Inspection on 06/11/07 for Danescourt

This inspection was carried out on 6th November 2007.

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 26/10/06

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 Ian Hall Key Unannounced Inspection 6th November 2007 09:00 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 DS0000007990.V350497.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. DS0000007990.V350497.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 F/P 01302 328455 NONE Doncaster and South Humber Healthcare NHS Trust Mrs Josie Rollings Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places DS0000007990.V350497.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 Brief Description of the Service: 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 eight elderly persons within the category of Learning Disability. The care manager who has responsibility for day- tomanagement 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. 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. People use the local shops and are able to access the town centre for shopping. The weekly fees are £326.24; this information was provided on the 6th November 2007. The home charges extra for chiropody, toiletries, clothing, telephone calls, holidays and hairdressing. A copy of the home’s Statement of Purpose was available in the entrance hall. DS0000007990.V350497.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over 4 hours. During the inspection we spoke to 5 people who live at the home and 3 staff members. The home’s annual quality assurance assessment (AQAA), surveys from relatives, health care professionals and people living at the home provided additional comment and information for the inspection. People spoken with were happy to assist with the inspection. Comments were positive when describing the care and motivation of the staff, these included: “the nurses are very nice to me”, and “its lovely here the girls are smashing”. At the end of the inspection verbal feedback was given to the homes registered manager. What the service does well: What has improved since the last inspection? What they could do better: Continue to monitor the suitability of Danescourt as appropriate accommodation for a group of elderly service users who are becoming increasingly frail and dependent. DS0000007990.V350497.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. The summary of this inspection report can be made available in other formats on request. DS0000007990.V350497.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 DS0000007990.V350497.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): 3 and 6. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service and sampling care records. The home provides detailed information to enable people to choose whether the home is the one for them. Detailed assessments showed that the home had ensured that people’s needs could be met prior to offering them a place. Opportunities were available for people to visit and sample the service provided. EVIDENCE: Records for a recently admitted person demonstrated a clear process and pathway for pre admission assessment. These included detailed records/reports of visits and included her comments and response to time spent at Danescourt. This person’s needs had been identified and plans developed prior to arrival. Care needs were being met by the resources and care provided. Written evidence from community agencies had been included within the assessment process. DS0000007990.V350497.R01.S.doc Version 5.2 Page 9 Pictorial resources could be developed to improve access to information for all people considering using the service. Intermediate care is not provided at the home. DS0000007990.V350497.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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service and sampling people’s case files. Care staff were proactive in ensuring that people’s health care needs were met. Staff attitude and approach to care was based on respect for the person and this helped to safeguard and promote people’s rights and dignity. Staff were working to the home’s policies for the administration of medication, which promoted the wellbeing of people who lived at the home. EVIDENCE: People’s care needs had been assessed; there were detailed care plans to inform staff how to meet these needs. These had been reviewed regularly. Most people we spoke to knew about their care plan, relatives were informed and involved whenever possible. There were records of visits by GP, community nurse, occupational therapist, dentist, opticians and chiropodist. DS0000007990.V350497.R01.S.doc Version 5.2 Page 11 People said staff helped them to go to the doctors when they needed to. One person has been admitted to hospital recently. The home provides the aids and equipment necessary to meet people’s moving and handling needs. All people are registered with the Francis Street Health Centre there is a good relationship with the doctors and the district nurses. No one was responsible for their own medication although this facility is available. Ordering storage, administration and disposal of medicines was checked. We observed medicines being given to people. They were helped and assisted to take them appropriately. Our observations were of mutual respect with very warm and close relationships between staff and people living at the home. Staff provided therapeutic touch with many observed hugs for people. Each person 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 person status. DS0000007990.V350497.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. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service sampling care files, talking with people and staff. Social and leisure activities are organised by staff, all people spoke favourably about their involvement in the activities. The home was providing a good catering service, which met people’s nutritional needs and food preferences. People who live at the home were encouraged to eat a healthy and varied diet. EVIDENCE: A range of activities was provided to meet people’s choice. Two people said they had enjoyed their holiday they’d taken with support staff in Scotland. There were records of people making telephone calls, visiting the local Gateway Club and attending the day centre nearby. There had been regular outings, shopping trips and visits to the cinema. A vehicle is available to transport small groups of people whose mobility has decreased. Danescourt is well equipped with TV and radio with games, books and magazines. Drinks and snacks are available throughout the day. There was a choice of menu for each meal, staff were observed to encourage and assist with meals. The meal was unhurried with extra portions available as required. DS0000007990.V350497.R01.S.doc Version 5.2 Page 13 Special diets are available. 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; we saw that a varied and nutritious menu was planned for the week. DS0000007990.V350497.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff and management operated an effective complaints policy to protect people. The policy and procedures for adult protection was in line with the local multi-agency approach. Staff had been trained to implement these procedures to protect people from all forms of abuse. 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. We spent time with five of the seven people currently accommodated at Danescourt. They spoke well of their home and the staff who care for them. DS0000007990.V350497.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean, well-maintained, odour free and homely. Bedrooms were clean, comfortable, well decorated and furnished to meet people’s needs. Good hygiene standards were maintained and this helped with the control of infection and making the home more pleasant. EVIDENCE: We toured the building accompanied by a member of staff. The premises had a good standard of décor and furnishings. There were no unpleasant odours all rooms entered were clean, tidy and well maintained. DS0000007990.V350497.R01.S.doc Version 5.2 Page 16 People’s bedrooms were comfortable and reflected their choice and own interests. 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. DS0000007990.V350497.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including looking at training and supervision records, speaking to available staff and people who use the service. The numbers and skill mix of staff were sufficient to meet peoples’ needs. Staff had received training to meet general and specific needs. Appropriate support and guidance was provided to new staff, enabling them to safely care for people who lived at the home. 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 people and noted that there was an atmosphere of mutual respect the conversations were relaxed and friendly. One new member of staff we interviewed was able to provide evidence both written and verbal of her induction training and developing knowledge of the care needs of people at Danescourt. She confirmed that she had been required to provide two satisfactory written references and a Criminal Records Bureau check before commencing employment with these vulnerable people. DS0000007990.V350497.R01.S.doc Version 5.2 Page 18 Staff files included the required information. The home operated a recruitment policy that promoted people’s protection. Current rotas provide for three staff on duty during the waking day with two working at night (one waking and one sleeping in). DS0000007990.V350497.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including interviewing the registered manager and observing staff as they work. Staff said that they were well supported by the manager. Systems were in place to protect people’s financial interests. The home is well organised and managed ensuring that people’s health, safety and welfare needs were promoted and protected. EVIDENCE: We saw that there was always a senior member of staff on duty at the home with advice and support readily available. Responsibilities for the day-to- day operation of Danescourt are shared between senior members of the team. DS0000007990.V350497.R01.S.doc Version 5.2 Page 20 Risk assessments have been completed and were reviewed regularly. The increasing frailty and people’s dependency has resulted in an assessment of toilet and bathing facilities and provision of additional equipment. Service records for the moving and handling equipment at Danescourt and the fire safety records plus other maintenance records were up to date; personal finances were properly recorded and personal allowances provided. DS0000007990.V350497.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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 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 3 X 3 X X 3 DS0000007990.V350497.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. 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. Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be made available in alternative (pictorial) format suitable for all people using the service. DS0000007990.V350497.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000007990.V350497.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. 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