Inspection on 04/05/05 for The Oaks

This inspection was carried out on 4th May 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.

Other inspections for this house

The Oaks 15/02/10

The Oaks 15/07/09

The Oaks 21/07/08

The Oaks 05/11/07

The Oaks 02/06/07

The Oaks 05/04/06

The Oaks 21/10/05

The Oaks 24/11/04

The Oaks 12/05/04

The Oaks 22/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Oaks 114 Western Road Mickleover Derby DE3 6RG Lead Inspector Vanessa Davies Unannounced 4th May 2005 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 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. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Oaks Address 114 Western Road, Mickleover, Derby, DE3 6GR Telephone number Fax number Email 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 Boyce CRH 28 Category(ies) of Dementia registration, with number of places The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24.10.04 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. There are registered nurses on duty 24 hours per day. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector spoke with 3 relatives and 3 residents, it was evident that all were very pleased with the service offered. 3 files were also examined. The Inspector did not discuss requirements from the previous inspection on this occasion, they have therefore been repeated in this report. What the service does well: What has improved since the last inspection? What they could do better: Assessments of need must include additional information about social likes and past history. The Registered Person should provide suitable activities and try to become more involved in the community. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 6 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 Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 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 standard(s) 1, 3, and 5 The home provides necessary information to enable residents to make an informed choice about the home and to ensure that they can meet the residents needs. EVIDENCE: The home has a very detailed Service User guide in place, providing prospective residents and their relatives/representatives with necessary information to make an informed choice about the home. Individual records are kept for each of the residents in the home, the inspector looked at 4 files. Each of the 4 files had an assessment of need. 1 file examined had an incomplete assessment, the resident moved to the home in December 2004. The inspector spoke with 3 relatives, all had visited the home prior to their relative moving in and all were sure that their relatives needs were being met at the home. All of the relatives spoken with visit regularly, 2 visiting on a daily basis. 1 of the relatives stated that she was involved with the care planning, however the other 2 had not been involved and their was no documentary evidence within the files to indicate that they were involved. All care plans within the 4 files were reviewed on a monthly basis. Three of the files had information dating back a number of years. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 9 None of the 4 files had a photograph of the resident in. All files had copies of a resident handling assessment, a nutritional assessment and a Waterlow risk assessment, however these had not been regularly reviewed. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8,10,11 This home 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: All residents are registered with a local GP. Dentists and chiropody appointments are made as necessary. There was evidence within files of residents being supported to attend a variety of health related appointments. One file examined documented a Flu vaccine being given, however there was no evidence of consent from the resident or relatives. There was evidence of a Waterlow assessment on file and a nutritional assessment. The Inspector found no information relating to residents wishes about terminal care and death. The inspector witnessed staff knocking on doors and waiting before entering and relatives spoken with stated that staff treated residents with respect at all times. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 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 standard(s) 12,13,15 Residents are offered choice and variety in some areas of their daily life. Other areas are not addressed which could potentially leave residents feeling isolated and under stimulated. EVIDENCE: The relatives spoken with felt that they were always made to feel welcome. They stated that they were contacted by the home following any incidents/accidents, GP visits and other appointments, this was evident in the files examined. The inspector evidenced the menus, they appeared to offer a varied, wholesome diet, the relatives spoken with stated that choices were always offered and the food was ‘lovely’. Specific diets are catered for and the cook has documentation relating to preferences. The assessments examined had little information relating to social needs of residents, 1 file had no information about hobbies and interests. 2 relatives spoken with stated that ‘few activities take place’ They also felt that the home should be more involved with the community. The Registered Person stated that she had tried to appoint an activity coordinator but was having difficulty. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 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 standard(s) 16, 18 There are systems in place to ensure the safety of residents, although the complaints procedure may require publicising further. EVIDENCE: The home has a detailed complaints procedure in place and staff spoken with were aware of what to do in the event of a complaint being made. The complaint procedure is displayed in the dining room on the notice board. Only 1 of the 3 relatives spoken with were aware of the complaints procedure. The manager keeps a clear record of complaints and responses. Staff spoken with were aware of what to do in the event of an allegation of abuse. There are detailed procedures for adult protection, management of violence and aggression and restraint. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 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 standard(s) 19,21, 23, 24, 25, 26 The Oaks is a very clean and safe home, ensuring the comfort and personal choice of individual residents. EVIDENCE: The home was very clean and tidy and free from offensive odours on the day of inspection. Relatives spoken with stated that the home was always like this. There are 3 lounge areas and 1 dining area. The inspector viewed 2 bedrooms, both were very individual and contained personal belongings. 1 relative stated “the manager is good about allowing residents and relatives choosing the colour of the décor in bedrooms” There are 26 bedrooms, 24 single with ensuite and 1 double. There is lift access to the first floor. Toilets and bathrooms are provided with call bells and grab rails. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 The Registered Person provides training to meet the needs of the service users. EVIDENCE: The staff spoken with stated that they received training to complete their role. The inspector did not evidence training records on this occasion but staff stated that manual handling, fire training and adult protection were up to date, they had also completed incontinence training and dementia care. The Registered Person stated that further fire training was due 3rd June 2005 and Adult Protection was scheduled for May, June, July and August. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, 38 The home is generally well managed to ensure the safety and welfare of the residents. Improvements to staff supervision are required. EVIDENCE: The staff and relatives at the home stated that the manager was very approachable and supportive, “Her door is always open”. Staff stated that formal supervision was not regular but they did work with the manager regularly. The inspector was unable to check records on this occasion as the manager keeps them in her office. The fire file evidenced fire drills taking place regularly, it is recommended that the manager details who attends. The alarm is tested weekly and fire doors tested monthly. The home has liability insurance to 13.05.05. The manager ensures that health and safety aspects of the home are monitored. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 16 The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 x 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 2 x 3 The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 18 NO 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 3 Regulation 14.1 (b) Requirement Timescale for action 31.07.05 2. 3. 3 10 4. 5. 6. 11, 12 12 36 The Registered Person must ensure that a completed assessment of need is on file for all service users. 14.2 The Registered Person must ensure that all assessments of need are regularly reviewed. 15.1 The Registered Person must ensure that service users/relatives are consulted about their care. 12.2, 12.3 The Registered Person must ensure that service users wishes are taken into account. 16.2 The Registered Person must (m,n) consult with service users about activites and their preferences. 18.2 The Registered Person must ensure that staff are suitably supervised. 31.07.05 31.07.05 31.07.05 31.07.05 31.07.05 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. The Oaks Refer to Standard 1 Good Practice Recommendations The Registered Person should consider archiving records C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 19 2. 38 older than 6 months to ensure the files remain easily acccessible. The Registered Person should document names of those attending fire drills. The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 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 The Oaks C52 C02 S2143 The Oaks V225652 040505 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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