Inspection on 06/10/09 for Deangate Care Home

This is the latest available inspection report for this service, carried out on 6th October 2009.

CQC found this care home to be providing an Good service.

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.

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Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Deangate Care Home Towngate Mapplewell Barnsley South Yorkshire S75 6AT Lead Inspector Ivan Barker Key Unannounced Inspection 6/10/09 12:00 DS0000072812.V377346.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deangate Care Home Address Towngate Mapplewell Barnsley South Yorkshire S75 6AT 01142 899050 01226 387358 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) Hill Care Limited Jane Elizabeth Bennett Care Home 50 Category(ies) of Dementia (50), Old age, not falling within any registration, with number other category (50) of places Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 50 New registration Date of last inspection Brief Description of the Service: The building is purpose-built. It consists of two units. One being for the care of older people and the other for people with dementia. It is situated near the main road which has transport, shops etc. The fees at the time of the inspection were Min 356.77 to Max 503.07 Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A number of the National Minimum Standards were examined at this inspection (with emphasis on the key standards). The person present at the inspection was M Ackroyd manager. Within this site visit, which occurred over a 4 and a half hour period, we examined requirements relating to the previous inspection. We toured the building, case tracked 3 people (case tracked means looking at the care and service provided to specific people living at the home; checking records relating to their health and welfare, by talking to the specific people; viewing their personal accommodation as well as communal living areas). We spoke with other people, relatives and also staff and examined assessments, care plans, risk assessments, menus, complaints files, staff records and quality monitoring documents. The history of the service was examined prior to the site visit. This included the AQAA (Annual Quality Assurance Assessment), a self assessment document, telephone contacts, letters and notifications. The manager information on the previous page is incorrect. The manager at the service is Mary Ackroyd. However she is not registered with the Commission. The correct telephone number for the service is 01226 383441. The overall rating for this service is two star good service. What the service does well: Peoples needs were known to the service prior to admission. The 2 assessments ensured that the service had sufficient information to assess if the service was able to meet the persons needs. Accurate care plans will contribute to the delivery of care. Activities were organised therefore this provided stimulation. People were able to exercise their right of choice regarding meals. Both will enhance their quality of life. People and relatives were satisfied with the care. We obtained the views of the people and relatives, during the visit. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 6 Their opinions were: “They (staff) are lovely, very kind and caring”. “We (people) are looked after really well”. “They (staff) let my husband stay in bed, and always save him a cooked breakfast”. There is an activities room where we do painting and craft work. We have been planting bulbs in pots ready for the garden. They (people) are always busy doing activities. They enjoy the lady that comes in on a Friday. The activities person is really lovely. The staff are very kind. The staff are very good. They (staff) are a caring team. The manager was able to provide evidence that staff had received all the necessary training which would reflect on the quality of care being delivered to the people. The staff recruitment process provided protection for the people. There was an experienced management team in place and this contributed to the effective organisation and operation of the service. What has improved since the last inspection? What they could do better: The service had a complaints procedure. However the recording could be improved so as to demonstrate the actions taken to resolve complaints within the 28 day timescale. People lived in a service that had been maintained to a good standard to provide a safe and generally well maintained and homely environment. However one newly created room was not useable because of the restricted access. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Deangate Care Home DS0000072812.V377346.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 Deangate Care Home DS0000072812.V377346.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs were known to the service prior to admission. The 2 assessments ensured that the service had sufficient information to assess if the service was able to meet the persons needs. EVIDENCE: On examination of the care management assessments within 3 care plans, it was established that there were assessments in place. On discussing the assessments with the manager, she advised that the service received copies mainly through the post, but sometimes these were faxed. She confirmed that assessments were always received prior to any person being admitted into the service. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 10 The manager advised that the deputy manager or herself visited the potential person and undertook an assessment prior to admission. These assessments fully detailed the persons needs and assisted in providing sufficient information for the staff to decide if the service could meet their needs. It also provided sufficient information for care plans to be drawn up. The manager advised that intermediate care was not provided within the service. Deangate Care Home DS0000072812.V377346.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Accurate care plans will contribute to the delivery of care. People and relatives were satisfied with the care. EVIDENCE: On examination of the care plans from 3 people, it was established that all 3 care plans were up-to-date, and had been evaluated on a monthly basis. There were daily entries within the care plans. These entries recorded the care delivered on a daily basis. Comprehensive risk assessments were included within the care plans and included moving and handling, nutrition, skin integrity and other risk factors. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 12 The records were set out in an easy to read manner with clear documentation and were easy to reference. We obtained the views of the people and relatives, during the visit. Their opinions were: “They (staff) are lovely, very kind and caring”. “We are looked after really well”. “They (staff) let my husband stay in bed, and always save him a cooked breakfast”. The storage, ordering, administration and disposal of medication were discussed with the manager. The procedures explained by the manager were satisfactory. On examination of the Medication Administration Records (MAR’s), the records were found to be fully completed. On examination of the medication storage areas, it was found that the medication trolleys were chained to the wall. It was discussed that the chains may be removed if the security of the door is to the high specification, equivalent to a 5 lever lock. Deangate Care Home DS0000072812.V377346.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities were organised therefore this provided stimulation. People were able to exercise their right of choice regarding meals. Both will enhance their quality of life. EVIDENCE: The manager advised that there was an activities coordinator who was employed for 22 hours per week. The activities coordinator provided activities on Monday, Wednesday, Thursday and Friday. We were advised that a lady visited on a Friday and people participated in the singing of hymns and songs. We were shown the activity records which identified that activities, entertainment and trips out did occur. It was discussed that the record keeping could be improved. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 14 The trips consisted of the visits to Blackpool and Manchester airport to observe the planes. The deputy manager advised that the airport trip was so enjoyed by the people that they plan to organise another trip. Entertainers visited the home every 2 months. The comments from people and relatives were: There is an activities room where we do painting and craft work. We (people) have been planting bulbs in pots ready for the garden. They (people) are always busy doing activities. They enjoy the lady that comes in on a Friday. Regarding the meals, we were informed that the staff took the menu round the previous day, and asked each person for their choice. Menus were also available on the dining tables. Evidence that choices were offered was seen when we visited the kitchens. The member of the kitchen staff was able to provide a list of the meals ordered for the day of the visit and one for the following day. The manager provided copies of a survey which was undertaken regarding the lunch and tea. It identified that 42 surveys were sent out, and 35 were returned. Most of the surveys had been completed by the relatives. The response was very positive and contained some suggestion which had been taken on board by the manager. The comments and the results of the surveys were on display for people, relatives and visitors to read. Deangate Care Home DS0000072812.V377346.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service had a complaints procedure. However the recording could be improved so as to demonstrate the actions taken to resolve complaints within the 28 day timescale. EVIDENCE: The complaints procedure was available within the Service User Guide. A copy was displayed. It contained the old contact details of the Commission. The manager agreed to remove these from the procedure. On discussing complaints with the manager, she produced the complaints file. Within the file was 1 complaint from July 2009, which had been acted upon. However there was no structured form to record the complaint, action taken and the date it was resolved. The manager identified that because she had only been in post a short period of time, she had concentrated on care issues and complaints were an area she was yet to review. The manager agreed to examine the complaints recording and to produce the necessary documents. Regarding safeguarding Adults, the service had policies and procedures which were available to staff. Staff had undertaken safeguarding training and the manager was able to evidence this by showing us the training records. Deangate Care Home DS0000072812.V377346.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People lived in a service that had been maintained to a good standard to provide a safe and generally well maintained and homely environment. However one newly created room was not useable because of the restricted access. EVIDENCE: On touring the building it was found to be generally decorated to a good and the 2 rooms which required some action were detailed in the redecoration programme, to be completed within the next 6 months. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 17 Several of the doors had sustained minor damage around the base. It was observed that the service had several people who were independent in their wheelchairs. The benefits of having door protectors and ‘hold open’ devices were discussed. The manager explained that one of the double rooms was being used as a single room and a new single room had been created. The new room was previous used as a staff room. We were informed that this room was Number 49, although it had no number on the door. The entrance to the room was immediately behind a fire door on the corridor. This fire door needed to be released to gain full access to the room, when entering with a wheelchair, hoist etc. However it was accepted that an able bodied person may squeeze past the fire door to enter the door. The room was empty when the inspection took place. The manager agreed that the room would remain empty until the fire service had visited and work had been completed to change the fire door to meet the requirements from the Fire Authority. The reduction of the double to a single room and the addition of the other room do not affect the registration of the service as the registered number remains the same. However the double room should not be recreated as this would place the numbers above the registration. A letter informing us of the changes would have been helpful rather than to find a problem with the changes when undertaking an inspection. Deangate Care Home DS0000072812.V377346.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager was able to provide evidence that staff had received all the necessary training which would reflect on the quality of care being delivered to the people. The staff recruitment process provided protection for the people. EVIDENCE: On examination of the staff rotas and examination of staff on duty, the following was established. AM shift: PM shift: N Shift: 1 qualified nurse and 6 care staff. 1 qualified nurse and 6 care staff. 1 qualified nurse and 3 care staff. Plus: The manager, administrator, kitchen and laundry staff, and a handyman. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 19 Caring for a present occupancy of 41 people. A full assessment of the dependency levels of the people was not undertaken and compared with the indicated staffing levels. However we questioned why there was only 1 qualified nurse on duty for 41 people. The manager informed us that there were only 12 people receiving nursing care and that many of the other people were of a low dependency. On examination 3 staff files, these were found to contain all the required documentation, including the Criminal Records Bureau and Protection Of Vulnerable Adults checks. On examination of the staff training records it was established a considerable amount of training did occur. The training consisted of moving and handling, fire, health and safety, infection-control, food hygiene, dementia awareness and nutrition. We were shown evidence that pressure care, challenging behaviour and care of the dying training had been planned. The comments from the people and relatives were: The activities person is really lovely. The staff are very kind. The staff are very good. They (staff) are a caring team. Deangate Care Home DS0000072812.V377346.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was an experienced management team in place and this contributed to the effective organisation and operation of the service. EVIDENCE: There was a manager in post. She advised that she had 41 years experience in the provision of care and 12 years experience in management. She also advised that she had obtained the registered managers award and was an NVQ assessor. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 21 She identified that she had only been in post a few weeks, but intended to apply to be the registered manager. Regarding Quality Assurance, we were shown evidence that monthly monitoring of specific areas did occur. This monitoring was undertaken by the manager. The service had a credit and debit system regarding personal monies. However the recordings in the book were not signed by 2 individuals. On examination of the receipts, these were found to contain 2 signatures on the back of the receipt. It was discussed with the manager that it would be beneficial to set up a system where the monies were reconciled on a weekly basis or at least monthly, by 2 people. Regulation 26 documentation, which were a record of the registered persons monthly visits were up-to-date. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc had been received by the Care Quality Commission. The information contained in the AQAA confirmed that all the health and safety and maintenance had been undertaken. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 22 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 3 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 3 X 3 X X 3 Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP19 Regulation 23 Requirement The newly created room should be fit for purpose and accessible. Therefore the instructions from the fire authority should be met. Timescale for action 04/12/09 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 Refer to Standard OP31 Good Practice Recommendations There should be a registered manager in post. Deangate Care Home DS0000072812.V377346.R01.S.doc Version 5.2 Page 24 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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