Inspection on 24/01/06 for Danes Lea

This inspection was carried out on 24th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Danes Lea 11/11/08

Danes Lea 06/12/06

Danes Lea 17/08/05

Danes Lea 22/02/05

Danes Lea 18/08/04

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

CARE HOMES FOR OLDER PEOPLE Danes Lea 133 Cardigan Road Bridlington East Yorkshire YO15 3LP Lead Inspector David Blackburn Unannounced Inspection 24th January 2006 09:30 X10015.doc Version 1.40 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 Danes Lea DS0000019662.V278531.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 Older People. 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. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Danes Lea Address 133 Cardigan Road Bridlington East Yorkshire YO15 3LP 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) 01262-672145 01262 672676 Humberside Independent Care Association Limited Miss Leah Anne Hart Care Home 29 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (29) of places Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 Brief Description of the Service: Danes Lea is a large adapted three-storey property situated in the seaside resort of Bridlington. It is located in a residential area of the town within easy walking distance of the seafront, shopping centre and local facilities and amenities. Public transport passes the door. There is a car park. Level access is available to all external doors. Communal space and bedroom accommodation are on the two lower floors with access to the first floor via a passenger lift. There are 21 single and 4 shared rooms. Some of the single bedrooms (15) have an en-suite facility. Communal toilets and bathrooms are suitably positioned throughout the home. Service facilities, for example the kitchen and laundry are located on the ground floor. The top floor is for storage and staff use only. There is a variety of seating areas. There is a large secure and private outdoor garden and seating area. Danes Lea accommodates people admitted by virtue of old age or infirmity, some of whom may be suffering from dementia. The staff provide personal care, an in-house catering service, laundry service and a domestic and cleaning service. Staffing cover is available throughout the 24-hours each day. Leisure and recreational facilities are offered in-house. Residents are registered with local general medical practitioners who address their primary health care needs and can access the more specialised health services as required. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection upon which this report is based was the second to be carried out in the inspection year April 2005 to March 2006. It was carried out over four hours including preparation time. The focus was on those key standards not assessed at the first inspection in August 2005 together with those that were the subject of a requirement or recommendation. A number of other standards were re-assessed. An inspection of some parts of the premises including a small number of bedrooms was undertaken. Documents including care plans, case files and policies and procedures were examined. Two staff files were seen. Discussions were held with the registered manager, care staff, catering and domestic staff. A number of residents and visitors were spoken with including a visiting health professional and their comments are included in this report. What the service does well: Good care planning systems were in operation that gave staff a clear indication of the needs of the individual and how they were to be met. Proper arrangements were in place for the storage, administration and recording of medication ensuring the promotion of residents’ good health. Every effort was made by staff to promote suitable communal and individual activities to widen residents’ life experiences. The building was clean, tidy and odour free giving residents a homely place in which to live. Good attention to detail was noted in the laundry system in the home. The laundry staff took an obvious pride in their work with residents having good clean linen, towels and properly ironed clothes. Adequate staff were on duty at all times. Staff training was thorough and paid attention to the needs of those caring for people with dementia. Over 50 of the care staff had achieved a National Vocational Qualification in care to at least level 2. Residents could therefore be assured they would be cared for by a competent, able and trained staff. The home was well managed with appropriate attention given to matters of health and safety. This gave residents a safe and secure environment. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of these standards was assessed. EVIDENCE: Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. There was a clear and consistent care planning system in place to adequately provide staff with the information they needed to properly meet residents’ needs. Proper attention to medication procedures ensured the promotion of residents’ good health. EVIDENCE: All residents had a case file that included a care plan. A number were examined. All were indexed and sectioned. The actual care plans had been updated in a revised format. These gave clear and comprehensive details of strengths and needs with regard to a number of activities of daily living. Risk assessments for a number of activities were also on file. The care plans and risk assessments had been reviewed through regular monthly recording, monitoring and evaluation. Any changes were recorded on the care plan. A daily record of events as they affected the individual resident was also maintained. The registered manager audited a number of care plans each month and copies of the audit sheet were seen. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 10 Residents and visitors felt individual needs were known and acted upon. All felt the care given was appropriate and met requirements. The visiting health professional said residents’ needs were well known and met in a proper manner. Proper procedures and systems were in place for the receipt, storage, administration, recording and return of medication including any controlled drugs. Observation of the administration of lunchtime medication showed these procedures were being followed. The registered manager was carrying out regular checks on all aspects of the medication procedures. Staff confirmed that only those who had received external training could administer medication. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. A variety of suitable leisure activities and good links with the community supported and enriched residents’ social opportunities and life experiences. EVIDENCE: A relaxed and informal daily routine was in operation. Residents were free to get up and go to bed when they chose. Some residents were observed taking a late breakfast while others were still in their bedrooms dressing. Lunch and tea were at set times though for those wishing to eat later the chef said a meal would always be available. Residents’ preferences and choices for their individual daily routines, where they were able to express them, were recorded on the care plan. Activities were provided in the home. Residents’ leisure interests were shown on their care plans. The registered manager said residents were encouraged to continue to follow pastimes that had interested them prior to admission though the onset of dementia often meant these skills were lost. Staff spent time in a number of one-to-one activities including beauty therapy, reading and taking out residents for walks. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 12 Visitors were actively encouraged and the registered manager described the home as an “open house”. Residents were asked whether they wished visitors. The decision of one resident not to see particular family members was being respected. Relatives and friends could stay overnight if a resident was unwell. Local community groups visited the home to entertain residents. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0. None of these standards was assessed. EVIDENCE: Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The standard of the environment within this home was good providing residents with an attractive and homely place to live. Good attention to detail by laundry staff ensured residents had properly cleaned and ironed clothes. EVIDENCE: A brief tour was made of the premises. The communal areas and a small number of bedrooms were seen. The building was well maintained internally and externally. The maintenance book was seen. A number of matters had been referred for attention including adjustments to hot water temperatures in one bathroom (appropriate warning notices were displayed) and attention to the emergency call system (residents had been given personal alarms). Those parts of the premises seen were clean, warm, tidy and free from unpleasant odours. Bedrooms were of different designs and layouts. All were well furnished, in good decorative order and carpeted. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 15 For those without an en-suite facility, communal toilets and bathrooms were located throughout the building. The laundry was of a good size, easily accessed from all parts of the building and was clean and tidy. The laundry assistant was able to describe the system for laundering of all items in the home. She took an obvious pride in her work. Visitors said the home was always warm, clean and odour free. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Residents’ overall care was promoted by a properly recruited, well-trained, competent and highly motivated staff team. EVIDENCE: Rotas showed sufficient care staff on duty. Cover for any vacancies, sickness or holidays was provided by existing staff or agency. The same members of agency staff were usually employed to ensure consistency of care. Care staff were supported by catering, domestic and laundry staff. 19 care staff were employed of whom 10 had a National Vocational Qualification in care to level 2 with five having achieved level 3. Others were working towards the award. One care staff had a Higher National Diploma (HND) in care and two had General National Vocational Qualifications. The registered provider had a robust and thorough recruitment and selection procedure designed to protect residents from harm. The files of the last two staff to be employed were seen. They contained an application form, written references, a POVA/First check (for one) and enhanced disclosures from the Criminal Records Bureau (CRB). The registered manager said that staff could only commence employment after receipt of a POVA/First check and then only work under strict supervision. Full duties would only commence on receipt of a satisfactory CRB disclosure. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 17 On commencement of employment staff undertook in-house induction conducted by the registered manager. This induction was recorded and signed. New staff were expected to complete further induction training organised by the registered provider externally to the home within their first month. This was followed by resident specific training including adult protection, dementia awareness, back-care and first aid. Supervision was offered every six weeks. A visiting healthcare professional said staff acted on the advice, guidance and instruction given. She felt them to be conscientious, caring and knowledgeable about the residents for whom they were responsible. Observation showed all staff to interact well with residents, to have friendly and warm exchanges though always with purpose and to ensure the overall health, safety and welfare of those in their care. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 35 and 38. The home was well managed providing residents with a safe and secure environment. EVIDENCE: The registered manager was experienced, knowledgeable and competent to manage the home. She had achieved the Registered Managers (Adults) NVQ4 award in March 2005 and was awaiting final verification of a National Vocational Qualification in care to level 4. She had a number of other relevant qualifications. She displayed a good and sound knowledge of all matters related to the management and running of a care home for older persons. She was a member of a local dementia care collaborative. A visiting health care professional spoke in complimentary terms about her management ability, supervisory role and the general support she gave. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 19 The registered manager held money for some residents. Money was banked under an umbrella account held in the home’s name. This system had been agreed with the regulatory authority. Records showed the daily balance for each resident, both of money held in the home and in the bank account. Changes had been made to ensure that no resident recorded a debit figure. The new system had been discussed and agreed at a Quality Circle Meeting (a forum for staff, relatives and friends). Proper attention was being given to matters of health and safety. Some safety certificates were held centrally. The fire manual was seen and examined. All certificates and records were up-to-date. Risk assessments were in place. Requirements were made at the last inspection in relation to the use of bed rails. These had been addressed and resolved. Risk assessments were on file though none had been dated and new extended rails had been purchased for use on beds with raised mattresses. A gas engineer’s report made a number of recommendations that should be considered by the registered provider. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 38 38 Good Practice Recommendations The risk assessments regarding the provision of bed rails should be dated. The registered providers should give consideration to the implementation of the recommendations of the gas engineer. Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 22 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 Danes Lea DS0000019662.V278531.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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