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Inspection on 18/06/09 for Daneside Court Nursing Home

Also see our care home review for Daneside Court Nursing Home for more information

This inspection was carried out on 18th June 2009.

CQC found this care home to be providing an Adequate service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People considering moving into Daneside Court are given information and have their needs assessed before they move in so they can be confident that their needs can be met at the home. The health and personal care needs of the people living at the home are met and medicines are stored and handled safely. Some of the people we spoke with were very satisfied with the care provided. Comments included, ‘I feel looked after, secure, all the staff are kind, the staff will help if needed’; ‘they look after people well, it’s good place to be’; I have no complaints, I wouldn’t want to be anywhere else’; ‘the staff are very good and helpful’; ‘my room is lovely, staff are great’ and ‘staff look after me well, food is lovely’. The company has policies on complaints and safeguarding vulnerable people so the people living at Daneside Court will have their concerns listened to and acted upon and they are protected from abuse and poor practice. Daneside Court provides a comfortable, clean and well-maintained environment for the people who live there. Equipment is tested and serviced regularly to ensure safety. There are good recruitment procedures, which mean that only people suitable to work in care are employed. Nearly all the care staff have achieved a national vocational qualification in care which means that there is a wellqualified staff group. One member of staff told us ‘I have worked at Daneside Court for five years and I love my job’.

What has improved since the last inspection?

The care plans are well written in plain English and are kept up to date so that staff have good information about the needs of each person and how those needs should be met. All parts of the home were clean when we visited and there were no unpleasant odours. We saw no inappropriate storage of equipment in bathrooms (which was found at the last key inspection). Fire safety has been improved by fitting all doors with self closing devices.Daneside Court Nursing HomeDS0000018768.V376184.R01.S.docVersion 5.2

What the care home could do better:

There should always be enough staff on duty to make sure that all the needs, including social needs, of the people living at Daneside Court can be met. Consideration should be given to providing more social stimulation for the more frail people living on the first floor. There should always be enough meal choices and alternatives available so that people can have meals that meet their tastes. The manager is now being considered for registration with the Care Quality Commission, but it has taken too long for the application to be made.

Key inspection report CARE HOMES FOR OLDER PEOPLE Daneside Court Nursing Home Chester Way Northwich Cheshire CW9 5JA Lead Inspector Wendy Smith Key Unannounced Inspection 18 June 2009 10:00 DS0000018768.V376184.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daneside Court Nursing Home Address Chester Way Northwich Cheshire CW9 5JA 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) 01606 40700 01606 40621 www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Manager post vacant Care Home 64 Category(ies) of Old age, not falling within any other category registration, with number (64) of places Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 The registered person may provide the following categories of service only. Care home with Nursing - code N, to people of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP. The maximum number of people who can be accommodated is: 64 Date of last inspection 24 June 2008 Brief Description of the Service: Daneside Court is a purpose built care home, built in the 1990s, which provides both personal and nursing care for up to 64 older people. It is owned by Southern Cross Healthcare, a company which operates care homes throughout the country. The home provides single room accommodation on the ground and first floors. There are four lounges for residents to use. There is access into the garden, which has seating and tables. The home is situated in the centre of Northwich within walking distance of local shopping facilities, public houses, bus stops and open park areas. It is well established within the local community. The current range of fees is from £367.54 - £654.72 per week. Additional charges are made for the hairdresser, chiropodist, outings, bingo and newspapers. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that the people who use this service experience adequate quality outcomes. Two inspectors visited Daneside Court unannounced on 18 June 2009 as part of this inspection. During the visit we spoke with residents, staff and visitors. We walked round the building to see all the communal areas and some of the bedrooms. We checked a sample of the records kept at the home and spent time talking with the manager and the operations manager. We also looked at any information that we had received about Daneside Court since our last inspection there. Before the inspection the manager was asked to complete a questionnaire to give us up to date information about the home, and survey forms were sent out for staff and residents to give us their views. We carried out a short inspection of the home on 3 December 2008 to check whether action had been taken to address statutory requirements and good practice recommendations made as a result of the key inspection on 24 June 2008. We saw no inappropriate use of bathrooms as storage areas at this visit. We looked at a sample of care plans and found that they had been written in detail and kept up to date. Regular monthly reviews were written to a good standard. We looked at staff rotas and these indicated that there are enough staff on duty to meet the needs of the residents. The staff we spoke with then said that there are enough staff except when someone is absent at short notice, and on the day that we visited there appeared to be an adequate number of staff on duty. The manager told us that she had applied for registration with the commission. The manager had informed us of an incident that occurred on 9 October 2008. Curtains in a bedroom were smouldering after getting hot from the sun reflected onto a mirror. Following this incident, a fire officer inspected the home and made a requirement that door closing devices should be fitted throughout the home. This was done, but resulted in the bedroom doors being very difficult for frail residents to open, and people being cared for in their rooms having to have their doors closed. Residents, their relatives, and staff expressed their concerns about this. Southern Cross had agreed to fit ‘holdopen’ devices on bedroom doors, so that the doors can be left open but will close automatically if the fire alarm is activated. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 6 What the service does well: People considering moving into Daneside Court are given information and have their needs assessed before they move in so they can be confident that their needs can be met at the home. The health and personal care needs of the people living at the home are met and medicines are stored and handled safely. Some of the people we spoke with were very satisfied with the care provided. Comments included, ‘I feel looked after, secure, all the staff are kind, the staff will help if needed’; ‘they look after people well, it’s good place to be’; I have no complaints, I wouldn’t want to be anywhere else’; ‘the staff are very good and helpful’; ‘my room is lovely, staff are great’ and ‘staff look after me well, food is lovely’. The company has policies on complaints and safeguarding vulnerable people so the people living at Daneside Court will have their concerns listened to and acted upon and they are protected from abuse and poor practice. Daneside Court provides a comfortable, clean and well-maintained environment for the people who live there. Equipment is tested and serviced regularly to ensure safety. There are good recruitment procedures, which mean that only people suitable to work in care are employed. Nearly all the care staff have achieved a national vocational qualification in care which means that there is a wellqualified staff group. One member of staff told us ‘I have worked at Daneside Court for five years and I love my job’. What has improved since the last inspection? The care plans are well written in plain English and are kept up to date so that staff have good information about the needs of each person and how those needs should be met. All parts of the home were clean when we visited and there were no unpleasant odours. We saw no inappropriate storage of equipment in bathrooms (which was found at the last key inspection). Fire safety has been improved by fitting all doors with self closing devices. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 8 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 Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 People using 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. People considering moving into Daneside Court are given information and have their needs assessed before they move in so they can be confident that their needs can be met at the home. EVIDENCE: Information about the home and the services it provides is available in the entrance area. In the information we received before our visit to the home, the manager told us that, ‘Any prospective clients are encouraged to visit and spend time in the home. We offer a trial period also to help in the decision making. New clients are given a copy of our brochure, a service user guide and statement of purpose. A full pre-admission assessment is completed by Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 10 either the home manager or a senior nurse to ensure that we are able to meet all their needs holistically’. On the day we visited Daneside Court, 60 people were living at the home, 28 on the ground floor and 32 on the first floor. The people living on the ground floor are those who do not need nursing care and so senior care assistants are responsible for all of the care, including medicines and care planning, in this part of the home. People who need nursing care live on the first floor of the home and there is at least one nurse on duty at all times. The care notes we looked at for people who had come to live at the home recently showed that their needs had been assessed before they moved in by a senior member of staff from the home and written information was available for the staff so that they knew what care the person would need. Intermediate care is not provided at Daneside Court so standard 6 does not apply. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using 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 health and personal care needs of the people living at the home are met and medicines are stored and handled safely to make sure they receive their medicines as prescribed to maintain their health. EVIDENCE: Each of the people living at the home has a care plan that details their needs and how their needs should be met. The care plan folders include risk assessments covering pressure ulcers, continence, dependency, moving and handling, falls, nutrition and any other identified risks. Residents and their families are included in the care planning process and the care is reviewed with them every three months or six months, depending upon the person’s needs. We saw records of these review meetings in the care plans. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 12 We looked at a selection of care plans of people living on the ground floor and the first floor. All the care plans we looked at were concise and well written in plain English so they were easy for residents and staff to understand. Daily records were detailed and give a good picture of how people have been each day. Equipment needed to meet people’s needs is provided and this is recorded in their care plans; for example, the type of bed and mattress and pressure area care is recorded. We looked at the records of a person who had a pressure sore and found a detailed care plan in place with records of the wound being measured and photographed regularly to monitor the healing process. The care plans also showed us that people are weighed monthly and have visits from GPs, district nurses and other healthcare professionals as needed. Residents can be registered with a local dentist and have regular six month check ups. A community chiropodist and an optician visit regularly. We spoke with several people living in the home and they all told us that they were very happy with the care provided. Comments included: ‘I feel looked after, secure, all the staff are kind, the staff will help if needed’; ‘they look after people well, it’s good place to be’; I have no complaints, I wouldn’t want to be anywhere else’; ‘the staff are very good and helpful’; ‘my room is lovely, staff are great’ and ‘staff look after me well, food is lovely’. However two relatives we spoke with considered that the standards of care are not always maintained when the home is short staffed. One person said that she had found her relative’s continence pad had not been changed when she visited earlier in the week. The other person said that her relative sometimes missed having a bath when there were not enough staff. We looked at the storage and recording of medicines. Storage, including controlled drugs, was good and secure. Most medicines are supplied in blister packs, but items supplied in boxes and bottles are counted daily to ensure accuracy. When medicines are delivered to the home they are checked and signed in. The medicine administration sheets were completed well and indicated that people receive their prescribed medicines at the right time. There was written guidance for staff about any medicines prescribed to be given ‘as required’. The senior care staff, who are responsible for medication for people not requiring nursing care, have all completed accredited training so they know how to give out medicines safely. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The range of activities available at Daneside Court meets the social needs of some residents but not all, so that some people living there do not have the chance to take part in social activities that would suit them. People are not always offered a choice of meals to suit their tastes. EVIDENCE: A full time activities co-ordinator is employed at the home. There are planned social activities and a weekly programme is displayed on notice boards in the reception area and on the first floor. Trips out are arranged to local shops or to places of interest. Many photographs of social events are on display. Entertainment is also provided in the home and a mobile library visits every two weeks. In the ground floor lounge we saw a group of residents sitting chatting after lunch and there was a nice lively atmosphere. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 14 A relative we spoke with said that the more frail people on the first floor are not included in any activities and three members of staff who completed our questionnaires commented that there should be more activities. Several members of staff told us that they often do not have enough time to spend with residents due to shortage of staff. They felt that they should have more time to spend talking to residents and taking them out but were often too busy making sure that basic care needs were met to be able to do this. Friends and relatives can visit at any reasonable time. We spoke with a visitor who told us that she comes every day to visit her aunt, who lives on the ground floor. She thinks it is a lovely home, the food is very good, on the whole the staff are lovely, one or two can be abrupt but this is not the norm. She said that there is always something going on every day, people can sit where they want to, and the manager is very approachable. In February 2009 we received a telephone call from the relative of a resident at Daneside Court. The person had rung to complain about the meals at the home. She told us that people do not get adequate food, the food is badly cooked, and people do not have a choice. She said that a number of people have made complaints about the meals. Other than this, the caller was very satisfied with the care her relative receives at Daneside Court. The manager was asked to investigate this complaint. We also received some negative comments in our staff surveys that suggested a lack of choice at meal times, and one of the residents who completed a survey form said they would like ‘more food choice’. In reply to the survey question ‘Do you like the meals at the home?’, two people said ‘always’, three said ‘usually’ and four said ‘sometimes’. On the day we visited the choice for lunch was chicken casserole or vegetable cannelloni. Nobody had chosen the cannelloni and the staff we spoke with didn’t know what it was. A relative told us that there are ‘too many sausages’. Staff we spoke to in the kitchen were rather negative about menu choices and the manager told us that providing choices to fit in with the Southern Cross healthy eating programme had caused some problems. There is a dining room on each floor of the home and some people had chosen to have lunch in their bedroom. Each of the dining rooms has a kitchenette where staff can make drinks for people. In the kitchenette on the first floor there was a list of people who have been prescribed dietary supplements to help maintain their nutrition. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using 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 company has policies and procedures on complaints and safeguarding so that people living at Daneside Court can be confident their concerns will be listened to and they are protected from abuse and poor practice. EVIDENCE: There is a complaints procedure for Daneside Court that informs people who to contact if they have any complaints and this is displayed in the home. The home manager keeps a record of complaints received. In the information she sent us before our visit, she told us that twelve complaints had been received in the last year. We saw that these were all recorded in detail showing what action had been taken and copies of letters sent to people who had made a complaint. In the eight resident survey forms that were returned to us, seven people said that they knew how to make a complaint and would know who to speak to if they were not happy. Southern Cross, the company that owns the home, has policies and procedures that give staff guidance about how to recognise and report abuse. The training records showed that staff receive training about this so they know how to protect the people who live at Daneside Court from harm and poor practice. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using 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. Daneside Court is well maintained so that it provides comfortable, clean and safe surroundings for the people who live there. EVIDENCE: The home was purpose built in the 1990s and provides spacious accommodation on two floors. It is close to the centre of Northwich so people can visit shops and other local amenities. There is a garden at the back of the home that is accessible for residents. All of the bedrooms are single and have en-suite facilities. There are four large lounges and two dining rooms. Bathrooms and shower rooms on both floors are spacious and well equipped. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 17 When we visited, all parts of the home were clean and tidy but the carpet in one of the lounges on the ground floor is badly marked. There is a very large laundry that also provides a service for Daneside Mews, another care home on the same site. The laundry was very clean, tidy and well organised and is a credit to the staff who work there. All of the people who completed our survey forms considered that the home is always clean. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not always enough staff working in the home so people living in the home may have to wait to receive the care they need. Recruitment procedures are thorough to make sure that staff are suitable to work in the home. EVIDENCE: At inspections in November 2007 and June 2008 we found there were not always enough staff working in the home to make sure that people’s needs were being met. When we visited in December 2008 there did appear to be enough staff. Before this visit we received seven comments cards from staff working at the home. In reply to the question ‘Are there enough staff to meet the individual needs of all the people who use the service?’, four people replied ‘never’, one replied ‘sometimes’, one replied ‘usually’ and two did not reply. The comments we received included, ‘The carers do the best they can due to short staffing and illness’ and ‘Carers working well over safe working hours’. Another person wrote, ‘Staff morale is at an all time low as we are constantly working short staffed. We are over staffed on paper but most certainly not in practice. We are unable to give the care and time to the people we look after’. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 19 We discussed this with the manager who told us that there are sometimes occasions when the home is under staffed and this is due to people going off sick at short notice. On the day of our visit, on the ground floor there were two senior care staff and three carers on duty. When we visited the first floor a relative asked to speak with us. She said that the home is always understaffed. She told us she had no complaints about the carers, they are very good. When asked how the shortage of staff affects the care of her relative she said she had found him wet and soiled earlier that week when there were not enough staff; he needs two people to provide personal care. She said that a lot of staff have left. Another relative also asked to speak to us. She believes that the home is short staffed and there are very rarely five carers on duty on the first floor. She said that this situation had been going on since before Christmas. She told us that the staff are very nice, but a lot of staff have left, including nurses. She visits her relative every day. She said ‘it is not now and again, it is regular that there are not enough staff’. We met with all the staff on duty on the first floor in the afternoon. They were unhappy about staffing levels and feel that they are not able to give good care as they are constantly short staffed. All staff feel tired as they are doing extra shifts. We looked closely at the staff rotas. These showed that there should be two nurses and five carers on duty during the day on the first floor, and one nurse with three carers at night. Although the planned rotas showed full numbers, due to sickness, holidays and staff being moved around, on many occasions these numbers were not maintained. For example, in the week commencing 31 May there was only one day when the full number of staff were on duty. On Monday 14 June there was only one nurse and three carers during the day. We looked at back rotas and for week commencing May 3 there were only two days when the full number of staff were on duty. Rotas for nights showed only two carers on 8, 9, 13 June and 31 May. The rota for the day after our visit, Friday 19 June, showed two nurses and four care staff on duty during the day, and for Sunday 21 June only two care staff for nights. We asked the manager what she was doing to cover these shortfalls and she said she didn’t know about them. The manager has been trying to recruit more care staff. She told us that she has found three people who are suitable but they had not started working at the home yet as their Criminal Records Bureau disclosures had not been returned. (This is the check to show whether people have a criminal conviction that may indicate they are unsuitable to work with vulnerable residents.) In view of the shortage of staff at the home, there is no reason why these new staff can not start working on a probationary basis until their Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 20 CRB arrives, provided other checks such as references and a POVAfirst check have been carried out and they are always supervised by experienced staff. We looked at the records of staff who had started working at the home recently. The records were good. They had all completed application forms including details of their previous employment, and all of the required checks had been completed. The records also showed that new staff receive induction training to ensure that they know how to work safely. In the information we received before our visit, the manager told us that there are 30 care staff working at Daneside Court and 24 of them have a national vocational qualification in care at level two or level three. This means that there is a well-qualified workforce. A training chart provided by the manager showed that staff receive updates of the mandatory training to ensure they know how to work safely. Some staff had not yet updated their training in 2009 but dates had been booked for them to do this. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not have a registered manager. The health, safety and wellbeing of the people who live at the home may be at risk if there are not enough staff on duty. EVIDENCE: The manager of the home has been in post since August 2007. She is a registered nurse with considerable previous experience. Although she has been in post for nearly two years she has not yet been registered with the commission. It is an offence under the Section 11(1) of the Care Standards Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 22 Act to manage a care home without being registered. After the inspection we were informed that our registration department has received and is now processing a valid application for the home for the manager to become registered with the commission. The home manager is supervised by an Operations Manager. Before our visit the manager completed a self assessment form and in this she told us, ‘The home manager ensures there is the correct number of staff on duty and manages sickness and annual leave’. We did not see evidence that this was happening. There were too many staff on annual leave that week. The manager was not aware of staff shortages for Friday 19 June and Sunday 21 June. Staff are moved from days to nights and from the first floor to the ground floor. We could not find out who was taking overall responsibility for rotas and this seemed to be shared between several people. No agency carers had been used to cover shortfalls in the numbers. We have records that the operations manager visits Daneside Court at least once a month and speaks with residents and staff. She told us that no-one has made any complaints to her about staffing issues and she was unaware of these problems. It is concerning that staff and relatives chose to tell us about the issues but did not approach the operations manager during her visits. The week after our visit the operations manager contacted us to inform us that she had been carrying out a full investigation of staffing levels and was taking action to address the situation. The home has a quality assurance system that includes regular audits and return of information to head office. The administrator sends out annual satisfaction surveys to find out people’s views and these are returned to head office. We saw evidence of heads of department meetings, health and safety meetings, staff meetings and resident/relatives meetings. One of the staff who completed a survey told us, ‘The home has excellent relationships with relatives’. Arrangements are in place for people living at the home to be able to keep small amounts of personal spending money in safe keeping. Individual records are kept and residents can have an update of their account on request. The fire officer visited the home on the same day that we did. He told us that he is satisfied with the measures that have been put in place to protect the people at the home from the risk of fire. Regular fire drills and weekly fire alarm tests are recorded. We were concerned that a shortage of staff, particularly during the night, could put people at risk if an emergency such as a fire occurred. We looked at accident records and found that there was good recording of accidents and monthly auditing to look at the occurrence of accidents and whether there are any trends that need to be followed up. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 23 The manager provided us with details of when plant and equipment in the home had been tested and serviced to make sure they are in safe condition and these were all up to date. Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 24 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 3 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 2 13 3 14 3 15 2 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 1 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 25 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 OP27 Regulation 18 Requirement There must always be enough staff on duty to ensure that the health, safety and welfare of the people living at the home are maintained. Timescale for action 06/07/09 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 OP12 Good Practice Recommendations Action must be taken to ensure that the social, emotional and recreational needs of all the people living at the home are considered, and every effort made to try to meet these needs. The people living at the home should be offered a choice of meals suitable for their tastes. 2 OP15 Daneside Court Nursing Home DS0000018768.V376184.R01.S.doc Version 5.2 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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