Inspection on 09/01/06 for Daleholme

This inspection was carried out on 9th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Daleholme 15/08/07

Daleholme 23/08/06

Daleholme 12/07/05

Daleholme 16/11/04

Daleholme 15/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Daleholme Station Road Settle North Yorkshire BD24 9AA Lead Inspector Caroline Long Unannounced Inspection 9th January 2006 09:30 Daleholme DS0000007872.V273906.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 Daleholme DS0000007872.V273906.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. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Daleholme Address Station Road Settle North Yorkshire BD24 9AA 01729 825769 01729 825769 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) St Anne`s Community Services Sean Martin Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 5 Service Users with Learning Disabilities some or all of whom may also have Physical Disabilities Persons in the category of LD(E) are restricted to current service users who reach that age whose needs can still be met within this service. 12th July 2005 Date of last inspection Brief Description of the Service: Daleholme is a care home registered by St. Annes Community Services to provide personal care and accommodation for up to five adults with learning disabilities some or all of whom may have physical disabilities. The home consists of a purpose built, detached bungalow situated on a busy road on the outskirts of the market town of Settle. The town is within easy walking distance of the home and has numerous and varied facilities including shops, cafes, churches and pubs. All five bedrooms are for single accommodation, one of which has en-suite facilities. Shared areas consist of a kitchen, a dining room/lounge and a conservatory. The home has a garden area to the side and rear of the premises with an area of hardstanding for parking to the front. There is level access to the home. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 9th January 2006. It was unannounced, 3 hours were spent preparing for the inspection and 4.30 hours were spent in the home. Two residents were in the home during the inspection, no relatives were present. Two staff members were asked about working in the home. The Deputy Manager on duty assisted with the inspection, the Registered Manager was not present. The inspection concentrated on the standards not covered at the previous inspection, in July 2005, and a check was made as to whether the home had complied with requirements and recommendations from the last inspection. Most of the shared areas were visited. A sample of Resident and Staff files were examined, verbal and written feedback was given at the end of the inspection to the Deputy Manager. What the service does well: What has improved since the last inspection? The Registered Manager has completed his Registered Manager Qualification and is awaiting the results of his NVQ Level and was awaiting the results of his NVQ Level Four in Care. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Daleholme DS0000007872.V273906.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 Daleholme DS0000007872.V273906.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): 5 only All residents and their relatives are provided with a contract that enables them to make an informed choice about the home. EVIDENCE: The Deputy Manager confirmed all residents are issued with a written contract with the home, this is updated through a personnel finance sheet, which details the cost of the accommodation and care to the resident, both of these are explained to the residents, and their relatives. Two resident files were examined both contained written contracts and finances sheets which had been updated on the 1st January 2006, both were signed by either the resident or their relatives. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Information about residents is handled appropriately. EVIDENCE: The home has policies, which cover the safe handling of information and confidentiality; staff are informed of any changes to policies and have to initial to confirm they have read them. At the time of the inspection, all residents’ files were kept in a locked cupboard. The Deputy Manager and staff members confirmed all residents have access to information held about them and relatives would only be given access with the residents’ approval. The residents report sheets inspected were written daily, contained appropriate information and were signed and dated by the member of staff. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 10 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 &17 Residents have the opportunity for personnel development, to improve their lifestyles. EVIDENCE: During the inspection all residents were accompanied out into the community, to participate in a variety of community based activities. The residents individually and at residents meeting are informed about and asked if they would like to experience any new activities. The Deputy Manager has regular meetings with the resource centre to assess the needs of the residents for the provision of activities that can aid their personal development, such as use of trains and buses. One resident attends the local college weekly. The home has the use of a vehicle to transport the residents. Staff explained residents are encouraged to make choices about the menu, on a Saturday night the residents have a take away meal of their choice. During the inspection staff were preparing spaghetti bolognaise for tea and resident were offered a drink as soon as they returned to the home from an activity. Staff said they were able to sit and eat with the residents. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 11 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): 21 The aging, illness and death of residents are handled with respect and as the individual would wish. EVIDENCE: Records examined confirmed all residents and their relatives agree a plan regarding ageing, illness and death, which was recorded and kept with the service user files. Residents were given the choice of remaining in the home if support services were available. The Deputy explained the home had accommodated a long term resident with terminal illness with the support of the GP and District Nurses. Support was available for staff and residents upon his death. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 12 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 residents are protected from abuse by the home. EVIDENCE: The home had the policies and procedures in place for the protection adults from abuse. Staff training records and discussion with staff members confirmed they had attended abuse training and understood how to protect service users. The Deputy Manager was aware of the Protection of Vulnerable Adults Procedure. Physical and verbal abuse by residents was understood and dealt with appropriately, through risk assessment and care planning. The records confirmed the home produced for residents an explanation and record of their finances, the residents had access to their money, details of any transactions were recorded and amounts checked regularly by staff. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 13 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): None were looked at EVIDENCE: Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 14 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): 31,32,35,36 The residents are listened and their needs met by a skilled and motivated staff team. EVIDENCE: Staff members had all been issued with their job descriptions and St Annes Code of Practice and were aware of their individual roles in the home. The care workers job descriptions were to the benefit of residents. There was a clear management structure, which was written in the Statement of Purpose. When questioned staff were aware of their limitations and felt able to ask for assistance. Many of the residents had lived at the home for a number of years; staff had therefore developed relationships with the residents that enabled them to meet their individual needs. Staff and resident observed together appeared to get on well. Two staff members, who spoke to the inspector, confirmed they had attended regular training. When observed with the residents the staff communicated well and appeared both interested and committed to the residents. Although the staff verbally confirmed they had attended training, this could not be evidenced in the training records, as copies of certificates were not available. The Deputy Manager explained at present there were 12 staff in total only four had commenced their NVQ Level 3 and one had completed the Registered Managers Award. All staff had carried out part of Learning Disabilities Awareness Framework Training during induction. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 15 Staff recruitment documents and CRB’s could not be inspected as they were held at the head office in Leeds. Although there had continued to be a shortfall in staff since the last inspection this had been covered by the staff team. A recent recruitment had enabled them to employ to further staff members whom they hope to commence soon. Staff interviewed said it was better for the residents when there were three members of staff on duty as this enabled the staff to take out the residents more. Staff records showed staff were supervised regularly and staff interview said they felt they were well supported. The Deputy Manager explained although they had not recently carried out annual appraisals, these were to be recommenced shortly. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 16 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): 37,39,42 Although the Residents benefit from a well managed home they are put at unnecessary risk by staff not carrying out health and safety inspections frequently. EVIDENCE: The records of the Registered Manager showed he had obtained his Registered Managers Award. Level Four. The Service Manager carries out monthly inspections in the home. All residents have an annual service review where members of the community who are involved in the residents care are invited, where they are invited to discuss how the home meets the needs of the resident. (This includes District Nurses, Resource Centre Workers and Relatives etc). The home has annual development plan which is accessible to all staff. Although all staff interviewed and the training records confirmed staff had a good knowledge of fire procedures. Three monthly training was not being carried out for night staff, at the time of the inspection. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 17 The records showed the water temperatures were checked monthly and some had been as high as 49 degrees, the Deputy Manager explained their had been a issue with the heating system. The electricity safety certificate was due for renewal. Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 18 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 2 33 X 34 X 35 2 36 3 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 3 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 2 X 2 X X 2 X Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 19 Yes 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA32 YA37 YA39 Good Practice Recommendations A minimum of 50 of care staff should be qualified to NVQ level 2 or above. The Registered Manager to complete the required qualifications. The views of families, friends, advocates and other people involved with the home, in respect of the quality of services, could be ascertained and incorporated into the quality assurance system currently in operation. Record of training could be updated and supporting evidence of training incorporated. The ongoing issue with the heating system causing high water temperatures needs to be investigated and resolved and the commission informed of the results. 4 5 YA41 YA42 Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. Extracts may not be used or reproduced without the express permission of CSCI Daleholme DS0000007872.V273906.R01.S.doc Version 5.1 Page 21 - 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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