Inspection on 07/11/05 for Daisy Vale House

This inspection was carried out on 7th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 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 14/03/06

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 7th November 2005 09:30 Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 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.V262837.R01.S.doc Version 5.0 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.V262837.R01.S.doc Version 5.0 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.V262837.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2004 Brief Description of the Service: Daisyvale 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. Daisyvale 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 Daisyvale House, on organising and encouraging service user 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 service users are encouraged and enabled to use the facilities provided. Staff are provided throughout the day and night. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 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 first 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 2.45pm. The purpose of the inspection was to ensure the home was being run properly and managed for the benefit of residents. The last inspection of this service was on 6th October 2004. At that time two requirements were highlighted with no recommendations. The registered person had to clarify the banking arrangements for residents and make sure there are sufficient staff on duty at all times. As a result of this visit, a separate letter was sent to the organisation in control reiterating concerns about night staffing arrangements and the required action. The work being done with banking arrangements was near completion. The inspector spent a large proportion of time speaking with residents, staff members and the manager. A number of documents were inspected and a tour of the premises carried out. All staff on duty were spoken to and observed carrying out their work. The inspector spoke to residents in private as well as in groups. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. After completion these are returned to the CSCI. In addition, information leaflets were given to residents with a brief description of the CSCI function and details of how to contact the lead inspector. Feedback about the findings from the inspection were given to the manager at the close of the visit. What the service does well: Daisyvale House is clearly a resident led home. Staff put residents first as much as possible. It was clear from the evidence gathered on the day that residents are able to make informed choices about their lives. Those residents with difficulties with communication or understanding are supported. Staff have been able to adapt their working practices to make sure everyone has a voice. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 6 Staff work hard to make sure residents develop at their own rate and create opportunities for them to achieve personal goals. Staff involve residents as far as possible in setting out their plan of care, which aim to achieve their expectations. Risk assessments are designed to minimise risk and not impose unnecessary restrictions on what people can do. Activities and training for residents is seen as an important part of their lives and staff support residents in this area. There is a good balance between educational, social and recreation. It was evident that people also had time to relax in the home and spend time with family and friends if they wished. The standard of the décor and maintenance of the building is good. The presence of a maintenance worker is seen as a key factor in this area. The home has good adult protection procedures and staff understand what to do if they observe or receive a report of inappropriate behaviour. The home gives training and support for staff, which enhances and develops their skills and abilities. Recruitment and selection procedures are in place to make sure suitable people are appointed and that residents are protected. What has improved since the last inspection? What they could do better: Night staffing arrangements were not satisfactory, additional night staff are required. The type of shift required, whether waking or sleeping in, will be determined when a review of resident need is carried out. Overall the standard of soft furnishings is good, however, the stair carpet is showing signs of wear and tear and needs replacing. The recording of medication needs to reflect the medication being given and must be accurate. The kitchen door needs a self-closing device, if it is to remain open for ease of access by residents. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 7 Some information e.g. contact with family; nutrition/dietary intake and health related matters were not consistent and could cause confusion to the reader. Further work is required in this area to make sure information is amended accordingly. 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.V262837.R01.S.doc Version 5.0 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.V262837.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home provides satisfactory information about the services and facilities provided. EVIDENCE: Since the last inspection there have been no resident admissions or discharges. The statement of purpose and resident guide is informative and provides the reader with an overview of what Daisyvale House provides. Residents with limited understanding have access to information in different formats, including pictures and symbols. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 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): 6, 7, 8 and 9 The care files seen were well ordered and provided a chronological record of the care being delivered. Some updating was required. Residents are helped to make choices about their lives. Residents who could communicate verbally gave an account of their experiences in the home and talked about their care plans and wishes. Thus providing the inspector with an insight into their lives and demonstrating they retained control over what happened to them. EVIDENCE: Staff have been trained to show them how to complete care plans. The files examined were all made up in the same format, which made it easy to find information in each section. The care plans are checked by a senior person from the organisation on a monthly basis. Some information e.g. contact with family; nutrition/dietary intake and health related matters had not been amended to reflect changes in the care residents were receiving or their current situation. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 11 Daily recording in most care plans gave a good picture of daily events. Some staff were better than others at recording their actions in response to care needs. This was acknowledged by the manager. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 12 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): 11, 12 and 15 Educational, social and recreational activities provide a good balance between structured programmes and opportunities for personal development. EVIDENCE: Information recorded on the daily events sheet and activity register showed there is a diverse range of structured activities for residents to take part in. Activities include further education and recreational events. On the day of the visit, some residents were out on a shopping trip, others were attending day services, going to work or relaxing at home. The inspector was observing a handover between the morning and afternoon staff when the ‘shoppers’ returned. Staff received residents in a friendly and welcoming manner. Listened to their experiences, viewed presents and gave them time to talk about the outing. The inspector gained the impression that it was important for residents to be given attention on their return home and that staff could be flexible enough to accommodate every eventuality. This was one example, of staff putting residents first, of several seen during the visit. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 13 Residents said they could welcome visitors and friends and that this was encouraged by the staff. It was clear from the information seen and shared that the home endeavours to maintain links with family and friends and promote opportunities where residents can meet people who do not have a similar disability or illness. Information held must be maintained to reflect any changes in authorised contact. This is covered in standard 6. Records and conversations with residents showed that they were encouraged to develop and keep intimate personal relationships with people of their own choice. Guidance has in the past been provided in house and from professional agencies, as required, to make sure residents are making appropriate decisions in this area of their lives. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 14 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): 18, 19 and 20 In general the care files seen give a good indication of the level of care each resident receives. Support around health needs is good. The record of medication was not accurate. EVIDENCE: The layout of care plans makes it possible to see how individual goals are to be met. The information identifies how much support is required to maintain people’s wellbeing and health. Staff access information from a variety of agencies and use the help of other professionals to make sure residents receive the best advice and treatment. The home has good links with the local doctors surgeries. All medication is delivered in pre-dispensed packages. The record of medication was found to be up to date, apart from one entry which showed the dosage of a drug to be given to one resident as required but did not include the name of the drug. The training record indicated that all staff have received training for the administration of medication. This was due for renewal and would be provided by the pharmacist. The medication file includes useful supplementary information of drugs in use. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 15 None of the current resident group takes responsibility for taking and storing their own medication. This decision is determined by a risk assessment and if appropriate a discussion with the resident. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 16 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): 23 The home has a robust adult protection procedure and all 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: The organisation provides a series of workshops around the protection of vulnerable adults. Training varies from base line in house training to a oneday session provided by an external trainer. In the last six months there has been one adult protection issue in the home. The manager and staff team have devised a way of recording and liaising with outside agencies to make sure strategies are in place to protect the resident involved. There has been one complaint made to the home directly in the last twelve months. This resulted in action being taken to ensure the continued protection of a resident. However, the initial investigation concluded that the complaint was not upheld with regard to Daisyvale House. A member of staff spoken with was able to describe the action to be taken in the event of concerns being raised or if they observed bad practice. Residents said they were confident in the abilities of the manager and that if they complained about anything, she would ‘see to it’. The manager and staff team try to resolve ‘grumbles’ within the home before they develop into a complaint. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 17 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, 25, 28 and 30 The home is comfortable, with a domestic feel to the furniture and fittings. There were some requirements highlighted during the inspection which are health and safety matters. Improvements, furnishings and redecoration are funded from the annual budget. EVIDENCE: The communal areas and most of the bedrooms were seen. Some residents were at home and using these areas for relaxation. Since the last inspection new armchairs and settees have been purchased. Residents said they liked the new furniture. The home was fresh and clean. Staff and residents clearly take a pride in the home. Residents assist with household tasks. Their involvement is determined by their individual skills and abilities. The stair carpet is showing clear signs of wear and tear. In some areas the carpet is threadbare. The manager said this was to be replaced in the next financial year. However, staff must remain mindful of any risks and trip hazards and take action if the condition of the carpet deteriorates further. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 18 The kitchen door needs a self-closing device if it is to remain open for ease of access by residents. The home has a rolling programme of refurbishment and redecoration. A maintenance worker is employed by the organisation. He spends a set amount of time in the home. He is involved in health and safety meetings and records any maintenance carried out on fire safety equipment and other services. All staff and residents have received fire safety training. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 19 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): 31, 33 and 36 The number of staff available on each shift is adequate, apart from the cover provided during the night. A letter was sent to the organisation immediately following the visit to inform them of the action required. Formal supervision is provided for all staff and records kept of the key points talked about. Routine training is given to allow staff to update their skills and knowledge. EVIDENCE: Since the last inspection there have been no changes in the staff team. A nucleus of staff have worked at the home from between six and fifteen years. The manager has worked in the home for over ten years. The set pattern for staffing includes three staff on duty in the morning and two in the afternoon. The manager is supernumerary. There is always a senior member of staff on duty and on call arrangements are well organised. The staffing levels during the night are not satisfactory. The home has in the past provided one waking and one sleeping in member of staff. This had been reduced recently. However, this must be reviewed in line with the needs of the resident group and health and safety matters. Whether this member of staff is waking or sleeping will be determined by the review. During the visit the inspector talked to a visiting community psychiatric nurse who was meeting with a resident. Her comments were positive and she described how the staff and manager had dealt with some difficult situations in Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 20 recent weeks. She said she was able to work with staff in an open and frank way to make sure the resident was receiving the care she required at this time. A longstanding member of staff confirmed that she has received regular in put from senior members of staff and felt the training she had been given allowed her to carry out her job well. The staff on duty were seen to reply to residents requests in a clear, competent and patient manner. Staff on duty said they had regular supervision sessions, which included looking at individual care files, training needs and working practices. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 21 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): 37, 38, 40, 41 and 42 The manager and senior team offer staff the opportunity to develop skills and keep their relationships with residents supportive. The health and safety of residents is safeguarded without unnecessary restrictions. EVIDENCE: The manager has been in post for over ten years. She was described by staff as being committed to the residents and their wellbeing. They said the ethos of the home was driven by the manager who would always put residents first. They said they were proud to be associated with Daisyvale House and the residents living there. Care files showed that risk assessments had been carried out and action taken to reduce any risks. The management of risk is done is such a way that it does not impose undue restrictions on peoples lifestyles. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 22 Since the last inspection banking arrangements have been put in place for five residents. Some personal accounts still need to be sorted out as they are still under the control of the organisation. The manager confirmed that this was in hand. For residents who require help with their finances, all transactions are recorded and receipts kept for all purchases. There is restricted access to the safe. The requirements noted in the body of this report impact on the health and safety of residents, these are itemised in the appropriate sections. Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 X X 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X 2 X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Daisy Vale House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 2 X DS0000001442.V262837.R01.S.doc Version 5.0 Page 24 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 YA6 Regulation 15 Requirement The registered person must make sure the care plans are kept up to date and reflect an accurate picture of current events. The registered person must make sure the medication record is kept up to date and is accurate. The registered person must make sure the floor covering in the home is safe and does not constitute a trip hazard. The registered person must make sure fire safety precautions are in place. The registered person must make sure there are sufficient staff on duty at all times. Timescale for action 16/01/06 2 YA20YA42Y 13(2) 16/01/06 3 YA25YA42Y 16(c) and 23(4) 09/02/06 4 YA33YA42Y 18 10/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000001442.V262837.R01.S.doc Version 5.0 Page 25 Daisy Vale House Standard Daisy Vale House DS0000001442.V262837.R01.S.doc Version 5.0 Page 26 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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