Inspection on 25/10/06 for 11 Denby Road

This inspection was carried out on 25th October 2006.

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

11 Denby Road 24/02/09

11 Denby Road 10/01/06

11 Denby Road 23/03/05

11 Denby Road 14/09/04

11 Denby Road 24/02/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Denby Road (11) Inkersall Chesterfield Derbyshire S43 3RR Lead Inspector Judith Beckett Key Unannounced Inspection 25th October 2006 10:30 Denby Road (11) DS0000019972.V316347.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 Denby Road (11) DS0000019972.V316347.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. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denby Road (11) Address Inkersall Chesterfield Derbyshire S43 3RR (01246) 471135 NONE 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) Enable Care & Home Support Limited Mrs Jacqueline Anne Cutts Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: 11 and 15 Denby road are adjoining semi-detached bungalows, each registered for two service users. The homes are located in housing association property, within a warden-controlled development of similar accommodation for older people. Denby road is situated on the edge of Inkersall, which is approximately 4 miles from Chesterfield. There are a range of shops and community facilities nearby. Although registered as two separate homes 11 and 15 are effectively run as one establishment with one manager, one person on duty at night and shared policies and procedures. The homes are not interconnecting internally, staff move between the two through a secured shared rear garden. Each bungalow has two single bedrooms for residents, a bathroom, a communal dining/lounge and a domestic style kitchen. One bungalow has a sleep room and office for staff. The grounds are well maintained and suitable for residents. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection a pre-inspection questionnaire had been received from the manager as well as a resident questionnaire. The inspection took place over two and a half hours. On arrival at the home the manager was present but three residents were out attending day centres. One was attending the doctors for their flu immunisation. During the morning two members of staff returned with one resident to number 11. The residents of number 15 remained out during the inspection. A tour of number 11 & 15 took place. The homes area manager visited during the inspection to carry out her unannounced visit. The inspection covered all the key standards. Discussions took place with the area manager, manager, resident and staff, records were inspected. One residents care plan was looked at. What the service does well: What has improved since the last inspection? The two tumble dryers the homes have obtained have now been installed in the kitchen areas. This has improved the drying facilities in the home. New washers have also been purchased. A new lounge carpet has been fitted in number 11. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 7 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 Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 8 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): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were provided with information about the home and its service, so they could make an informed choice about whether the home was suitable for them. EVIDENCE: The statement of purpose and service user guide were well written and easy to read. Both documents included photographs. Simplified copies of the service user guide have been provided for all residents. One resident was case tracked and had a comprehensive needs assessment in their files. Residents were supported to access local learning disability services. Prior to admission residents receive a full needs assessment. Prospective residents are given the opportunity to spend time in the home, one of the residents explained that she had come at weekends for a trial prior to admission. Observations of interaction between staff and service users indicated that the home was able to meet the assessed needs of its service users. Each service user had a contract and statement of terms and conditions, detailing the fees covered. These related to Derbyshire Care and Home Support Ltd.and now requires changing since the change of company name. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 9 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): 6,7,8,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to enable them to achieve an independent lifestyle as possible. EVIDENCE: The individual written care plan of one resident was examined and their care was discussed with the manager. Care plans were formulated within a framework of risk management and in accordance with their assessed needs. They were up to date and regularly reviewed with residents. All the residents have lived at Denby Road for some time. It is evident that staff know them well. All attend varying services according to their needs and abilities. All are treated as individuals and have different hobbies and pastimes. Residents are encouraged to use any independent living skills they have and are encouraged to make independent choices according to both ability and need. Some are able to carry out small tasks in the home including laying the table, cleaning, shopping, washing up and helping to prepare meals. They all have access to advocacy services. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 10 Care plans have been developed by the staff for each service user and were reviewed on a regular basis. A key worker system is in place. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15,16,17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ individual rights, independence, wishes and lifestyle preferences were well promoted in accordance with their risk-assessed needs. EVIDENCE: Three of the residents had been on holiday recently. Two had been to Spain with two carers. They had enjoyed it so much that they were requesting to go again next year. One resident had been away with one carer in England. Arrangements had been made for the District nurse to visit the hotel to administer medication. The remaining resident was too frail to go away. Residents are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. Management seeks views of the residents and considers their varied interests when planning holidays and routines of daily living. One resident has chosen to attend a pop concert at the Sheffield Arena for their forthcoming birthday. Residents are taken shopping with their key workers to choose personal items and furnishings to their bedrooms. Residents Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 12 participate in domestic tasks according to their assessed abilities. This is recorded in their care plan. All of the residents have access to day centre services. These are reviewed regularly. They attend activities outside the home as they wish, accompanied by staff from the home. Denby Road is integrated into the local community and staff were fully aware of the facilities local to the home. Residents are enabled to access local facilities. Staff focus on involving residents in all areas of their life and actively promotes the rights of individuals to make informed choices this includes maintaining family and personal relationships. One resident returns to her family home for alternate weekends. Residents open all their own mail but some require assistance and have it read to them. Choices are available for meals. Three residents are diabetic but staff were aware of their needs concerning diet. Residents were actively encouraged to engage in meal planning, shopping and preparation in accordance with their abilities and wishes and food provided was a nutritious and balanced diet. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 13 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): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were suitable systems and arrangements in place to ensure that residents are well supported in terms of their personal and health care needs. EVIDENCE: The personal support needs of the resident case tracked were documented by way of their individual assessments and care plans including their preferences. Discussions were held with staff about the arrangements for monitoring the health of residents, including access to outside health care professionals for the purposes of routine health care screening and specialist care. One resident who is becoming increasingly frail is closely monitored concerning her needs, regular reviews are held and the possibility of nursing care being required is anticipated. Records were kept in respect of residents’ health care needs and interventions. Individual records were kept of service users access to outside health-care professionals. All residents were registered with a G. P.in Staveley.All visit a chiropodist and have dental treatment according to their needs. The District Nurse visits daily to administer insulin to two residents. The insulin is kept in a locked container in the fridge. Daily blood sugar samples are taken and recorded. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 14 Recently all staff has completing a Certificate in the safe handling of medicines. All medicines were kept in a locked cupboard in the hallway. No controlled drugs were kept on the premises. The medicine cabinet and drug sheets were inspected and seen to be in order. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 15 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): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is suitable information provided for residents and their representatives to enable them to raise concerns and to complain. EVIDENCE: The home has a clear complaints procedure. There is a copy for each service user in an easy to read format in their service user guide and this is displayed in the hallway. A record of all complaints or issues in the home are recorded. No complaints had been received about the home since the last inspection. The manager stated she is always available to discuss concerns with relative’s service users, health care professionals and staff. Staff have a good knowledge and understanding of Safeguarding Adults issues, which protects service users from abuse. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 16 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): 24,25,26,27,29,30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good providing service users with an attractive and homely place to live. EVIDENCE: A tour around both bungalows took place. The homes were clean well ventilated and well lit. Resident’s rooms were personalised, well decorated and all had new curtains and new bedding. The residents had all chosen their own colour schemes and had been taken shopping for them. Each bungalow has a bathroom equipped with handrails and a shower. These are homely. The new tumble dryers had been installed in the kitchens and new washers had also been purchased. A new lounge carpet had been purchased for 11 Denby Road and all other carpets were cleaned as well as the curtains. Residents see it as their own Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 17 home; it is very well maintained and attractive, spotlessly clean and free from any odours. One ralative commented on the exceptional cleanliness of the home. Residents are fully involved in decisions about the decor or any changes in accommodation. Fixtures and fittings are of a high quality, well maintained and adapted to meet the wishes of the residents. Residents personalise their own rooms and bring in their own furniture if they wish. New light fittings are to be chosen for the lounge. New DVD boxes have been fitted and one resident has their own in their bedroom. A new aerial has been purchased for the Digital box. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 18 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): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are well supported by a stable staff team and the manager constantly seeks to facilitate staff development in accordance with the needs of the service user group accommodated. EVIDENCE: A total of eight staff work in the bungalows. Each bungalow is staffed independently. Discussions were held with the manager about the arrangements for staffing in the home and staff duty rotas were examined. Two members of staff have retired since the last inspection and two new members have been appointed from other homes within the group. Both had done relief work at the home prior to commencing full-time employment. Two members of staff have achieved NVQ 2 and one member (the manager) NVQ 4. Other members are reaching retirement age and therefore reluctant to undertake any further training. This leaves the home with below the 50 level of staff that will have achieved NVQ 2.Efforts should be made to correct this. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 19 Monthly visits by the home managers line manager are recorded. These were looked at. During the inspection the area manager made one of her unannounced visits. Three monthly home manager meetings are held by the organisation. Discussions were also held with the manager and staff about training and development of staff, including training undertaken in the previous 12 months and that planned. New training records had been issued from headquarters to monitor all training received. Seven staff had attended the driver awareness course. All were booked for moving and handling. All had completed safe handling of medicines and undertaken a drug assessment. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 20 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): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is well managed and service users rights and interests are promoted within the framework of effective communication and management systems. EVIDENCE: The manager has now completed her N.V.Q 4.in management. Quality of service questionnaires had been completed and were seen. One relative commented on not being aware of the inspections or a report being available in the home. Discussions around this issue took place with the manager. Reports of regular visits to the home by the registered provider were made. There were satisfactory arrangements for the annual maintenance of equipment in the home. A new weekly water check was recorded in line with the organisations prevention of legionnaires policy. Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 21 There were suitable systems in place for the reporting and recording of accidents and untoward occurrences. A range of policies and procedures were in place and developed by the organisation. Denby Road (11) DS0000019972.V316347.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 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 3 4 3 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 4 25 4 26 3 27 3 28 X 29 3 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 4 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 Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 YA1 YA32 Good Practice Recommendations A copy of the most recent inspection report is made available to service users and their families. 50 care staff in the home achieve a care NVQ 2 Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. Extracts may not be used or reproduced without the express permission of CSCI Denby Road (11) DS0000019972.V316347.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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