Inspection on 15/11/07 for Daisy Vale House

This inspection was carried out on 15th November 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Daisy Vale House 04/01/07

Daisy Vale House 14/03/06

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 Carol Haj-Najafi Key Unannounced Inspection 15th November 2007 09:30 Daisy Vale House DS0000001442.V354063.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 Daisy Vale House DS0000001442.V354063.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. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daisy Vale House Address Daisy Vale Terrace Thorpe Wakefield West Yorkshire WF3 3DS 01924 822209 01924 872619 daisyvale.house@craegmoor.co.uk www.craegmoor.co.uk J C Care Ltd 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) Mrs Diane Crawley Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2007 Brief Description of the Service: Daisy Vale House is owned by J C Care, which is a subsidiary of Craegmoor Health Care. The home is registered to provide care and accommodation for up to sixteen adults who have a learning disability. At the time of the inspection there was one vacancy. 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. 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. It is within easy walking distance of local amenities, which are well utilised by people who use the service and is well served by public transport. The fees charged by the home range between £361.57 and £1104.93 per week. This information was provided on 15 November 2007, during the inspection. Information about the home including a Statement of Purpose, Service User Guide and previous inspection reports are available at the home. Up to date information about fees can be obtained directly from the home. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care (CSCI) inspects care homes to make sure the home is operating for the benefit and well being of the people who live there. More information about the inspection process can be found on our website www.csci.org.uk The last key inspection was carried out in January 2007. Before this unannounced inspection visit on the 15th November evidence about the home was reviewed. The registered manager completed an annual quality assurance assessment (AQAA) and we used this to help us decide what we should do during our inspection. Survey forms were sent out to people living at the home, their relatives and health and social care professionals. Ten surveys were returned. Three were from people who live at the home; care staff had helped them complete the surveys; six surveys were from relatives and one was from a healthcare professional. Comments from the surveys have been included in the report. The inspector was at the home between 9.30am and 6.10pm. For some part of the visit, the inspector was joined by an ‘expert by experience’. An expert by experience is someone who has expert knowledge of care services through their own experience of using services. They join the inspector to help them get a good picture of the service from the viewpoint of the people who use it. The expert by experience talked to seven people who live at the home and had a look around the home. Their views have been included in the report. Feedback was given to the registered manager and acting business support manager at the end of the visit. During the visit the inspector looked around the home, spoke to seven people who live at the home, three staff, and the registered manager. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: People are happy living at Daisy Vale. There is a lively and friendly atmosphere and people enjoy spending time with others who live and work at the home. Seven people talked about living at the home. They said, ‘it’s a nice home’, ‘staff are absolutely brilliant’, ‘staff are nice and kind’, ‘we like the parties’, ‘the food is very good’, ‘staff come and stop us arguing’, ‘staff are good at cooking’. People also talked positively about leisure activities and doing jobs around the home. They clearly enjoy the organised evening activities including a disco on a Wednesday night and a ‘TV and drink’ evening on a Saturday. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 6 Surveys from relatives were very positive and it was evident people were happy with the care provided. The following are a sample of typical responses and comments: • • • • • • I am free to visit at anytime and always made to feel welcome I am asked if I agree with decisions they would like to make The atmosphere is great The people always seem to be very happy and content It’s a safe and caring place They encourage people who live at the home to help and befriend each other Good systems are in place to make sure health and personal care needs are met. The expert by experience said, ‘the building was pleasant. It was tidy and spacious, and it looked like a proper home. There were plenty of places to sit, and people were able to do what they wanted to around the house.’ Many staff have worked at the home for a long time and they have good knowledge about the people who live there. There was some lovely interaction between staff and people living at the home and it was clear that staff and the people who live at the home have good relationships. People were very positive about the manager, she is respected and people think she does a good job. What has improved since the last inspection? New person centred care plans are being introduced. Staff were still completing the plans and working with people who live at the home and relatives to make sure the right information is in each plan. The new care planning approach is giving people more opportunities to say how they want their care needs to be met. One person has recently moved out of the home because people involved in the person’s care decided the home was no longer suitable. It took a long time to find the right placement and during this period staff spent a lot of time supporting them. Staff said after the person moved people who live at the home have received more individual quality time with staff and had more opportunities to go out. Staff and management said everyone had benefited from the recent change. Staff and management are recording more information and making sure there is enough information to monitor people’s health and welfare. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 7 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. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 8 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.V354063.R01.S.doc Version 5.2 Page 9 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): 2 People who use the service experience good quality outcomes in this area. People’s needs are properly assessed before they move into the home so everyone can be sure that the person is moving into the right home and their needs can be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: At the time of the last inspection in January 2007, one person who wanted to move in had started visiting the home and meeting other people who live at the home. The manager and other professionals were completing assessments to find out if the home could meet the person’s needs. Soon after the inspection the person moved into the home. The person has settled in well and they said they ‘like living at the home’. No other people have moved into the home for a number of years. One person has recently moved out and the manager said they were looking at filling the vacancy. She was very clear about completing pre-admission assessments to make sure the home can meet their needs and giving people time to get to know each other. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 10 In the AQAA, under the ‘what we do well’ section, the manager said, ‘Complete a full assessment before admission, ensure people come for visits, meals, and overnight stays to make sure it is the right environment, staff training is given on admission procedures. A service user guide is in operation and this is given to the person and their family before admission.’ Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 11 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 & 9 People who use the service experience good quality outcomes in this area. The new care planning approach is giving people more opportunities to say how they want their care needs to be met, and once it is fully implemented, people will receive care that is based more on their preferences and choices. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The organisation introduced new person centred care plans in June 2007. Staff were still completing the plans and working with people who live at the home and relatives to make sure the right information is in each plan. People who live at the home talked about their care plans. One person said they had done the care plan with their keyworker and had been asked what they like doing. Another person knew everything that was written in their care plan and said they had talked to the senior support worker about it. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 12 The manager talked about the introduction of the new plans. She said they had included the basic information but they still had to add more information. She said it had taken time to introduce them because they had made sure people were properly consulted. The manager said staff had received care planning training, which also covered communication and record keeping. Three plans were looked at. They all had good information about the person and provided guidance on how their needs should be met. For example, one plan stated ‘keep near the bathroom whilst bathing’, another plan stated ‘staff must be present during bathing’. Plans also gave guidance on how privacy and dignity must be respected. The care plans did have gaps and there is still some work to do before the care plans will provide a full picture of the type of care each person should receive. Either the person who lives at the home or their relative had signed two of the care plans. One plan had not been signed. Staff had not spent time reading the new plans. This is an important part of the care planning process because staff must understand what type of care is the right type of care for each person. In the AQAA, under the ‘how we have improved’ section, the manager said, ‘Person centred care plans are more service user friendly, this enabled them to take part in their care plan.’ The AQAA also said, ‘the plans for improvement in the next twelve months’ are ‘for staff to continue to improve in care planning and documentation skills.’ People who live at the home said they can make choices about what they want to do and several people gave examples. One person said they had recently chosen the colour to paint their bedroom. Another person said they go out with staff to choose toiletries. One person said they make drinks when they want and they enjoy making drinks for other people. Three surveys were received from people who live at the home; all received help to complete the forms. They said; • • • They always make decisions about what they do each day Staff always treat them well Staff always listen and act on what they say Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 13 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, 15, 16 & 17 People who use the service experience good quality outcomes in this area People are happy living at Daisy Vale. There is a lively and friendly atmosphere and people enjoy spending time with others who live and work at the home. More community participation would create better opportunities for integration into community life. Meals are not planned properly and this could lead to people having an unhealthy diet. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: During the site visit people at the home looked relaxed and enjoyed interacting with staff. They were comfortable when talking to staff and were seen asking for support. Staff responded positively and with warmth. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 14 Seven people talked about living at the home. They said, ‘it’s a nice home’, ‘staff are absolutely brilliant’, ‘staff are nice and kind’, ‘we like the parties’, ‘the food is very good’, ‘staff come and stop us arguing’, ‘staff are good at cooking’. People also talked positively about leisure activities and doing jobs around the home. They clearly enjoyed some organised evening activities including a disco on a Wednesday night and a ‘TV and drink’ evening on a Saturday. They also talked about going out shopping with staff. Three holidays were organised in 2007, a barge holiday, and two holidays to Blackpool. People talked about their holidays and said they had a good time. Holiday photographs were displayed in the home. Daisy Vale provides a service to people of different ages. Staff talked about meeting people’s different needs and said the age difference did not cause any difficulties. Surveys from relatives were very positive and it was evident people were happy with the care provided. The following are a sample of typical responses and comments: • • • • • • • • • The home is always clean and tidy I am free to visit at anytime and always made to feel welcome I am asked if I agree with decisions they would like to make The atmosphere is great The people always seem to be very happy and content It’s a safe and caring place They encourage people who live at the home to help and befriend each other Four surveys said the home always meets the needs of the people who live at the home; one said almost always; one said usually Four surveys said the care service always supports people to live the life they choose; one said usually Under the ‘how do you think the home can improve’, three surveys suggested the following: • Perhaps more exercise and outside activities • More outings • Could organise more like walks, swimming and outings • The last inspection identified that some people didn’t get many opportunities to go out with staff to use community facilities. People were using services at the home rather than community services, particularly hairdressing, chiropody and optical. There has been very little progress in this area; one person Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 15 regularly visits a community hairdresser; two other people have occasionally used a community hairdresser. All other services are provided at the home. The manager said people had been asked if they would like to use community services and had declined. However, if they have never used community services they do not have any experience to base their decisions on. This must be reviewed and people should be encouraged and given real opportunities to maintain appropriate lifestyles outside the home. One person has recently moved out of the home because people involved in the person’s care decided the home was no longer suitable. It took a long time to find the right placement and during this period staff spent a lot of time supporting them. Staff said after the person moved people who live at the home have received more individual quality time with staff and had more opportunities to go out. In the AQAA, under the ‘what we do well’ section, the manager said, ‘staff respect privacy by always knocking on doors and asking permission to enter, some people have their own keys to their rooms, staff do not open mail unless asked to do so, people choose their own menus at ‘your voice’ meetings’. The AQAA also said, ‘staff talk, interact and encourage people to help around the home, and encourage people to develop and maintain new relationships, for them to be happy, love and respect their home environment’. Staff said menus are developed with the people who live at the home. Daily records had details of what people had eaten. In the main, menus did not correspond with what was written in the daily records. On the day of the inspection shepherd’s pie was on the menu but people were given pizza. A staff member said people had decided that morning that they wanted pizza but the pizzas were in the fridge and had to be eaten that day and the ingredients for shepherd’s pie were not available. It was difficult to monitor nutrition and variation because the only accurate record of meals was in individual daily records. However meals were not generally nutritious or varied. For example people ate fish and chips four times over a two week period and had chips five times over an eight day period. The expert by experience said, ‘one person told me that it was the staff who chose what the meals were going to be, and I saw that there was only one choice on the menu for each days meal, although you could choose to have a sandwich (or salad in summer) instead if you wanted to. If people missed dinner, they could still get a sandwich, or a salad in summer, later on, even if the kitchen was locked. Two of the people who live at the home went shopping with the staff.’ Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 16 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 People who use the service experience good quality outcomes in this area. The home has good systems in place to make sure health and personal care needs are met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: In the AQAA, under the ‘what we do well’ section, the manager said, ‘Personal support is carried out in private respecting the dignity of the service user at all times, their rooms are personalised to their choice and colour scheme, staff give support with health issues and seek professional help when needed. All staff have received accredited training in medication and first aid’. One healthcare survey was returned. This raised several concerns about the home, it said: • The care service sometimes seeks advice and acts upon it; the manager did act upon advice; some care staff did not seek advice or act upon recommendations made DS0000001442.V354063.R01.S.doc Version 5.2 Page 17 Daisy Vale House • • • Individual’s health care needs are sometimes met by the care service; the approach was not person centred The care service had difficulty understanding the mental health needs of the people at the home The care service does not respect individuals’ privacy and dignity because there is no space to talk to people on an individual basis apart from their bedroom or office (This issue has been addressed in the environment section.) The manager discussed the issues raised in the healthcare survey. We agreed that the issues related to the care of one person and at a time when the home and other professionals had clearly agreed the home was no longer suitable and not equipped to meet the needs of the person. The person has since moved to more suitable accommodation. It was evident people’s health and welfare was being properly monitored. Daily records had information that people were regularly supported with personal care tasks. Healthcare appointments were clearly recorded. Once a month people’s weight was checked to make sure they have not put on or lost too much weight. Care plans had details of the support that people need with their personal and health care. The home’s medication system is a Monitored Dosage System. Medication records were looked at and they had been completed correctly. The registered manager confirmed that staff who administer medication must have completed medication training. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. People who live at the home and their relatives are confident that they will be listened to and that appropriate action will be taken when necessary. People who live at the home are safeguarded from abuse. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People who live at the home said they talk to the manager, staff or relatives if they are unhappy. Surveys from people who live at the home said they knew who to speak to if they were unhappy and how to make a complaint. Relative surveys stated they knew how to make a complaint about the care provided and the care service had responded properly if they have raised concerns. There have not been any complaints made about the home since the last inspection. The complaint’s procedure was displayed near the entrance of the home and this provided details of who to contact if people were unhappy with the service. Staff and management have attended safeguarding training and were familiar with the adult protection procedures. Whistle blowing procedures were displayed near the entrance of the home. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 19 Personal allowance records were looked at. All financial transactions were recorded. Three people’s monies were counted and the amount corresponded with the amount on the balance sheet. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 20 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, 26, 27, 28 & 30 People who use the service experience good quality outcomes in this area. People live in a nice, homely environment and are encouraged to personalise their own space, which gives people ownership. However, he lack of private communal space restricts the right to privacy. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home was clean and tidy and there were no odours. Decoration and furnishings were of a high standard. There is an enclosed garden that people freely access. People were keen to show their bedrooms and were very clear this was their personal space. Bedrooms were personalised and each room had a lot of items that reflected individual preferences. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 21 There are four main communal areas, kitchen, dining room, lounge and small lounge. People who live at the home were using all the communal rooms and were seen to walk freely around the home. There were photographs, pictures and ornaments in communal areas, which helped enhance the homely environment. The expert by experience said, ‘the building was pleasant. It was tidy and spacious, and it looked like a proper home. There were plenty of places to sit, and people were able to do what they wanted to around the house.’ He also said, ‘all the bedrooms I saw were tidy. Residents had chosen their own furniture, ornaments and posters, often from the Argos catalogue. The bedrooms had locks, and I saw somebody lock their door because he wanted to have privacy. A resident told me that they could use the bathroom in private without anyone walking in.’ The healthcare professional survey raised concerns about speaking to people in private, other than in their room, which is sometimes not appropriate. People cannot have a private conversation in any of communal rooms because they all link to each other and access to each room is open. The issue with privacy was discussed with the manager and staff. They agreed that people would benefit from having a more private area and thought minor changes to the small lounge would make the room suitable. Throughout the home there were supplies of wipes, hand wash, aprons and thermometers for testing the temperature of bath water. The water temperature was tested in several sinks that are accessed by people who live at the home. The temperature at some hot water outlets was 46 degrees centigrade which exceeds the recommended temperature. The manager explained that people accidentally catch the temperature knob on the boiler when they are in the laundry. Hot water temperature records confirmed that temperatures above 43c have previously been noted. The registered provider must make sure the water temperature is safe. The ground floor bathroom ceiling was damaged because there was a leak from the shower room above. There were a couple of tiles and some black mould on ground around the tiles. The bathroom suite and flooring looks dated; replacement of these would improve the environment. Surveys from people who live at the home said the home was always fresh and clean. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 22 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 & 36 People who use the service experience good quality outcomes in this area. A caring and knowledgeable staff team support the people who live at the home. Good systems are in place to make sure the staff feel supported. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has a low turnover of staff and many staff have worked at the home for a long time and they have good knowledge about the people who live there. People who live at the home have a genuine interest in staff and obviously enjoy spending time with them. They talked to staff about their home life and family members. There was some lovely interaction between staff and people living at the home and it was clear that staff and the people who live at the home have good relationships. Three staff are on duty during the day and on an evening. During the night there is a waking night staff and a sleep in person. Staff said the staffing levels Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 23 were much better recently but sometimes it was difficult to cover shifts when staff are on holiday or sick. This had been identified as a potential problem and the manager was in the process of recruiting an additional 37 hour post to make sure sufficient cover is in place. The expert by experience said, ‘a person who lives at the home told me that there were more staff now (there had been not enough before), so staff had time to spend with people who live at the home and talk to them, and there were more activities and more care plans as well, because of having more staff. He said that there were usually three staff on at night, and at the weekends, and one might go out with a group of five residents at the weekend.’ In the AQAA the manager said, ‘Five out of nine care staff have completed NVQ level 2 or above and one staff is completing the award’. Training records confirmed that staff training was up to date. Staff said they were happy with the training that is provided and they thought it gave them the knowledge to do their job properly. Staff talked positively about support from management and colleagues and working as a team. Staff confirmed they spend time, on a one to one basis, with the manager or senior talking about things that relate to the home and their personal development; this is called staff supervision. Only one staff member has been recruited since the last inspection. These recruitment records were looked at and all the relevant information was available. The staff member confirmed they were completing their induction programme. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 24 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 People who use the service experience good quality outcomes in this area. The home is well managed. People who live and work at the home feel valued and enjoy a friendly and relaxed atmosphere. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The registered manager has managed the home for several years and is suitably qualified. People were very positive about the manager, she is respected and people think she does a good job. In the AQAA, under the ‘what we do well’ section, the manager said, ‘the manager has NVQ 4 in care management, ensures the home’s budget is Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 25 managed properly, has undergone budget training and staff management training’. People at the home have monthly meetings. They talk about various topics that relate to the home. At the last meeting they talked about Halloween and Bonfire parties, menus and keyworkers. The registered manager and registered provider tell the CSCI about important events that happen at the home. Since the last inspection the CSCI have received regulation notifications and monthly reports about the conduct of the home. No concerns around safe working practices were seen on the day of the inspection. The last inspection identified that there were some problems with the general reporting and recording systems. The AQAA said, ‘documentation in the home was improving’. This inspection confirmed that the recording systems had improved. The AQAA also said they carry out audits on quality, infection control, medication, finances, and health and safety. In the AQAA the manager said relevant policies and procedures were in place, and many were reviewed in 2006 and 2007. She also said equipment has been serviced or tested as recommended by the manufacturer or regulatory body. Portable electrical equipment was tested in September 2007 and gas appliances were serviced in May 2007. The healthcare survey raised a concern about evacuating the home during the night. The manager said they were satisfied this could be carried out safely and speedily. The home does not have an emergency call system. The manager said people would call for assistance if required. This should be properly assessed to make sure the right people are alerted in the event of an emergency. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 26 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 X 4 X 5 X 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 2 25 X 26 3 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Care plans must continue to be developed to make sure they provide a full picture of the type of care each person should receive. This will make sure people receive person centred care and their health and welfare needs are identified properly. Staff must be given time to read the care plans so they understand how to meet each person’s needs. People must have more opportunities to use community facilities to enable them to integrate into the local community. (Timescale of 31/03/07 not met) Meals must be properly monitored to make sure people who live at the home are offered choice and a suitable nutritious and varied menu. Hot water outlets that are used by people who live at the home must be distributed at a safe temperature to make sure DS0000001442.V354063.R01.S.doc Timescale for action 31/01/08 3. YA13 16 29/02/08 4. YA17 16 31/01/08 5. YA24 13 31/01/08 Daisy Vale House Version 5.2 Page 28 people are not scalded. 6. YA28 23 People who live at the home 31/03/08 must be able to meet others in private which is separate from their bedroom. This is to make sure their privacy is respected. An assessment must be carried 31/01/08 out to make sure people can get help from others in an emergency during the day and at night. This will make sure help is available when it is needed. 7. YA42 13 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 YA24 Good Practice Recommendations The bathroom suite, tiling and flooring should be replaced so people who live at the home can bathe in a pleasant environment. Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Daisy Vale House DS0000001442.V354063.R01.S.doc Version 5.2 Page 30 - 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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