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Inspection on 06/11/07 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 6th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What has improved since the last inspection?

The management of medicines has improved since the last inspection. Residents can now be confident that they will receive their medicines as prescribed by the doctor. A new activities co-ordinator has been appointed and this has resulted in a marked improvement in the activities provided in the home. However this needs to be further developed to ensure the needs of all residents are met. The dining rooms have been refurbished and decorated. New carpets have been purchased for two of the lounges and new chairs purchased so providing a pleasant environment for residents. Staff have received fire safety training so that they know what to do to keep people safe should a fire break out.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Daneside Court Nursing Home Chester Way Northwich Cheshire CW9 5JA Lead Inspector Helena Dennett Unannounced Inspection 6 November 2007 4:00pm 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 Daneside Court Nursing Home DS0000018768.V348886.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. Daneside Court Nursing Home DS0000018768.V348886.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 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.V348886.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 4 April 2007 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 353.91 – 632.90 per week. Additional charges are made for the hairdresser, chiropodist, outings, bingo and newspapers. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place over 9 hours. Two inspectors visited the home from 4pm to 1030pm one evening; one inspector returned the following morning to complete the inspection. Before the visit the acting manager was invited to provide information about the home as part of this inspection process. The views of residents and relatives were also sought and their comments are incorporated into this report. During the visit the inspector spoke with people who live at the home, staff and to the operations manager. The inspector also spoke with some relatives before the visit to the home. The care records for four people who live at the home were examined as part of the inspection, in respect of the care they receive. Records of medication, care plans, and training were also examined. What the service does well: All prospective residents are assessed before coming into the home so they can be confident that staff at Daneside Court Nursing Home will be able to meet their needs. Staff respect the privacy and dignity of residents. Many of the staff have completed national vocational qualifications (NVQ), which means that they should have the knowledge and skills to care for people living in the home. There are also good recruitment procedures, which means that only people suitable to work in care are employed. Residents’ bedrooms looked homely and contained their own possessions The following comments were received back on survey forms to CSCI before the visit in response to the question ‘what do you feel the home does well’: • • ‘Staff do their best to help my relative and seem to be competent in their job. The housekeeping staff manage to keep the place clean.’ ‘Generally Daneside Court is extremely satisfactory. My relative has been in residence in the nursing unit for 1¼ year’s approx and he has been very well cared in all ways. I feel that the home does well in all areas especially cleanliness. Everywhere is always lovely and clean and sweet smelling’. DS0000018768.V348886.R01.S.doc Version 5.2 Page 6 Daneside Court Nursing Home • ‘Very good care – pleased with staff commitment.’ What has improved since the last inspection? What they could do better: Some of the care plans need to identify the individual needs of the resident to make sure that all their care needs will be met. For example, residents with sensory impairments such as being blind or deaf should have a set of care plans that take this into consideration. Care plans should be reviewed more regularly and the reviews recorded in terms of outcomes so that staff are aware of the persons needs and whether the care identified in the plan is still relevant to meet those needs. The care plan should reflect clearly the actual care being delivered to a resident. Staff should monitor residents’ health and record this in the plan of care, in particular if a resident develops a pressure sore. This means that the resident can be confident that the most appropriate care is being provided. Although there has been a marked improvement in the provision of activities within the home, more needs to be done for the people who have disabilities and may not be able to join in the general activities. Residents should be encouraged and enabled to use dining room and lounge areas in the evening and consideration should be given to the provision of activities/entertainment in an evening. The provision of specialised equipment such as mobile hoists and bath hoists should be reviewed and additional hoists purchased to ensure that residents are not left for long periods of time before getting assistance. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 7 The management of adult protection issues needs to improve. Members of staff should be reminded of the correct action to be taken should an allegation of abuse be made so that residents are not place at risk. A review of staffing levels is needed as concerns have been raised there are not enough staff working in the home to meet resident’s needs. The following comments were made on survey forms returned to CSCI before the inspection to the question ‘how do you think the care home can improve’ • • • ‘More and better quality trained staff’ ‘Couldn’t pin point anything’ ‘Employ more staff.’ Comments made to other questions included the following: • • ‘If there were more staff available some time could be spent with residents on a one to one basis.’ ‘I feel my relative always appears to be in bed even though I‘ve been told she needs to sit out’ 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. Daneside Court Nursing Home DS0000018768.V348886.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.V348886.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Possible new residents have their needs assessed before they move into the home to make sure that their needs can be met there. EVIDENCE: Information is available for any person considering moving into the home. This includes a service user guide, which provides information on the staff and the facilities that are on offer. The service user guide is also available in audiocassette. The guide says there is an attractive garden to the rear of the home – this is not the case as it is a lawned area with a steep decline near the fence. The fence at the back is not secure as it is a right of way for the general public. People moving into the home are issued a contract at the beginning of their stay. This outlines the terms and conditions of the home. They and/or their representatives are asked to sign this. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 10 One person who had recently moved into the home spoke with one of the inspectors. She confirmed that a member of staff visited her before she came in and that her relatives had looked around the home to make sure it was suitable to meet her needs. Most of the survey forms received back to CSCI before the site visit indicated that people had been provided with enough information to make a decision on whether the home was suitable for them. Intermediate care is not provided at Daneside Court so Standard 6 does not apply. Daneside Court Nursing Home DS0000018768.V348886.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The dignity of the people who live at the home is maintained but they do not always receive health and personal care that is based on their individual needs so there is a risk that their needs might not be met. EVIDENCE: The care records for five people who live at the home were looked at during the visit. The records all contained an assessment of needs and from this a care plan was drawn up. The structure of the care plans had improved since the last inspection although some work is still needed to make sure that the care plan identifies individuals needs. Although there was evidence that some of the care plans had been reviewed, in some instances the review did not give any information on the care that had been provided and whether this met the person’s needs. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 12 For example the review for one person’s care plan was the same for the past six months so it was difficult to establish whether the care identified on the care plan was still relevant to the person. The care plan for one person in particular was not person centred and did not address their needs. This person had sensory difficulties and the care plan lacked information on how staff should address this particular need and how this impacted on the rest of the person’s care. There was no evidence that any special adaptations or considerations were made for this person. Another person’s care plan identified that the person tires easily but sits out most days, getting back into bed after lunch. On the evening of the visit the person was in bed. According to the daily progress notes the resident remained in bed for the four days before this visit. Before that the resident had sat out on alternate days. One of the carers said that the resident had been left in bed because they had a small pressure sore. There was nothing in the notes to suggest this resident had a pressure sore. The last review of her skin took place on 16/20/07, which stated that her pressure areas were intact. The qualified nurses on the unit told the inspector at the beginning of the visit that there was no one with a pressure sore that had developed whilst living in the home. It was therefore difficult to assess whether appropriate care was provided for this person. Residents spoken with were all generally positive about the care provided at the home. One person said there were times when they had to wait for assistance because of the lack of hoists available. A concern had been also been raised with CSCI about the lack of lifting equipment, particularly on the downstairs unit, so residents had to wait to be assisted. The company that runs the home was asked to investigate. Assurances were given at that time that there were enough hoists available to meet the needs of the residents. However the nurse in charge of the shift confirmed that because of the dependency levels of the current residents, another hoist has been ordered and that the hoists upstairs were shared with residents on the ground floor. There were only two showers and one assisted bath working on the first floor. This means that at times the mobile hoists might be used to assist people in and out of the other baths so putting additional demands on the hoists in the home. The management of the medicines in the home was found to be satisfactory in the main. A detailed policy was available and accessible to staff. On the ground floor one of the locks on the medicine cupboard was broken and in need of repair. Medicine administration records (MAR) were looked at. These were found to be satisfactory and showed that residents are receiving their medicines as prescribed. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 13 Members of staff were seen to treat people with respect, and bedroom and bathroom doors were shut before any personal care was carried out. The privacy of residents could be compromised in that members of the public were seen walking past one resident’s bedroom window. The resident said that this was a common occurrence. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a good variety of activities available during the day but more choice needs to be given in respect of evening activities to ensure that residents are kept active and stimulated. EVIDENCE: There are plenty of planned activities carried out in the home during the day. A full time activity co-ordinator has been employed. A weekly activities sheet is put on the notice board in the main reception area and is also on a notice board upstairs. Notices about special events are displayed throughout the home. A cheese and wine evening is held once a month on a Saturday evening. Group activities are generally held in an afternoon. Trips out have been arranged recently including trips to Blackpool, Anderton boatlift and a shopping trip to Warrington. During the visit there was very little activity going on for the residents. Most residents were seen watching television in their rooms with only two people in the lounge area upstairs after tea. Upstairs a large number of people were in bed. One resident confirmed that on most evenings there is little to do. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 15 The residents lounge downstairs was not used after 7.30pm – the light was turned off giving the impression that people living in the home are not encouraged to use this area after that time. Some people living in the home were wandering in the corridors during the evening, going for an occasional cigarette. Other people were watching television in their rooms. The following comment was made to the question on the survey form, ‘are there activities arranged by the home that you can take part in?’ The resident ticked ‘never’ with the following comment: ‘I am blind and permanently in bed’. Another person commented that the care home does little to motivate their relative, as they do not want to join in with the activities. The person went on to state that activities dry up from 7.30pm. People living in the home are enabled to follow their religion as they wish. A lay preacher visits the home on Wednesdays and Holy Communion is served fortnightly. Members of the Roman Catholic Church also visit. Visitors can meet with service users in private, and at any reasonable time. Some visitors can share a meal with service users. People living in the home were positive about the menu and the food provided to them. The chef confirmed that menus are nutritionally balanced as Southern Cross Health Care has a computer system to ensure that the menus are varied and nutritionally balanced so everyone is getting a healthy and varied diet. She also said that she monitors what comes back in from lunches etc so that she knows what is eaten and what needs changing on the menu. She confirmed that she caters for a number of different diets and has attended various courses. She was very positive about the system and the menus. She said that everyone gets at least 5 portions of fruit/vegetables per day. The following comment was received on a comment card made to CSCI before the site visit: ‘I feel the ‘soft food’ menu is rather boring. It should have more variety’. This was discussed with the chef. She confirmed that she addressing this and that she tries to separate the different foods on the plate so the resident knows what he/she is eating. There is now a designated dining room on both floors. On the evening of the site visit on the nursing unit (upstairs) tea was served to residents in their rooms. The light in the dining room was turned off giving the impression that it is not used in the evening. There was evidence in residents’ records that residents are maintaining weight. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 16 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there is a good complaints procedure in the home, adult protection procedures are not always followed and so residents could be place at risk. EVIDENCE: The complaints procedure is displayed on the notice board downstairs in the residential unit. This needs to be updated as it still has the name of the previous manager on it. A records of complaints received is kept by the manager of the home. There was evidence that some of the complaints received have been addressed and meetings held with the complainants. CSCI received two complaints, which were forwarded to the provider to investigate. One of the complaints was about the numbers of staff working at night on the downstairs unit. Although the provider found the complaint was not upheld, this issue was looked at again during this visit. The findings are included in this report in the section on staffing. There is an adult protection procedure for the home which all staff are aware of. One alleged incident about poor practice was logged as a complaint and investigated by the acting manager; this should have been refereed to social services under the local safeguarding adults procedures. The company investigated another incident regarding poor practice by a member of staff. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 17 The operations director agreed that there was insufficient evidence to determine why the person investigating the matter came to the conclusion they had and that appropriate action may not have been taken as a result. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 18 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, 20, 22, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home is generally well maintained, its security is compromised by the lack of a secure gate at the rear of the property. There are not enough specialised hoists or suitable assisted baths so the needs of the residents may not be met adequately. EVIDENCE: Daneside Court Care Home is situated near to the centre of Northwich. It is set in its own grounds; however, there is a public right of way that runs through the back of the grounds and that people use as a short cut through to the town centre. As this has caused security problems and can compromise the privacy of some of the people who live at the home, the company that runs the home has been in contact with the local authority about this problem. The maintenance man confirmed that the local authority has agreed to the Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 19 construction of a secure gate and fence to ensure that residents’ safety and privacy can be maintained. This work is due to be completed shortly. The gardens of the home are in need of improvement. Information received before the inspection visit indicated that plans are in place to improve the gardens. This will make sure that residents have better use of the grounds particularly in warmer weather. Residents rooms were seen to be comfortable, many contained the personal belongings. The two dining areas have been refurbished with new carpets and some new furniture provided. The carpets in two of the lounge areas have also been replaced. There are not enough baths or showers with specialist aids in the home to meet the needs of the residents. On the upstairs floor, which accommodates thirty-six people requiring nursing care, there are two showers and one bath being used. In one of the bathrooms a notice stating ‘out of order, do not use,’ was on the bath hoist. This should be repaired. The bathroom opposite the nurse’s station was used for storage. Two rails of residents’ clothes, two mattresses, a bedside rail bumper and an empty linen skip were placed there. This means that residents could not use this bathroom if they wished and also it could be a fire risk, as bathrooms do not contain smoke detectors. On the ground floor, which accommodates people requiring personal care only, members of staff confirmed they do not use one bathroom, as it does not have any aids for people with mobility problems. This means that residents may not be able to have a bath as frequently as they may wish to. One of the company managers identified that staff, having used a hoist to help people into a bath, were then leaving them in the hoist sling whilst they were in the bath, so reducing the number of hoists readily available for use by other residents. This problem needs to be resolved. There are a number of communal areas that residents can use. However, as stated previously, residents do not appear to be encouraged to use these areas after 7.30pm and most of them were in their rooms after that time. The laundry was visited and found to be satisfactory. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are not always enough staff working in the home so residents needs may not all be met. Recruitment procedures are thorough enough to make sure that staff are suitable to work in the home. EVIDENCE: Before the visit, inspectors received some concerns about the number of staff available to meet residents’ needs particularly at night time. This appeared to relate to people living in the downstairs unit where two staff are employed to look after twenty-four people overnight. One person living in the home stated that residents sometimes have to wait for assistance if the senior carer is giving out medicines. The company has investigated the concerns and concluded there are enough staff working at the home to meet the needs of the residents. The following comments were received by CSCI before the visit: • • ‘The home should employ more staff as I don’t feel there is enough to do the job.’ ‘If there were more staff available some time could be spent with residents on a one to one basis.’ DS0000018768.V348886.R01.S.doc Version 5.2 Page 21 Daneside Court Nursing Home • • • • ‘Need to employ a third person on nights. At least to 1130pm. My relative needs assistance and has to put up with long delays in getting it. This very bad around the medicine dispensing time.’ ‘Staff do their best to help my father and seem to be competent at their job.’ ‘Care is good– pleased with staff.’ ‘The staff are very approachable and friendly.’ Members of staff spoken with confirmed that two staff working at night on the residential unit is not enough to meet residents’ needs. This must be addressed. There was evidence that staff are provided with training courses as necessary. Information submitted by the manager before the inspection visit stated that 20 care staff have a National Vocational Qualification (NVQ) or above. The home employs 28 care staff. This means that most of the staff working at the home are qualified staff that have knowledge and skills to carry out their role. A sample of recruitment records was looked at. All of the necessary checks have been done to make sure that the person is suitable to be employed in care to work with vulnerable people. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 22 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, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home is generally well managed more needs to be done to ensure that the views of residents are sought and acted on so the home is run in their best interests. EVIDENCE: There has been a change in manager recently at the home. The person in charge is acting manager and is new to the home. She was on holiday at the time of the inspection visit. The operations manager visited the home in the evening and received feedback from the inspectors on the findings of their visit. Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 23 There is a quality assurance system in place. Information received before the inspection visit stated that staff hold regular residents’ meetings and that minutes are taken. However the administrator could not find any minutes of these meetings. A relatives meeting had taken place since the new acting manager had come into post. Detailed minutes were taken. A concern was raised at that meeting regarding staffing levels in the home. The acting manager said she would love to have more staff but must conform to CSCI guidelines. This is not accurate in that there are no CSCI guidelines except that the company is expected to provide sufficient suitably qualified staff to meet the dependency needs of residents in the home at all times. This was discussed with the operations manager at the end of the visit. Inspectors were informed that it is the policy of the company to send out survey forms to relatives of 3 nursing and 3 residential clients per month. The completed forms are returned directly to the company’s head office. It was not clear whether staff at Daneside Court get the full results of the surveys; the administrator confirmed that staff were alerted to any issues so that action could be taken to address them. There was no evidence to suggest that the results of the surveys are collated and distributed to residents for their information. Staff at the home manage some of the residents’ money. A separate account is kept in Southern Cross Health Care’s name and transactions are carefully monitored. Residents can have an update on their account on request. Receipts are kept whenever possible and two signatures are also obtained for all transactions. The maintenance man confirmed that all essential equipment is maintained in accordance with manufacturers instructions. A sample of service certificates was seen and these were satisfactory. Tests of the fire safety equipment in the home are carried out regularly and staff have attended fire safety training. A fire risk assessment is in place; the last review is dated 2004. It would be advisable to do a further review of this to make sure that it is up to date and relates to the current residents in the home. Daneside Court Nursing Home DS0000018768.V348886.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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X 1 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 3 Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 17 (3) (a) Requirement Care plans must be specific to the individual and kept up to date, reflecting residents’ current needs so that the most appropriate care is provided to residents. Enough suitable specialised equipment must be provided in to meet the needs of residents. Staff must follow adult protection procedures should an allegation of abuse or neglect arise. The registered person must ensure that the back fence is secured and a suitable gate provided to maintain the privacy of residents. (Timescale 31/08/07 not met) Adequate numbers of staff must be provided so that residents are not waiting long periods of time before they can get assistance. Timescale for action 15/12/07 2 3 4 OP8 OP18 OP19 23 (2) (n) 13 (6) 23 (2) (o) 31/01/08 13/11/07 31/01/08 5 OP27 18 (1) (a) 06/12/07 Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 26 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 The range of activities provided should be reviewed to ensure that people with different disabilities can take part. Consideration should be given to providing activities for residents in the evenings. Residents should be enabled to use dining room and lounge areas in the evenings. The gardens should be landscaped so that all residents could use the gardens and outside areas if they wish. A review of storage facilities should be undertaken so that bathrooms are not used to store items. Residents views should be sought and acted on whenever possible to ensure that the home is run in their best interests. The reasons for any decisions made following investigatory procedures should be clearly recorded so residents can be confident that their complaints are considered fully and appropriate action taken as necessary. 2. 3 4 5 6. OP12 OP19 OP22 OP33 OP37 Daneside Court Nursing Home DS0000018768.V348886.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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. 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