Inspection on 26/10/06 for Danescourt

This inspection was carried out on 26th October 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

Danescourt 06/11/07

Danescourt 04/01/06

Danescourt 14/09/05

Danescourt 13/01/05

Danescourt 27/08/04

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 HOMES FOR OLDER PEOPLE Danescourt 1 Rectory Gardens Doncaster DN1 2JU Lead Inspector Bob Burkinshaw Key Unannounced Inspection 11:30 25th October 2006 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 Danescourt DS0000007990.V309569.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. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Danescourt Address 1 Rectory Gardens Doncaster DN1 2JU 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) 01302 328455 01302 328455 NONE Doncaster and South Humber Healthcare NHS Trust Mrs Josie Rollings Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10) of places Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Danescourt is a residential home owned by Doncaster & South Humber Healthcare Trust who, in conjunction with other independent, private and voluntary organisations, provides small community homes for people with learning disabilities needing long-term care. Danescourt provides care for people who have previously spent many years living in large institutional hospitals. The home is registered to provide personal care and accommodation for up to ten elderly persons within the category of Learning Disability. The care manager who has responsibility for day- to- management of the home is Mrs J Rollins. The home is a large detached house that is situated at the junction of Rectory Gardens and Thorne Road. It has a prominent position overlooking Town Fields and is 2 miles from Doncaster town centre. The home was formerly a private family residence that has been extended and adapted to meet the specific needs of the residents. There is a choice of two lounges and a dining room that overlook the well maintained gardens. A passenger lift provides access to the first floor bedrooms. The home is set within well-stocked and maintained gardens. There is a private and secluded area at the rear of the property that is regularly used for barbecues and activities. Pathways within the grounds are level to enable easy access. There are limited car-parking spaces available at the home; a bus route is nearby. Residents use the local shops and are able to access the town centre for shopping. The weekly fees are £321.42; if carers or prospective residents require further information about the home they can ask for a copy of the home’s Statement of Purpose or the service user guide provided by the Doncaster & South Humberside Healthcare Trust. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 11:30 and concluded at 14:30. The inspection included a tour of the buildings, reading records, discussions with staff and service users, observation of service users, and observation of a meal. The Inspector also met with the registered manager, a senior nurse and other members of staff. What the service does well: What has improved since the last inspection? What they could do better: Remove the unnecessary divider in one service users private bedroom. Continue to monitor the suitability of Danescourt as appropriate accommodation for a group of elderly service users who are becoming increasingly frail and dependent. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 6 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. Danescourt DS0000007990.V309569.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 Danescourt DS0000007990.V309569.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4, National Minimum Standard 6 does not apply to Danescourt Quality in this outcome area is good. This judgement has been made using available evidence including looking at admission and discharge procedures. EVIDENCE: The Regulation 26 report from August 2006 stated that a lady from the Core Unit at St Catherine’s Hospital was considering a transfer to Danescourt. The process included a visit to Danescourt by the service user to view the accommodation and meet the rest of the service user group at the home. Following this visit the lady declined the offer of a place at Danescourt as she felt the current service user group were too old for her and she wished to be closer to the shops. Two service users have left Danescourt since the last inspection as their assessed needs could not be met at the home and they were transferred to more appropriate accommodation. The majority of the remaining residents at Danescourt are showing increased dependency due to their age, health problems and general disabilities; their needs are kept under regular review. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 9 Danescourt DS0000007990.V309569.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including sampling service user personal files and inspecting the storage, administration, disposal and recording of the medication presribed for service users. The home provides the essential equipment for the moving and handling of service users. EVIDENCE: This inspection visit found that the healthcare of service users is promoted. One service user has been admitted to hospital recently with bronchial problems, the staff liaised with the service users G.P., as there were fears that the service user may have pneumonia, as a result of these concerns a hospital admission has taken place. Another service user with chronic health problems was referred to the dietician from Doncaster Royal Infirmary and as a result they are now on a minced texture diet (Stage 2 diet sheet was available for staff guidance) supplemented by Fortifresh. The home provides the aids and equipment necessary to meet the moving and handling needs of the client group. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 11 All service users are registered with the Francis Street Health Centre and the registered manager reported that there is a good relationship with the doctors from there and good support from the district nursing service. Two service users whose assessed healthcare needs could not be met by the care available at Danescourt have moved on since the last inspection. None of the residents was responsible for their own medication although this facility is available. A check of the medication administration records, medication storage and disposal arrangements are satisfactory. The Inspector observed the interaction between the members of staff and residents and saw that dignity and respect were observed. Each service user has their own private bedroom with the exception of two gentlemen who are friends and share by agreement. If for any reason one of them leaves Danescourt the room will revert to single user status. Danescourt DS0000007990.V309569.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14 Quality in this outcome area is good. This judgement has been made using available evidence including sampling service user personal files; talking with the registered manager and other staff plus inspecting the catering arrangements. EVIDENCE: The Inspector reviewed the range of activities and opportunities for service users at Danescourt and the outcome was interesting. All service users have access to incoming and outgoing telephone calls; family and friends are always welcome as visitors; service users can also make home visits to friends and family. The local Gateway Club is only a short walk away and three service users attend the day centre nearby. Two service users went on holiday to Blackpool, outings, shopping trips and visits to local theatres take place regularly on a planned basis. All of these opportunities are constrained by other factors. The family and friends that have seen it as their duty and responsibility to visit the service users down the years and to take them out or into their own homes have grown old and frail themselves. Their commitment is no longer available or has lessened considerably due to changes in personal circumstances and health; this applies to befrienders as well. This decline means that the staff at Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 13 Danescourt now have the major responsibility for the daily life and social activities of service users. The majority of the service users themselves cannot leave Danescourt without an escort due either to a dependency on wheelchairs or because of impaired mobility. Increased efforts are now made to bring entertainment into the home and Danescourt is well equipped with audio and visual entertainment facilities plus board games and printed materials. Nourishing drinks and snacks are readily available throughout the day. There was a choice of menu for the midday meal, staff were observed to encourage and assist with meals as needed. The meal was unhurried with extra portions available as required. Specialist diets are available for those requiring this service. The dietician has assisted with compiling the menu. Lunchtimes tend to be a light meal with the main meal of the day taken at teatime; the Inspector saw that a varied and nutritious menu was planned for the week. Choice and independence are the basis for all care and services provided, visiting relatives are able to assist their loved ones with meals. Danescourt DS0000007990.V309569.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service; conversations with service users and staff and inspection of the complaints record. EVIDENCE: There have been no complaints or protection issues from any source since the last inspection. Conversation with a new member of staff found that their induction training included information regarding both the complaints policy and the adult protection policy of the Doncaster & South Humberside Trust; the member of staff was aware of their responsibilities in these areas. The Inspector spent time with five of the seven people currently accommodated at Danescourt. They were happy to converse with him and spoke well of their home and the staff who care for them. The only complaint was from one 90- year old who wanted to work! Danescourt DS0000007990.V309569.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a tour of the premises, viewing of the private bedrooms and the communal areas and evidence of the specialist equipment required for these service users. The allocation of service users to upper and ground floor accommodation was also considered. EVIDENCE: The inspector took a tour of the premises accompanied by a member of staff. He found that the premises had a good standard of décor and furnishings. There were no unpleasant odours throughout the tour and rooms were clean, tidy and hygienic. Danescourt is equipped with all the required moving and handling equipment to meet the needs of service users and the South Yorkshire Fire & Rescue Service have reviewed the fire safety arrangements and there is now a direct alarm link to the fire service. A service user who could not safely use the stairs in the case of an emergency evacuation even with the assistance of staff has been provided with a bedroom on the ground floor. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 16 Two gentlemen share a bedroom on the upper floor by choice; their privacy is promoted by the use of a head-high wooden panel installed between their bed spaces. The bedroom will revert to a single bedroom status in the event of one of the gentlemen leaving Danescourt. Another bedroom on the upper floor has a similar arrangement from the time it was occupied by two people. It is now a single bedroom providing accommodation for one service user only, however the wooden panel divider remains installed and this should be removed as it restricts the amount of natural light in the room. Despite these changes that have been made the increasing dependency of service users currently accommodated at Danescourt continues to raise questions regarding its suitability for an elderly and frail resident group. The Doncaster & South Humberside Trust is keeping the registration of the home under constant review in the light of these concerns. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including looking at staff personnel files and their training and supervision records. A newly recruited member of staff was interviewed as part of this inspection visit. EVIDENCE: The inspector met with five members of staff including the registered manager during the course of this inspection. He also observed them working with service users and noted that there was an atmosphere of mutual respect between staff and residents and that conversations were relaxed and friendly. A number of staff have worked with the service users for a long time. One new member of staff was available for interview and was able to provide the inspector with evidence both written and verbal of her induction training and developing knowledge of the care needs of the residents at Danescourt. Current rotas provide for three staff on duty during the waking day with two on a night (one waking and one sleeping in). The senior on duty is included in the three and depending on the demand on their time this may delay written work such as updating staff Personal Development reviews and service user reviews. The registered manager reported that an additional member of staff had now been allocated in recognition of the increasing dependency levels of the service users at Danescourt. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 18 Two new member of staff have commenced work at Danescourt since the last inspection, the inspector saw their personnel files and established that the recruitment policy of the Doncaster & South Humberside Trust required both applicants to provide two satisfactory written references and a Criminal Records Bureau check before commencing employment with this vulnerable client group. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 19 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including interviewing the registered manager; observing staff as they work. Rotas and lire safety and other health & safety records were inspected along with the personal allwance arrangements for service users. EVIDENCE: The inspector saw that there was always a senior member of staff on duty at the home with advice and support readily available. On those occasions during this visit whenever staff required the advice and support of the senior on duty it was available and given. Responsibilities for the day-to- day operation of Danescourt are shared between senior members of the team. Risk assessments have been completed and are reviewed regularly. The increasing frailty and dependency of service users has resulted in an Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 20 assessment of toilet and bathing facilities and a positive response by the provision of additional equipment and an additional member of staff. Two service users whose assessed needs could not be met were transferred to a more appropriate setting. The remaining service users remain under constant review as management both within the home and at the Doncaster and South Humberside trust learning disabilities community homes service are aware of their increasing frailty and dependency and the limitations presented by Danescourt as a suitable building. Service records for the moving and handling equipment at Danescourt and the fire safety records plus other maintenance records were up to date; service users finances are properly recorded and personal allowances provided. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 21 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 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 3 3 3 3 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 3 x 3 x x 3 Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 22 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 OP23 Regulation 23 Requirement The divider must be removed from the bedroom that was previously shared by service users. Timescale for action 31/03/07 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 OP7 Good Practice Recommendations As it is agreed that the service user group at the home are increasingly dependent and frail the Doncaster & South Humberside Trust should continue to keep all service users under monthly review with regard to the suitability of Danescourt in meeting their needs. If it is found that Danescourt is not suitable for any individual a sympathetic and suitable plan for transfer to more appropriate accommodation should be put in place. Danescourt DS0000007990.V309569.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Danescourt DS0000007990.V309569.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. 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