Inspection on 14/03/06 for Daisy Vale House

This inspection was carried out on 14th March 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Daisy Vale House 15/11/07

Daisy Vale House 04/01/07

Daisy Vale House 07/11/05

Daisy Vale House 06/10/04

Daisy Vale House 08/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Daisy Vale House Daisy Vale Terrace Thorpe Wakefield West Yorkshire WF3 3DS Lead Inspector Karen Westhead Unannounced Inspection 14th March 2006 10:30 Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 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 Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 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. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Daisy Vale House Address Daisy Vale Terrace Thorpe Wakefield West Yorkshire WF3 3DS 01924 822209 01924 872619 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) J C Care Ltd Mrs Diane Crawley Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Daisy Vale House is owned by J C Care, which is a subsidiary of Craegmoor Health Care. It is managed on their behalf by Ms Diane Crawley. The home is registered to provide accommodation for up to sixteen adults who have a learning disability. At the time of the inspection there were no vacancies. Daisy Vale House was adapted and extended to provide the present accommodation. It was originally a Methodist chapel. There is a good amount of communal space including a large lounge, a dining room and a quiet room. There are fourteen single bedrooms and one double, all of which are well decorated and personalised to the wishes of the occupants. There is a well-kept garden area to the front of the home facing on to the main road and on the road parking, in the cul-de-sac. There is a designated car park, however this is rarely used as the surrounding households use the area for parking and at times block the entrance. There is a notable emphasis, at Daisy Vale House, on organising and encouraging resident involvement in a variety of activities including college and training centre attendance, holidays/trips, and social events. The atmosphere is relaxed and friendly. The home provides all domestic services and where possible residents are encouraged and enabled to use the facilities provided. Staff are provided throughout the day and night. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the Commission for Social Care Inspection (CSCI) is required to undertake a minimum of two inspections of all regulated care homes. This was the second inspection of this home for the 2005/2006 inspection year. One inspector undertook the inspection, which was unannounced. The visit started at 10.30am and finished at 2.40pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. The last inspection of this service was on 7th November 2005. At that time four requirements were highlighted. These have all been addressed. During the course of the visit, the inspector spent a large proportion of time speaking with residents, staff members and the manager. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. All staff on duty were spoken to and observed carrying out their work. Individual and group discussions were held with residents. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. One comment card asks questions about the inspection process and the way the inspector carried out her duties. After completion these are returned to the CSCI. Feedback about the findings from the inspection were given to the manager at the end of the visit. What the service does well: The home continues to provide a good level of care. During the visit the inspector spent a good proportion of time talking and interacting with residents. Residents are clearly comfortable in the home and staff work hard to make sure their needs are met. Attention to detail is evident and the staff group know the residents so well they are able to notice subtle changes quickly. Staff are proactive in their efforts to ensure residents attend leisure activities, educational placements and therapeutic recreation. Overall there is good organisation around leisure. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 6 Whilst speaking to staff it was clear that they feel well supported by the manager and that they work as a team to make sure the residents receive a good quality service. What has improved since the last inspection? 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. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 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 Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 5 Prospective residents are fully assessed before coming to stay at the home. They are given an opportunity to visit Daisy Vale House before making a decision about moving in. The assessment is used to make sure the home can meet the resident’s needs. All residents have a contract with the home and know what services are to be provided. EVIDENCE: The home has the necessary procedures and strategies in place to successfully admit new residents. However, the current group of residents have lived at the home a significant amount of time and there have been no admissions or discharges for about four years. One resident, with the encouragement of family members, is being supported in looking for alternative accommodation. The staff have voiced their views on this, however, they are working with staff from another care setting to make sure all the necessary information is shared and that if the move goes ahead the resident and future carers have a full picture on which to base their decision. It was evident that the manager from the new provision had visited the resident at Daisy Vale House and talked at length with staff about specific care needs and challenges. During the inspection the resident left to begin a short stay at the new home. Staff assisted him and gave verbal support as he left. A subsequent telephone call confirmed he had arrived safely. It was clear Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 9 that staff want the best for the resident and their concerns were around continued progress. During the visit the inspector spent a good proportion of time talking and interacting with residents. Residents are clearly comfortable in the home and staff work hard to make sure their needs are met. Attention to detail is evident and the staff group know the residents so well they are able to notice subtle changes quickly. In particular residents who have limited communication and understanding. Staff are very attentive and are able to pick up nonverbal triggers, which can indicate discomfort, unhappiness or illness. Therefore enabling them to take appropriate action promptly. The inspector gained the impression from observing and talking to residents that they were satisfied with the care and attention provided. No complaints were raised with the inspector. The inspector viewed a random selection of files. Those seen contained an up to date contract, plan of care, evaluation and review. Work has been done to make sure all the care plans include up to date information about each resident. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Residents, who were able to express a view, are confident that information held about them is kept private and handled appropriately. Information is not shared with others unless the reasons are discussed with them and agreed. Residents understand that information given in confidence may need to be shared if it is serious. EVIDENCE: Records and personal information is kept in the office, which can be locked. During the course of the inspection some residents referred to ‘their file’ and knew a broad outline of what was kept. The policy on confidentiality is referred to in the staff handbook and staff, when signing their contract of employment, sign to acknowledge their compliance. In discussion with staff, they were clear about their roles and responsibilities and that information given to them in confidence may on occasion have to be shared with senior staff and others. The organisation has a statement regarding confidentiality; this is available to outside agencies, residents and other interested parties. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 16 and 17 Residents are offered a healthy diet and enjoy mealtimes. Staff share mealtimes with residents and encourage them to become involved in the tasks in the kitchen. Residents have appropriate support from staff, outside agencies and other professionals in order for them to lead a fulfilling lifestyle inside and outside the care home. Educational, social and recreational activities provide a good balance and allow the opportunity for personal development. Family links are maintained and residents are able to develop intimate and personal relationships with people of their choice, where appropriate. Assistance and guidance is provided in these areas. EVIDENCE: Residents share their meals with staff in the dining area. They have access to basic food items during the day and work alongside staff when preparing meals. The lunchtime meal consists of a variety of snacks and the main meal of the day is served at teatime when most residents have returned from their Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 12 day’s activities. The menu plans seen included a range of dishes and residents spoken with said it was good because they all liked the menu choices and had helped to write the menu for the coming week. Budgets for food provision were said to be adequate and the weekly shop is done at a variety of large supermarkets. The inspector observed the serving of the meal at lunchtime. This was well organised and residents were given a choice of snack, time to eat their meal and time to chat at the tables afterwards over a cup of tea. Written evidence on file and in the daily notes showed that residents were maintaining outside links and being given help, reassurance and assistance to engage in meaningful and fulfilling relationships with people of their choice. All residents have a key to their rooms. The inspector noted that residents respected each other’s belongings. Residents are involved in household tasks and this is distributed according to individual skills and abilities. Residents who are reluctant to engage are given support. Some residents were proud of their achievements and enjoyed showing the inspector around the home. A number of residents can access community facilities unescorted. This includes services locally and out of area. Other residents are escorted. Staff are proactive in their efforts to ensure residents attend leisure activities, educational placements and therapeutic recreation. Overall there is good organisation around leisure. During the course of the visit residents were seen interacting with staff about their days activities. Appropriate support was being offered and the inspector gained the impression that this practice was the norm. Residents with specific and complex needs are provided with specialist support from other agencies if required. Residents, who were able to share their experiences, confirmed they were satisfied with the levels of activity provided. Those residents with limited understanding and speech were supported appropriately and systems were in place to monitor their involvement in organised and ad hoc events. Residents were pleased with the delivery of a ‘people carrier’, which is to be used for their benefit. Some residents informed the inspector about their forthcoming holidays. A summer holiday in Blackpool, a barge weekend and a trip to Benidorm were mentioned. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 21 A policy relating to care of the dying is in place. The medication records are maintained accurately therefore making sure the correct prescribed drugs are given properly. EVIDENCE: At the last inspection the medication records were found to be incomplete and did not reflect the medication, which had been given. This was checked again during this visit and the matter had now been rectified. There is a policy in the home, which relates to care of the dying. Where possible the wishes of residents in this area have been documented. For residents with limited understanding, staff have made enquires with either family members or representatives to make sure records are accurate. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a robust adult protection and complaints procedure. All but one member of staff have been trained to understand the subtle aspects of abusive behaviour and the action to be taken if suspected abuse is reported to them. EVIDENCE: There have been no complaints since the last inspection. Two adult protection issues have been investigated. One resulted in a member of staff being dismissed, the other confirmed the home had not been at fault and ongoing measures have been put in place when the resident involved is out of the home. All accidents and incidents are recorded. The home does not use any form of restraint when dealing with residents. The organisation uses the skills of a ‘clinical governance’ team. It is their responsibility to visit the homes to carry out audits and assess care practices. The manager confirmed that an audit had been carried out in recent weeks and the result had been good. In addition to this a financial audit had also been done. As a result of this the manager had purchased a money safe for residents cash to provide additional protection. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 and 30 The premises are well maintained. Attention to detail makes for a homely atmosphere. The home was found to be clean and tidy. There is no ramped access to the front door, therefore presenting some difficulties for those with mobility problems. There is one double bedroom; all the others are for single occupancy. Therefore residents are able to have their own private area and decorate and furnish this according to their taste. EVIDENCE: Daisy Vale House is a no-smoking building. Staff support residents in their efforts to keep the home clean and tidy. The range of tasks undertaken rely on the skills and abilities of the resident. However, staff are aware of their duty of care and make sure thorough cleaning is undertaken where necessary. A full inspection of the premises was not done during this visit. However, many areas were seen on the ground floor. The staircase and landing have been recarpeted and the home is presented well. Appropriate systems are in place to check the fire safety equipment. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 16 Residents have access to all communal areas. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Staff have clear roles and responsibilities. The manager must make sure all staff are appropriately trained. There are sufficient staff on duty to cater for the needs of the current resident group. The organisation has a sound recruitment and selection process. EVIDENCE: The manager confirmed that the overall staffing levels were good. Since the last inspection one member of staff has been dismissed and another appointed. Whilst speaking to staff it was clear that they felt well supported by the manager and that they worked as a team. Since the last inspection the home now has a permanent arrangement for night staffing. There is one waking night staff and a sleeping in who is available if required. Staff have attended a number of courses, some routine and others more client focused. Staff were seen carrying out their respective duties. One situation, which required sensitive handling by the member of staff present, was dealt with competently and professionally. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 18 The recent recruitment and selection of a new staff member included completion of an application form, a satisfactory police check (enhanced), production of two written references and an interview. The new starter confirmed they were in the process of completing an induction programme, had a job description, a handbook and contract of employment. They also intended registering to undertake a course, which would result in them getting a national vocational qualification. All other staff have already qualified to NVQ level 2. The home now has a male member of staff to work along the previously all female team. The male residents at home during the visit said they were glad there was a male carer and said he seemed to have settled into the staff team well. The manager confirmed her attendance at a two-day training course around recruitment and selection. IN view of the low staff turn over she said she was pleased to have been able to update her practice. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 43 There is a defined management structure. The homes policies and procedures are written in a way, which is resident-focused and protects their best interests. The home has a system in place to check out levels of quality. EVIDENCE: The fire records were checked and found to be in order. The organisation has adequate insurance cover in place. Senior managers within the organisation have a business plan and managers in the home are expected to contribute to this. Managers present their budget forecasts and discuss the needs of each home as part of the overall financial plan. During the course of the visit no problems with highlighted regarding the financial viability of the home. The home is visited on a monthly basis by an official from the main office. A report about the running of the home is completed and a copy forwarded to the CSCI. The organisation has initiated a quality assurance scheme. This has Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 20 yet to be introduced at Daisy Vale House. However the manager continues to seek the views of relatives and residents regularly. No problems with viability. Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 21 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 X 2 3 3 4 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 3 25 X 26 4 27 3 28 X 29 2 30 3 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 X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 4 14 4 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 X X 3 X X X 3 Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 22 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 YA29 Regulation 23(2)(n) Requirement The registered person must provide a ramp to the main entrance of the home. Timescale for action 29/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Daisy Vale House DS0000001442.V285693.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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