This inspection was carried out on 25th October 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Oakapple Care Home Debdale Hall Bungalow Debdale Lane Mansfield Woodhouse Mansfield Nottinghamshire NG19 7EZ Lead Inspector
Stephen Benson Unannounced Inspection 25th October 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 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. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Oakapple Care Home Address Debdale Hall Bungalow Debdale Lane Mansfield Woodhouse Mansfield Nottinghamshire NG19 7EZ 01623 622 588 01623 631 959 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) Mrs Wendy Mary NG Yin Kwong Mrs Wendy Mary NG Yin Kwong Care Home 10 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (10) of places Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13/05/05 Brief Description of the Service: Oakapple is a care home providing personal care and accommodation for 10 older people. The home provides long term care and will accept emergency admissions. The home is owned by Mrs Wendy Mary NG Yin Kwong, which is run as a family business. The home is located in the grounds of Debdale Hall between Mansfield and Mansfield Woodhouse about a mile from shops, pubs, the post office and other amenities. The home was opened in 1987 and consists of an extended bungalow.6 of the homes bedrooms are single, and 3 of the bedrooms have en-suite facilities. The home has large gardens that are well maintained and easily accessible. There is car parking available for 6 cars. The home does not have a website but further information can be obtained from the manager. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection focussed on key standards not inspected at the last visit and the requirements that were set. The inspection lasted for 3 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with a senior carer and the care staff on duty. No managers were present at this time. Care practices were observed and a visiting relative was spoken with. The premises were not inspected in detail but various areas of the home were visited as part of the inspection What the service does well: What has improved since the last inspection?
Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 6 The recording made when administering controlled drugs is now done correctly although it is also recommended that staff sign using their surname rather than just their first name. The decision to use bedrails on a resident’s bed is no longer made within the home, as the district nurse comes in to assess whether these are needed and to ensure that the correct ones are provided. When a resident is unable to manage a solid diet a record is kept of their nutritional intake to ensure they are still receiving a healthy and balanced diet. What they could do better: 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. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 7 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 Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10 Correct practices are now in place for recording the administration of medicines. Bed rails are only used in appropriate circumstances. EVIDENCE: At the last inspection a requirement was set that doses of medication should be altered by the appropriate medical practitioner. The Medicine Administration Records (MAR) were seen which showed that the visiting doctor entered any changes to medication on the MAR sheet. A requirement was also set that the correct procedures are followed when completing the controlled drugs register. This was inspected and found to be fully completed and two signatures accompanying each entry, however staff are signing only using their first name. It would be better practice to sign using first and surnames and it is recommended that this is done. A further requirement was set that bedrails should only be used following an assessment. The district nurse has been contacted when it has been felt that these may be needed who has carried out an assessment and arranged for the correct rails to be provided that are compatible with the bed. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents on a soft diet can now be monitored to ensure they are receiving sufficient nutrition daily. EVIDENCE: A requirement was set at the last inspection to monitor the nutritional intake of any resident on a soft diet. A system has been introduced that records all intake by residents on a soft diet to enable their nutritional intake to be monitored. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 A proactive response is made to any complaints or concerns raised. EVIDENCE: A requirement was set at the last inspection to update the complaints procedure to show the correct registering authority, which has been done. A record is made of any occasion a resident is affected by events outside of the home (for example a cancelled medical appointment). Residents spoken with said that staff would sort out anything they asked them to. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The cleanliness of the home is maintained to a high standard. EVIDENCE: All areas of the home were maintained of a high standard of cleanliness and smelt fresh throughout. Residents said that they thought the home was kept to a high standard of cleanliness. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28 Records do not show that residents are being cared for by sufficient and suitably trained staff. EVIDENCE: A requirement was set at the last inspection that the rota must be an accurate reflection of the staff cover provided and training records the training undertaken. The rota for the current week did not accurately show the cover provided and did not contain sufficient information. The rota must show the name, position and hours each member of staff works. There is a record of training undertaken by staff displayed on the wall, however this record is not up to date. Staff on duty were seen administering medication, but neither have undertaken the medication administration training. The care manager is currently working towards NVQ level 4; one senior care is working towards NVQ level 3 and 4 care staff are working towards NVQ level 2. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38 Staff are unaware if their health, safety and welfare are promoted and protected. EVIDENCE: Staff were not aware of the home managing the finances of any residents and believed that these are all handled by relatives. A requirement was set at the last inspection to ensure that all cleaning products are kept in a locked cupboard. There were some cleaning materials on a shelf in the laundry. Whilst the laundry was locked this does not provide sufficient security for cleaning materials and they must be kept in a locked cupboard. Staff spoken with said that they would move them to the cleaning cupboard. There is a very good fire book and log, which, contains all the required information, however alarm and emergency lighting tests have not been carried out recently.
Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 15 Staff on duty were not aware of any systems in place for gas, electrical or water safety checks and tests, and those who would be expected to ensure these are taking place were not available at this inspection. Confirmation that these are being undertaken must be forwarded to The Commission for Social Care Inspection. Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 4 STAFFING Standard No Score 27 2 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 17 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 OP27 Regulation 17 Requirement Timescale for action 01/11/05 2 3 4 OP38 OP38 OP38 12 23 13 The rota must be an accurate reflection of the staff cover provided and training records the training undertaken Ensure that all cleaning materials 25/10/05 are kept in a locked cupboard Undertake fire safety tests at the 01/11/05 required frequency Send confirmation to the 01/12/05 Commission or Social Care Inspection that all gas, electrical and water safety checks and tests are being carried out 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. Refer to Standard OP9 38 Good Practice Recommendations Use first and surname when signing the controlled drug register Make staff aware of the required health and safety checks that are carried out in running the home Oakapple Care Home DS0000008724.V261753.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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