person receives the right support. Care staff complete daily reports and the information they record should relate to how that person has spent their day and how their care needs have been met. The daily reports examined did not provide this level of detail and there was very little evidence that people’s health care needs, as mentioned previously, are being monitored. The manager explained that she herself identified this as an area of improvement and intends to do further report writing training with the staff. Risk assessments have been carried out to identify any risks to the individual and measures are put in place to reduce and or eliminate these. Manual handling plans used to identify the support people require with their mobility describe the level of assistance required so staff are clear about what is expected from them. Assessments (known as “Waterlow” assessments) are completed in respect of those people who are at risk of developing pressure sores. Specialist equipment such as mattresses and cushions were seen in use. One person said that staff are quite good at ‘keeping an eye’ on his skin as he is at risk of developing pressure damage to his skin. People living at the home confirmed that if they are unwell the staff are prompt at calling the doctor. There was good evidence in the three care records looked at, that people have seen their doctor regularly and other visits made by the dentist, optician and chiropodist are also documented in people’s records. Relatives confirmed as part of the survey they completed for the CSCI, that they are kept informed of important issues affecting their relatives, for example, being admitted to hospital or following an accident, such as a fall. The medication system used at the home is supplied by the chemist in blister packs, which enables staff to easily audit medication received. A sample of three people’s medication was checked during the visit. This showed there to be good systems in place for the recording, storing, administration and disposal of medications. The medication record sheets were neat, tidy and easy to follow. Staff were observed attending to people’s needs in a respectful and dignified manner. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are offered a good range of activities and appear to be able to make their own choices about how they spend their time. Meals provided are good, varied and served in a pleasant environment. EVIDENCE: Good progress has been made in terms of providing a range of activities that people can take part in. Since the last inspection the home now employs an activities co-ordinator who is responsible for encouraging people to join in the different activities they have available to them. In the front entrance of the home there is a daily activities timetable that informs visitors of the type of activities taking place on a daily basis. Activities include, board games, baking, arts and crafts, reminiscence, exercise and movement and sing a longs. More recently, evening activities have been introduced on a weekly basis and usually take place between 6-7pm. Additional staff are on duty during the afternoon to enable the activities programme to take place. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 14 Two people spoken with during this visit said they choose not to join in the activity sessions but they were aware that different events do take place. People were observed coming downstairs for breakfast at varying times during the morning of this visit. Those people spoken with said there are no restrictions in terms of what time they get up and go to bed. One lady said she prefers to spend the majority of her time in the privacy of her room, she said she likes it that way. Another person said they tend to spend their time between their own room and the downstairs lounge. Whilst looking around the home people were observed sitting in the different areas available to them. The home benefits from having a number of seating areas and there are a number of corridors that enable people to walk about freely. Surveys sent to relatives asked if they felt that the care home supports people to live the life they choose. One responded ‘always’ and three responded, ‘usually’. Those staff spoken with said they feel that people are able to make their own choices about every day things and they confirmed that they are not put under pressure to get people up by a certain time. They also explained that although some people find it difficult to express themselves because of their dementia, over a period of time staff begin to recognise people’s preferred routine and preferences which assists staff to care for people in the way they would choose if they were able. The inspector spoke with the chef who explained that people are able to choose from two different meals at lunchtime and at teatime they are offered a number of different choices. Those people who spoke with the inspector said they enjoy their meals. The majority of people have their meals in the dining areas although some people prefer to eat their meals in the own rooms. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are protected from abuse and they can be confident that their complaints will be listened to and acted upon. EVIDENCE: Three relatives who completed the CSCI’s survey said they knew how to make a complaint, and one person said they didn’t know how to. The complaints procedure is displayed in the front entrance of the home and in each person’s bedroom. It is also available in the home’s statement of purpose. The manager keeps a log of any complaints received and there was good evidence that peoples’ concerns had been taken seriously and the appropriate action had been taken to resolve the matter wherever possible. There are policies and procedures in place to reduce this risk of abuse. All staff commencing employment have a CRB (Criminal Records Bureau) and a POVA (Protection of Vulnerable Adults) check before starting work in the home. All staff have received safeguarding (adult protection) training which provides information on how to protect people from abuse. Those staff who spoke with the inspector said they found the training useful and that they were clear about safeguarding issues, such as when and why they should report poor care practice. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 16 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers people a homely, comfortable and clean environment. EVIDENCE: Since the last inspection a maintenance programme has been implemented and areas within the home have been redecorated and new carpets have been fitted. The front entrance has been repainted and is awaiting a new carpet. One of the downstairs lounges has been completely redecorated and is a pleasant place for people to relax. Another lounge also recently decorated is waiting for new curtains; the manager explained that measurements have been taken for the new curtains. It is unfortunate that the curtains were not ordered prior to the room being decorated, as people using the room after dark will be easily seen for outside the home without curtains in place. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 17 Since the smoking ban came into force in July 2007 the home now has a designated smoking room, which is used by a small number of people who choose to smoke. The room itself is quite small and there was no ventilation in place and there was a build up of smoke, which was unpleasant. The manager confirmed during this visit that an extractor fan would be purchased and will be fitted as soon as possible. The standard of cleanliness noted throughout the home was good and there were no unpleasant odours noted in any part of the home. The atmosphere on the day of the visit was warm and friendly and people looked comfortable whilst sitting in various parts of the home. The manager acknowledges that refurbishment needs to continue to bring all rooms up to a good standard. One person’s bedroom door was propped open with a chair. This is not safe practice and it could put people in danger in the event of a fire when the door would need to be closed. The manager said she would make arrangements for a Dorguard (an automatic device which holds the door open, but releases when the alarm sounds) to be fitted, which will be linked to the fire alarm system. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are met by trained staff who have undergone a thorough recruitment process before they are allowed to work in the home. EVIDENCE: Relatives’ surveys asked if the care staff have the right skills and experience to look after people properly. Three responded ‘always’, one relative said ‘usually’. The duty rota confirmed there to be seven care staff on duty during the morning shift; five/six staff during the afternoon shift and three staff work during the night. The manager said that the home retains staff well and recently introduced back to work interviews have improved sickness levels at the home. Regular staff working at the home creates better continuity of care for people living there. There is 58 of the care staff that has achieved an NVQ (National Vocational Qualification) Level 2 qualification in Care. A further six are working towards NVQ level 2 and nine are working towards NVQ level 3. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 19 The recruitment files of three members of staff were audited in detail and found to contain the required information and recruitment checks. These checks are necessary to help protect people from potentially unsuitable staff. The manager explained that all new staff receive induction and mandatory training such as moving and handling, fire, health and safety and food hygiene. All new staff work alongside more experienced staff as part of their induction and they are expected to complete the Common Induction Standards set by the “Skills for Care” which is the National Training Organisation for care staff, within the first twelve weeks of their employment. Those staff who spoke with the inspector said there are good training opportunities at the home. Some staff have undertaken dementia training which has taken six months to complete. The staff explained that this training as helped them immensely in providing quality care to people with dementia. The training records provided by the manager indicates that the majority of staff have undertaken moving and handling training, food hygiene, health and safety, infection control, fire risk awareness and safeguarding training. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 20 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 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, safety and welfare of people living at the home and staff is promoted and protected. EVIDENCE: Miss Rachel Bedford has been the manager at Oxford Grange for the past three years. She is well regarded and respected by her peers. Miss Bedford has completed NVQ Level 2, 3 and 4 in Care and is planning to complete the Registered Manager’s Award in the near future. She is keen to continue with her own self-development and recently completed a Moving and Handling Facilitators course enabling her to teach staff. She has also completed a Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 21 dementia training course which she found beneficial in terms of understanding the behaviours of people with dementia. Since the last inspection the home has introduced a quality assurance system whereby satisfaction surveys are sent to relatives and other professionals in order to seek their views on how the home is run. Meetings take place between the home, people who live there and their relatives. The last meeting to take place was in January 2008 where people were advised about the redecoration programme and the affect that this may have on everyone. As part of November’s meeting the menus were discussed and new meals were introduced to the four weekly menu. The meeting also gave people the chance to organise Christmas events as well as discussing any other issues. The manager is keen to involve staff in the running of the home and staff meetings take place on a regular basis. Since the last inspection a Representatives Group has been introduced; the purpose of this group is to discuss the home’s business plan and to discuss the home’s aims and objectives and how these will be achieved. Representatives of the group who are made up of care staff, domestics, night staff and team leaders feed back issues discussed in the meetings to other staff. The company’s operations manager is responsible for carrying out visits to the home to form an opinion of the standard of care provided and a report is then produced. The inspector read the latest report during this visit. It was informative and showed evidence that the visiting manager had spent time talking with people who live at the home and the staff and their views about the home had been recorded. Some people have small amounts of personal money that is held safely at the home by staff. Records are available to show when money is deposited on behalf of people. The records show the individual cash balance for each person and how their money is used on their behalf, including receipts for goods and items purchased. Three peoples’ finances were checked during the visit and were found to be correct. All staff receive individual supervision sessions which gives them the opportunity to have one-to-one time with their supervisor to discuss work related issues, performance and training needs. The manager said she has had a positive response about the supervision sessions from staff, who are said to feel valued as part of the team at Oxford Grange. All staff received their annual appraisal in December 2007. The home’s quality assurance assessment indicates that routine maintenance and servicing of equipment takes place. The home carries out weekly fire safety checks and these are recorded and staff are involved in fire drills periodically to ensure they know what to do in the event of a fire. Accident Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 22 reports are completed and audited on a monthly basis by the manager identifying any trends that may be apparent and taking the necessary action. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X X 3 X 3 Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP7 OP7 OP19 Good Practice Recommendations Care plans should be updated, as people’s needs change. This will ensure they receive the right level of care they need. Daily reports should describe how people have spent their day and show evidence that their needs have been met. The manager should confirm in writing to the Commission when the Dorguard has been fitted. Redecoration of the home should continue in accordance with the maintenance programme. Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 25 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 Oxford Grange DS0000045070.V358426.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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