Inspection on 06/12/06 for Danes Lea

This inspection was carried out on 6th December 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 24/01/06

Danes Lea 17/08/05

Danes Lea 22/02/05

Danes Lea 18/08/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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 Rob Padwick Unannounced Inspection 6th December 2006 1:00 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.V318971.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 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.V318971.R01.S.doc Version 5.2 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.V318971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Danes Lea accommodates people admitted by virtue of old age or infirmity, some of whom may be suffering from dementia. Staff provide personal care, an in-house catering service, laundry service and a domestic and cleaning 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, a shopping centre and other local facilities and amenities are close by. Public transport passes the door. There is a car park. Level access at Danes Lea 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. There is a large secure and private garden providing a variety of seating areas. Danes Lea is operated by Humberside Independent Care Association Ltd which is a not for profit organisation. The standard fees charged by the home range from £328.80 to £470 with additional charges made for hairdressing, chiropody, toiletries etc. Danes Lea provides information about the home to Residents in its Statement of Purpose and Service User Guide. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit lasted for 6 hours and included a tour of the building. During this period, time was spent talking with residents in the communal areas of the home and observing their daily lives. Further time was spent reading care plans and files and talking to staff. A Pre Inspection Questionnaire asking for information about the service was sent to the manager before this visit and information collected from this was included as part of the inspection process. Other information used included reports from monthly visits carried by a senior manager from the parent company and notifications received by the Commission for Social Care Inspection about serious incidents that had taken place in the home. Questionnaires were distributed to a random group of the residents’ relatives together with professionals associated with the home. The responses gained from these were mostly positive in nature, with one relative commenting on the consideration shown towards her family. 5 of the 8 relative comment cards however, expressed some concerns about the staffing levels in the home. As part of this unannounced inspection visit, the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: The home provides good information about the service for residents thinking about moving into the home. The home is well maintained and residents are treated with care and respect by staff that have been trained well, in order to meet their needs. Staff were friendly and committed to doing their jobs, in order that the welfare of the residents welfare was met. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 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.V318971.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. Assessments of the residents’ had been undertaken, in order to ensure that the home was able meet their needs satisfactorily. Updated information about the home was available, in order to ensure that residents were kept informed about any changes to the service that would affect them and that prospective residents could make an informed choice about moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and relatives spoken with indicated that they had been involved in decisions about moving into the home and recently updated information about the service had been developed, to ensure that residents were kept informed about changes to the service that would affect them. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 9 Due to the levels of dementia experienced by the individual residents, most of them were unclear about who was paying for their placement. However, copies of the Provider organisation’s Statement of Terms and Conditions were present in two of the three files inspected. These indicated that the Local Authority was responsible for making payment for the fees and residents’ representatives had signed these, to indicate that they were in agreement with this. The Provider organisation had recently introduced a third party “Top UP” charge for individual placements, and copies of signed agreements to indicate those responsible for making this payment, were present in the files inspected. The file of a third resident did not contain a Statement of Terms and Conditions. However, discussion with the home’s manager indicated that this resident had been admitted to the home before this documentation had been introduced. A recommendation is made in this matter. The files of recently admitted resident’s confirmed that assessments of their needs had been carried out prior to them moving into the home, in order to ensure that the service was able to meet their needs. Danes Lea does not admit residents for intermediate care. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. The residents’ health and personal care needs were being sensitively met, but better recording concerning their medication was needed in order to ensure that they were kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents indicated that their health and personal care needs were being met and inspection of their case files confirmed that individual support plans had been developed, in order to guide staff in meeting the residents’ individual care needs. A member of Social Services staff contacted as part of the inspection process, commented favourably on the quality of the care planning documentation and inspection of the support plans confirmed that these were being reviewed and updated on a regular basis. Daily recordings were included in these, together with assessments of known areas of risk, and evidence was seen that residents had been consulted about their wishes concerning the care that was given. Case files contained evidence that that the residents’ health conditions were being appropriately monitored and comments received from both relatives and health professionals were positive in this respect. A Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 11 Community Psychiatric Nurse contacted as part of the inspection process commented that she had “no qualms about the service”. Support plans contained evidence of quality time being spent with individual residents, however it was not always possible to determine the amount of time or what activities had been undertaken, in relation to this aspect of practice. Staff were observed being courteous and respectful, patiently giving support and reassurance to the more confused residents, but owing to the high levels of complexity of need experienced by some of the more dependent residents, their were times when staff were observed to be struggling to meet the collective needs of all of the residents. A requirement is made in this matter (See Staffing) The home had policies and procedures, in order to safeguard the residents, and case files contained evidence that they had been assessed for their ability to self medicate. A notification received by the Commission from the home about a joint decision made by medical professionals concerning the covert use of medicine for a resident, was discussed. However, despite confirmation in her file that her family were consulted about matters affecting her, no specific recording was present in this instance, to indicate that they had been involved in and were in agreement with this decision and a requirement and recommendation is therefore made. Staff responsible for the administration of medicine confirmed that they had received training in this aspect of practice, however despite this, a random inspection of the home’s medication systems found errors concerning the recording and storage of a controlled drug. A requirement is made in this matter. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. The residents’ daily lives were being met by a number of social activities, but their wellbeing would be enhanced by the provision of more staff time, in order that ensure that their emotional and psychological needs are better met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents indicated that they were content and that the quality of their daily lives was to their liking. A staff member was involved with a group of residents making Christmas cards on day of this visit and information submitted by the manager indicated that a range of activities were available for the residents to participate in. Posters were on display advertising a number of special events scheduled to take place over the forthcoming seasonal period, including a meal out in a local restaurant, visits from entertainers and local churches. The case file of one resident indicated that she had strong connections with the Salvation Army and discussion with staff indicated that she was supported to maintain these and that a visit from them was due to take place over the Christmas period. A senior staff member is employed in the home as an activities organiser for 6 hours a week, however a Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 13 recommendation is made that consideration is given to extend these hours, in order to ensure that the wider emotional and psychological wellbeing of all of the residents is better met. The home has visitors’ policy and discussion with staff indicated that friends and family members are welcomed, in order to ensure that residents’ links with them are maintained. A relative was bringing her mother back from an overnight stay on the evening of this visit, and discussion with her indicated that this was a regular practice. The relative was very complimentary of the caring nature of the staff, but commented that their were “never enough hands” to meet the residents needs as well as she would like. The home has a significant number of highly dependent residents and as indicated elsewhere in this report, their were times when staff were observed to be struggling to meet the combined needs of all of the residents. Case files inspected indicated that residents had been consulted on the way that their care was to be delivered and discussion with them confirmed that they were supported to make choices. On the day of this inspection a new kitchen was being installed and discussion with residents and staff indicated that satisfactory arrangements were in place to ensure that minimal disruption was caused. Residents confirmed that the food was good, and the cook confirmed that the residents were always given a choice of meals on offer. The home has achieved a “heartbeat” award for the provision of its meals and inspection of the menus indicated that a balanced and nutritious diet was being provided. Case files contained evidence of nutritional assessments being carried out, together with the monitoring of the residents weight being appropriately monitored. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The residents’ views and concerns were being listened to and taken seriously and training had been provided to staff to ensure that residents were safeguarded from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy in order to ensure that the concerns of residents are taken seriously. Residents confirmed that staff were “kind” and “very good” and indicated that staff listened to them well. Information submitted by the manager indicated that 13 complaints had been received since the last inspection, but inspection of the complaints log indicated that most of these were of a minor nature. Information in the complaints book confirmed that the manager was taking this aspect of practice very seriously and that appropriate actions was being taken to follow up any issues that were raised. Policies and procedures were in place to ensure that the residents were protected from abuse. Staff training on these is included in the staff induction process and discussion with them indicated that they would take appropriate action should this be needed. Following an allegation of abuse from a resident, a referral for investigation to the Local Authority Social Services Department had correctly been made, and this had been satisfactorily completed. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The residents’ environment was safe and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was warm, comfortable and well maintained. Bedrooms and lounges and been decorated to a good standard and evidence of on going safety checks were seen in the home’s records. A new kitchen was being fitted on the day of this inspection visit and discussion with the chef confirmed that this would now comply with the recommendations of the Gas engineer. One of the lounges had a malodour at one point during the inspection visit, but staff took prompt action to remedy this successfully. The home is built on two floors with access to the top floor via the lift. The dining room is located on the top floor and as such is not ideally situated, although discussion with residents indicated that this was not a problem for them. Aids and adaptations had been installed in the home’s bathrooms in order to assist with the residents’ independence and the home’s laundry was tidy and clean. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Staff had been safely recruited and training had been provided for them, in order that health and personal care of the residents were met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were observed to be friendly and supportive in their approach to working with the residents and discussion with them indicated that they were committed to their jobs. A staff training programme has been developed by the Provider organisation and inspection of the staff records confirmed that a good range of topics relating to the individual needs of the residents accommodated, had been delivered. Information submitted by the manager as part of the inspection process, indicated that 63 of the staff group had obtained an NVQ level 2 qualification in care, which is in excess of the recommended level and is therefore to be commended. Residents said that staff were kind and helpful and a comment card received from a relative stated that the staff are “considerate and keep us informed of treatment”. However, as indicated elsewhere in this report, owing to the complexity of needs experienced by some of the more dependent residents, their were times when they were struggling to meet all of the residents’ needs. Discussion with staff indicated that they were aware of this, with some of them being sometimes out of breath. A requirement is made in this matter. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 17 A recruitment policy and procedure was in place to ensue that staff are safe to care for the residents. Staff records inspected indicated that this was being followed appropriately with copies of Criminal Records Bureau checks and two written references being taken before staff could start work. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 and 38 Quality in this outcome area is good. The conduct and management of the home ensured that appropriate checks were being carried out to ensure that the health, safety and welfare of residents and staff were being safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback received from residents, relatives and professionals associated with Danes Lea indicated that it was being well run. Discussion with the staff confirmed that the manager is qualified to run the home and that she was open and approachable. The Provider Organisation has robust systems in place to monitor the home against its stated aims and objectives, and inspection of the home’s records indicated that the manager was carrying these out effectively. An annual plan had been developed in respect of these and questionnaires had been circulated to obtain the views of residents and Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 19 stakeholders as part of this process. Discussion with residents and inspection of the minutes of various meetings with residents and staff confirmed that their views were considered and that they were consulted about matters affecting them. The Provider organisation has a computerised system for the management of individual resident’s personal allowance’s and a random check of the records for these indicated that their finances were being safeguarded. Inspection of the home’s records indicated that the health, safety and welfare of residents and staff were being promoted and protected. Maintenance records were up to date and in good order and the home’s training plan indicated that staff had covered a variety of health and safety issues or that these been identified for them as a future development need. Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 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. 1 Standard OP9OP9 Regulation 12 Requirement The registered person must ensure that the representatives of residents unable to make informed judgements about their care are kept informed of decisions taken on their behalf and that they are in agreement with them. The registered person must ensure that that records of medication stored in the home are accurately maintained and that the medication administered to residents is accurately documented. The registered person must ensure that there is sufficient staff on duty to meet the collective needs of the residents. Timescale for action 06/01/07 2 OP9OP9 13 (2) (4) 17 (1) (a) 06/12/06 3 OP27OP27 18(1(a)) 06/01/07 Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 22 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 OP9OP9 Good Practice Recommendations The registered person should review the homes medication policies and procedures, in order to safeguard the best interests of residents unable to make informed decisions and ensure that their representatives are involved in decisions that directly affect their welfare. The registered person should ensure that the activities organiser’s hours and role is developed in order to ensure that the wider emotional and psychological well being of all of the residents is better met. 2 OP12OP12 Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Danes Lea DS0000019662.V318971.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!