Care Home: Three Oaks Care Home

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What the care home does well The care provided for the residents of this home is good and each person is treated as an individual with their own needs and preferences. Some current residents have very limited means of communication but the care staff work hard to ensure they understand and promote all individual views, feelings and choices. There are residents in the home who use a wheel chair for all activities but there are no residents with broken skin or pressure areas in the home. There are a range of areas in the home where residents can go if they either want company or want to be quiet. All areas of the home and garden are accessible to all residents. The home is kept clean, hygienic and well maintained. There is well established management and staff team who support one another and work well together. The proprietor also provides care on some shifts and is fully involved in the day-to-day running of the home. Residents are aware of the complaints policy and those we spoke with said they would not hesitate to voice a concern if they had one. Copies of the complaints policy are provided in pictorial form to assist the understanding of some residents. Staff training is updated annually and 98% of staff are already trained to NMVQ level 2 with many undertaking NVQ level 3 training. We were told by all the staff we spoke with that the staff team work well together and that staff enjoy working at the home. This professional approach is directly beneficial to the residents. What has improved since the last inspection? CARE HOME ADULTS 18-65 Three Oaks Care Home 14 Gwynfa Close Welwyn Hertfordshire AL6 0PR Lead Inspector Pat House Unannounced Inspection 7th April 2008 10:30 Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 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 Three Oaks Care Home DS0000054490.V360991.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 Adults 18-65. 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. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Three Oaks Care Home Address 14 Gwynfa Close Welwyn Hertfordshire AL6 0PR 01438 712939 F/P 01438 712939 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) Three Oaks Care Home Limited Mrs Tracy O`Dwyer Care Home 9 Category(ies) of Learning disability (9), Physical disability (9) registration, with number of places Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service 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 categories: Learning Disability - Code LD Physical Disability - Code PD The maximum number of service users who can be accommodated is 9 2. Date of last inspection 1st May 2007 Brief Description of the Service: Three Oaks Care Home is a large detached bungalow set at the end of a cul-desac in the village of Welwyn. The building has been extended and converted for use as a residential care home for people with learning and physical disabilities. All bedrooms are for single occupancy and there are a variety of communal rooms providing residents with the choice of being in a quiet area or in rooms with a television or where music can be played. All areas are spacious allowing easy access for wheelchairs. There is a garden to the rear and ample space for car parking in front of the building. The village of Welwyn is a short drive away and has a range of shops and pubs. The main A1 road is also nearby. Fees for the home range from £1259.86 to £1501.17 per week. A copy of the home’s Statement of Purpose/Service User’s Guide and a copy of the latest CSCI inspection report are kept in the entrance hall, where they can be viewed. Copies are also available from the office. Three Oaks Care Home DS0000054490.V360991.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. The information in this report is based on an unannounced visit to the home by one regulation inspector carrying out the work of the Commission. For the purposes of this report the Commission will be referred to as ‘we’. The inspection took place over two days. The deputy manager was on duty on the first day and the registered manager was in the home on the second day and able to provide us with sight of recruitment records which are kept locked. The home’s proprietor was also present for some of both days. The home was full at the time of the visit. Residents were spoken with and observed and we spoke with staff on both days. We visited all areas of the home and examined a selection of records during the visit. We have also reviewed the information we have received about this service between inspections. Since the last inspection the manager has completed and returned a selfassessment questionnaire, sent out by the Commission. This is the Annual Quality Assurance Assessment document, called the AQAA in this report. We have included information from this document in this report. Quality surveys have also been distributed to some residents, staff and relatives, and comments from these forms, when returned, will be included in the next inspection report. What the service does well: The care provided for the residents of this home is good and each person is treated as an individual with their own needs and preferences. Some current residents have very limited means of communication but the care staff work hard to ensure they understand and promote all individual views, feelings and choices. There are residents in the home who use a wheel chair for all activities but there are no residents with broken skin or pressure areas in the home. There are a range of areas in the home where residents can go if they either want company or want to be quiet. All areas of the home and garden are Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 6 accessible to all residents. The home is kept clean, hygienic and well maintained. There is well established management and staff team who support one another and work well together. The proprietor also provides care on some shifts and is fully involved in the day-to-day running of the home. Residents are aware of the complaints policy and those we spoke with said they would not hesitate to voice a concern if they had one. Copies of the complaints policy are provided in pictorial form to assist the understanding of some residents. Staff training is updated annually and 98 of staff are already trained to NMVQ level 2 with many undertaking NVQ level 3 training. We were told by all the staff we spoke with that the staff team work well together and that staff enjoy working at the home. This professional approach is directly beneficial to the residents. What has improved since the last inspection? What they could do better: We have indicated throughout the report some areas where improvements or updates need to take place. In all cases, the manager has made plans to undertake this work and some issues, discussed during the inspection, have already been addressed by the deputy manager. The contract, containing the terms and conditions of occupancy needs to be produced in a user-friendly format and needs to indicate which bedroom in the home is being offered. This is so that all parties are clear about the costs, roles and responsibilities of occupancy of the home. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 7 Person Centred care planning and advocacy services need to be introduced for residents in the home in line with current guidelines and to ensure that individual aims and aspirations are identified and met. New policies are needed for Infection Control and for Safeguarding Adults and Safeguarding training is needed again for all staff. Fire evacuation records also need expanding so that any shortfalls in the system are noted and dealt with, for the safety of everyone in the home. The recruitment process must include written evidence of each member of staff’s fitness for the job in question and must ensure a full employment history is provided by all candidates. This information forms a necessary part of a sound recruitment process, which is required to ensure residents are protected from abuse. 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. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is kept up to date and provided for all prospective residents and everyone wishing to enter the home has a full assessment of need completed. This ensures that all parties can be sure the home can meet all individual needs. The terms and conditions of the home are agreed in writing so that people are clear about the roles and responsibilities of all those in the home. EVIDENCE: There had been two new residents admitted to the home since the last inspection. We looked at the records of these people and saw copies of care summaries, which had been provided by referring agencies before the residents entered the home. Detailed assessments had also been completed by staff from the home and initial care plans had been drawn up from all this information. The manager confirmed that every resident has a written contract, outlining the terms and conditions of occupancy. These documents are currently being reviewed and in the AQAA the manager states that they will be provided in a format more suitable for the residents’ understanding and will indicate the actual room to be occupied. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 10 Since the inspection the home’s Statement of Purpose/Service User’s Guide has been updated to incorporate details of all the latest changes in the home. A copy has been provided for the Commission. Copies in pictorial form will again be given to residents. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home support the residents to be as independent as possible but assess all activities to ensure individual safety is promoted. The residents’ changing needs and wishes are recorded and reviewed appropriately so that everyone can be clear about current individual plans of care. EVIDENCE: We examined a selection of care plans after we had spoken with the residents concerned. The records were up to date and relevant to the current needs of the residents. Monthly reviews of the plans were documented and the records contained a variety of risk assessments relevant to individual circumstances. The manager stated in the AQAA that every resident also has a “My Life “ book, which is completed by the resident with staff assistance. We did not look at these books on this occasion. The manager is also aware of the need to introduce changes to the care plans to reflect a more person centred approach to care planning. Staff training is being planned to support this new approach. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 12 The residents who were able to give us clear opinions told us that they were supported by the staff to make their own decisions about their daily lives. One resident said that he had agreed a plan with the care staff about where and how often he would smoke cigarettes. He also told us he was proud to have cut down the number of cigarettes he smoked daily as a result of this plan. A risk assessment, completed for one of the newer residents in the home has resulted in an alarm being fitted to the front door, which some residents can open independently. The manager has, in the past tried unsuccessfully to access independent advocates to the home. The availability of advocates has generally increased as a result of the Mental Capacity Act and the manager said she would be trying again to introduce this service. Advocates may then be involved in the residents’ on-going person centred planning agreements. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home assist residents to enjoy their chosen activities, to maintain family links and to use local facilities. This ensures that residents receive appropriate stimulation and remain part of the wider community. Residents enjoy well-balanced meals, which help to promote their good health and well-being. EVIDENCE: During the two-day visit we observed the interaction between staff and residents, some of whom had very limited means of communicating their wishes. We saw staff helping and talking to the residents in a variety of situations and in all cases they treated everyone concerned with dignity and respect, seeking residents’ views where appropriate and explaining what each situation meant. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 14 Residents are supported by staff to attend day centres and clubs, in accordance with individual wishes and activity plans for the week are on display so that everyone knows who is going out or staying in the home. Residents attend an evening club once each week and we saw pictures painted and drawn by one resident displayed around the home. Staff said they usually undertake the decoration in the building and, in the AQAA, the manager states that residents assist with this. The manager also states that residents are always involved in choosing colours and any new furniture for the home and that the two new residents chose their own bedroom décor. Staff explained to us that plans to provide a computer for one resident had been abandoned as the resident had decided they did not want this equipment. The home has a large fish tank and a pet cockatiel bird. One care worker we spoke with said that activities in the home took place mostly at weekends, when no one went to day centres. Activities then included art, cooking, music and bingo. However, in the AQAA the manager states that more activities are being planned for the residents and that accessible flower beds are to be provided for residents to plant and tend. Care staff we spoke with said that relatives were encouraged to visit at any time and that one resident had an annual holiday with a parent. All residents have an annual holiday arranged by the home and are offered trips out. The residents we spoke with said they enjoyed the food provided in the home. The week’s menus were displayed on the wall in the dining room in written and pictorial form. Staff said that menus are decided in consultation with the residents and follow a four-weekly plan. We saw residents gently encouraged by care staff to eat the food and all assistance was provided discreetly and appropriately. The staff we spoke with said that they are all involved in food preparation and that they have annual Food Hygiene training provided in the home. Staff we spoke with confirmed that the temperature of fridges and freezers were checked daily but we reminded these staff members that the temperatures should be recorded to evidence that food was being stored safely. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed by staff in the home ensure a safe system for administering medication is followed, for the protection of the residents, and ensure that all appropriate support is provided for residents in a way they prefer. EVIDENCE: The care plans we looked at contained details of external specialist involvement in appropriate areas and we saw records of attendance at hospital appointments and weight checks. Currently no resident has any pressure sores, although two individuals use wheel chairs permanently. In care records we saw details of bruising recorded and recommended that body charts should be used to clarify these records. In the AQAA the manager states that the home has very good relations with doctors and that there is regular contact with local district and community nurses. We looked at the storage and system for administering medication in the home. Currently, no residents are able to administer their own medication. Record sheets contained written information about specific events or changes Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 16 and the manager is aware that two staff signatures should be in place when any written instructions are included. Staff we spoke with confirmed that they receive training in medication administration, both at induction and on an annual basis. They also said that the manager would not sign their competency record until she was sure of their ability and understanding in this area. The deputy manager has just completed an accredited training course in medication administration and is planning to cascade this training to staff throughout the home. Currently no controlled drugs are administered to residents but the home has an appropriate book for recording these drugs. However, the manager said that the local district nurses have agreed to administer controlled drugs for residents at Three Oaks, should the need arise. Since the inspection a new Medication Policy, which includes new auditing arrangements has been produced for the home and a copy has been provided for the Commission. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures planned and followed in the home ensure that residents have their concerns listened to and are protected from all aspects of abuse. EVIDENCE: The home has written policies on Complaints, Adult Protection and Whistle Blowing, which staff we spoke with were aware of. The manager said that information given to prospective residents and their families includes a copy of the Complaints Policy and we saw this policy displayed in the entrance hall of the home. The Complaints policy is also produced in pictorial form and the residents we spoke with said they had a copy of this and were fully aware of how to make a complaint. The deputy manager has completed a file, which gives staff information about the Protection of Vulnerable Adults, but the home’s Safeguarding Policy needs updating and the manager said this will be done soon. Training is also being planned to update staff in the current inter-agency procedures for Safeguarding Adults. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their daily lives enhanced by living in a home which is comfortable and well maintained and which is kept clean and hygienic. EVIDENCE: We visited all areas of the home briefly and all areas were clean and well decorated. Bedrooms were bright and had mostly been personalised by the residents. The residents have a choice of areas within the home where they can spend their time. Some rooms are quiet and others have the television or music equipment in. The gardens looked very attractive during the visit and are clearly well kept. All areas of the home are accessible to wheel-chair users. The laundry contained paper towels and liquid soap and the home has a sluice washing machine for dealing with soiled washing. Staff we spoke with said there were always good supplies of disposable gloves available. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed for staff training in the home are robust and ensure that the needs of residents are met by a well-trained and professional group of staff. Recruitment procedures are generally good and help to safeguard the residents from abuse. EVIDENCE: We spoke with care staff on both inspection days. All confirmed that they had received thorough induction training when they started work at the home. Staff also said they had regular meetings where information was shared and which were minuted. The residents and staff we spoke with felt there were usually enough staff on duty in the home and said that the staff team worked well together and supported one another to everyone’s benefit. The home had achieved the target of having 50 of care staff trained to at least NVQ 2 standard at the last inspection. Currently 98 of staff now have this qualification and many have NVQ level 3. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 20 Updates of basic training courses are planned to take place each year and certificates from an external training company were seen on staff files. All staff receive annual training in basic First Aid. The manager should also complete a risk assessment to demonstrate that the first aid needs of the residents can be met by the level of staff training provided. In the AQAA the manager states that staff had received Pressure Care training in the last year and that dementia training has been booked for all staff. It was recommended however that a training overview matrix should be produced to evidence everyone’s training and show where more courses were needed. A selection of staff recruitment files was examined and we saw evidence that two written references and clearance from the Criminal Records Bureau had been obtained before staff started work at the home. However, it was noted at the last inspection that not all candidates completed a full employment history on their application form and this information has still not been provided in all records seen. At the last visit we also noted that evidence that the candidate was physically and mentally fit for the job was also not obtained and again was not evidenced on this occasion. The manager said that application forms would be amended to make clear this information was needed to ensure the protection of the residents and would ensure that all applicants completed the forms appropriately. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by an established management team and the views of both staff and residents are listened to and directly affect the running of the home. Procedures followed in the home promote safe working practices, which help to protect both residents and staff. EVIDENCE: The manager of the home is registered with the Commission and has been in post for ten years. The manager has the NVQ4 qualification in management and the deputy has completed NVQ3 and is now completing NVQ4 training. The staff and residents we spoke with said that the managers were supportive and always listened to their views. Staff felt their views and those of residents were listened to and acted on whenever possible. The proprietor is also fully Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 22 involved in the home on a daily basis and also provides care on some shifts. All staff spoken with said that the proprietor always provided whatever the home needed in a timely manner. Since the inspection, a new Quality Assurance Policy has been produced and a copy has been provided for the Commission. In the AQAA the manager states that the views of residents and other stakeholders in the home are regularly sought and changes are made accordingly. We looked at Fire Safety records and checks and audits were made regularly. The staff we spoke with confirmed that fire drills took place, but records of these evacuations need to be more detailed, and should include outcomes of the drills as well as details of who took part. The manager said these expanded records would now be kept regularly. We checked the homes’ accident records and these were well documented. Three Oaks Care Home DS0000054490.V360991.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 Adults 18-65 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 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets This requirement had a timescale of XX/XX/XX (you insert the original date for compliance), which has not been met. Enforcement action is now being considered. 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 01/06/08 1. YA34 19(5)(c) To ensure residents are safeguarded from abuse, the recruitment procedures followed must ensure that evidence is obtained that anyone employed to work at the home is physically and mentally fit for the purposes of work he or she is to perform and that a full employment history is provided in writing before employment commences. Part of this requirement had a timescale of 01/06/07, which has not been met. A new timescale has been issued. Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Three Oaks Care Home DS0000054490.V360991.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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