CARE HOMES FOR OLDER PEOPLE
Oaks, The 114 Western Road Mickleover Derby DE3 6GR Lead Inspector
Vanessa Davies Unannounced Inspection 21st October 2005 10:00 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 Oaks, The DS0000002143.V261709.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. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Oaks, The Address 114 Western Road Mickleover Derby DE3 6GR 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) 01332 510447 Mr Hassan Khan Ms Teresa Clare Boyce Ms Teresa Clare Boyce Care Home 28 Category(ies) of Dementia - over 65 years of age (28) registration, with number of places Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: The Oaks is a detached home, which has been adapted and extended to provide nursing care for up to 28 older people with dementia. The home is situated in the residential area of Mickleover. The home has 26 single bedrooms all with an en-suite facility and 1 double bedroom. The home is set within its own well kept, pleasant gardens, which are secure. There are registered nurses on duty 24 hours per day. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second unannounced inspection since April 2005. Although the manager was available, on the day of inspection she was not able to access staff files, therefore staffing was not assessed on this occasion but will be assessed at an additional visit. Information for this report was gathered by speaking with the manager and deputy manager and speaking with relatives. What the service does well: What has improved since the last inspection? What they could do better:
Assessments of need do not contain sufficient information, this was highlighted at the previous inspection and has not been addressed. The and The had this home need to document residents wishes in the event of terminal illness death. inspector left an immediate requirement at this inspection as the manager admitted a resident who did not meet the criteria of the registration and is an offence.
DS0000002143.V261709.R01.S.doc Version 5.0 Page 6 Oaks, The 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. Oaks, The DS0000002143.V261709.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 Oaks, The DS0000002143.V261709.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): 3, 6 Lack of information within the assessment of need potentially prevents staff from meeting the needs of the residents. EVIDENCE: The inspector examined 2 files, 1 file had a detailed assessment of need the other had very limited information, was not signed or dated. The home does not offer intermediate care. Oaks, The DS0000002143.V261709.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): 7,8,11 As at the previous inspection, this home still endeavours to meet the health and personal care needs of the residents, however in some areas the lack of information could lead to some needs and wishes not being fully met. EVIDENCE: One of the files examined did not have sufficient detail to ensure that staff were able to meet health, personal and social needs of the residents. There was no information about the families understanding of the illness, only the first name of the next of kin was documented, no contact details. No date of admission. One family spoken with stated that during the short time their relative had lived at the home she had been cared for appropriately and they felt she was treated with respect by the staff whilst dying. The relatives were able to spend as much time as they wanted with her throughout this time and staff supported them. There was nothing documented regarding the residents wishes in the event of terminal illness and death, within one of the files examined.
Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 10 Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: Standards within this section were not examined on this occasion. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: Key standards 16 & 18 were assessed at the previous inspection and were met. They were not assessed on this occasion. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 13 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): 19,20,21,22,23,24,25,26 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: Areas of the home are being refurbished. The home is safe and wellmaintained. Thought has clearly gone into the décor and furniture to ensure that residents are needs are met and that they have a comfortable environment. There is a large front lounge with big picture window and large screen TV. There is a smaller lounge are with TV and seating for 8 and a large lounge/dining room, also with a TV. There are 24 single rooms all with en-suite toilet and a double bedroom without an en-suite. Throughout the home there are 6 additional toilets. The ground floor toilet highlighted on the day of inspection needs a privacy lock fitting. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 14 Specialist equipment is provided as necessary. Grab rails are available throughout the home. The inspector looked at a number of bedrooms all were personalised and had sufficient furniture to meet the needs of the residents. Relatives spoken with felt that furniture was practical and comfortable. Many of the bedrooms had a number of personal belongings. One bedroom had a telephone provided at the request of the resident. The home was clean and free from offensive odours on the day of inspection. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: The home manager was not officially on duty on the day of inspection and therefore unable to access staffing records, these will be assessed at the next inspection. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: This area was not assessed on this occasion. The inspector left an immediate requirement as the manager had admitted a resident outside of the registration and this is an offence. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 17 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 3 Regulation Requirement Timescale for action 30/11/05 2 3 3 10 4 11,12 The Registered Person must 14.1 B ensure that a completed assessment of need is on file for all service users. (previous timescale 31.07.05) The Registered Person must 14.2 ensure that all assessments of need are regularly reviewed. (previous timescale 31.07.05) The Registered Person must 15.1 ensure that service users/relatives are consulted about their care. (previous timescale 31.07.05) The Registered Person must 12.2, 12.3 ensure that service users wishes are taken into account. (previous timescale 31.07.05) 16.2 M,N The Registered Person must consult with service users about activites and their preferences. (previous timescale 31.07.05) The Registered Person must ensure that staff are suitably supervised. (previous timescale 31.07.05) 30/11/05 30/07/05 30/11/05 5 12 30/11/05 6 36 18.2 30/11/05 Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 19 7 7, 8 12.1 Arrangements must be made to meet the health and welfare needs of the residents. The home must have a record of the date of admission of residents. The manager must ensure that residents living at the home are within the current registration. (immediate requirement left) 30/11/05 30/11/05 8 9 3 31 17.1 a Sch 3 (3d) 43.1 21/10/05 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 1 38 21 Good Practice Recommendations The Registered Person should consider archiving records older than 6 months to ensure the files remain easily accessible. The Registered Person should document names of those attending fire drills. A lock must be provided on the ground floor toilet identified on the day of inspection. Oaks, The DS0000002143.V261709.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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