Inspection on 18/04/07 for Daneside Mews

This inspection was carried out on 18th April 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

Daneside Mews 23/01/06

Daneside Mews 19/07/05

Daneside Mews 06/01/05

Daneside Mews 11/08/04

Daneside Mews 11/03/04

Daneside Mews 23/10/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Daneside Mews Chester Way Northwich Cheshire CW9 5JA Lead Inspector Bronwyn Kelly Unannounced Inspection 18 April 2007 09:30 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 Mews DS0000006631.V320782.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 Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daneside Mews 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 351935 01606 331500 www.schealthcare.co.uk Southern Cross Healthcare Services Limited Mrs Catherine Johnson Care Home 34 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (32) of places Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 32 Service users may be DE(E) No more than 2 Service users may be DE Date of last inspection 23rd January 2006 Brief Description of the Service: Daneside Mews is a registered care home providing accommodation and personal care for up to thirty-four older people who have dementia. Two of these beds are registered for people with dementia who are under 65 years of age. The home is in the centre of Northwich, making it well placed for various community facilities, and for access for visitors who may have to rely on public transport. All the bedrooms are single rooms with en-suite facilities, and a there is a variety of communal lounges and dining areas. There are large enclosed, secure grounds with seating areas and walkways. The pleasant garden also has a summerhouse for people who live at the home to use in warmer weather. The current weekly fees range from £460 to £520. Further details about fees are available from the manager. Additional charges are made for newspapers, hairdressing and toiletries. Prospective residents are able to read the latest CSCI inspection report, which is available in a copy of the Service User Guide in the entrance hall. Other information about the home is available in leaflets on display in the hall. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit by one inspector took place on the 18 April 2007 and lasted 6.5 hours. This visit was just one part of the inspection. Before the visit the home manager was also asked to complete a questionnaire to provide up to date information about services in the home. Questionnaires were also made available for residents, families, and health and social care professionals such as doctors, nurses and social workers to find out their views. Other information received by CSCI since the last key inspection was also reviewed. During the visit various records and the premises were looked at. A number of residents and relatives were also spoken with and they gave their views about the service. What the service does well: Residents who were able to communicate said they were well cared for, and visitors also gave positive comments about the care in Daneside Mews. One visitor wrote on a comment card, “Some very caring staff employed at this home”. Another visitor wrote, “The staff are friendly and caring towards my mum and to us as a family”. Residents have comfortable en-suite bedrooms in which to live, and are able to bring possessions including favourite pieces of furniture with them to make them feel more at home. Pleasant gardens with walkways and seats are available for those who enjoy being outside. The atmosphere in the home is warm and welcoming and there is evidence of good relationships between residents, relatives and the staff. A variety of activities take place which residents can join in with if they wish, to keep themselves active and stimulated. Residents were seen to be enjoying their food, and relatives said the food was good. Snacks are available at all times in-between meals for residents so they receive a varied diet. The staff team is a happy group, with staff who are continuing with their training and able to meet the needs of the residents, ensuring the standard of care is good. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Daneside Mews DS0000006631.V320782.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 Daneside Mews DS0000006631.V320782.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. Standard 6 does not apply as intermediate care is not provided at the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed before they move into the home. This ensures that each resident and their family know that these needs can be met when they move into Daneside Mews. EVIDENCE: The manager visits each person who might move into Daneside Mews in their own home or hospital before they move in to check on what their care needs are. Assessments from social services and/or medical professionals such as specialist doctors are also part of this process, to ensure that all the person’s needs can be met at the home. The care files of four residents were checked, including one of a resident who had recently moved into the home. Completed assessment forms, which were Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 9 thorough, were available in each care file and had been used to draw up the person’s care plan. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home are well looked after, ensuring their health, social and personal care needs are met. EVIDENCE: Four residents’ plans of care were seen and each showed what staff need to do to meet the majority of their needs. They were well written, up to date and reviewed regularly and care plans updated. This ensured that people’s changing needs were always recorded in the plans of care. All the files checked contained risk assessments, moving and handling information, information about contact with medical professionals such as doctors and nurses, nutritional records and a variety of other records to ensure the residents’ wellbeing. There was evidence that staff work closely with health professionals and there are good links with local GPs. One doctor wrote in a CSCI comment card - Happy environment. Always smells clean and residents appear to be well looked after. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 11 There was not much information in the files about each person’s lifestyle and past history. This information would enable staff to have a greater understanding of each resident. This work had been undertaken with one person and their family, and the staff agreed that it helped in planning this residents care. This should be undertaken for each person who lives at the home. Staff should become familiar with the use of life history techniques and have an understanding of the importance of person centred planning. Senior staff in the home who give out medicines have attended a medication training course. The home has a medication policy and the manager regularly audits that the medication procedures are followed. The storage, returns and recording of medication were all in good order, ensuring that the people who live at the home receive their medicines safely and as prescribed. Care staff were observed to treat the residents with dignity and respect and communicate with them in a variety of appropriate ways. One visitor to the home said he had only ever seen the staff treating the residents well. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are helped to choose their lifestyle, social activities and food, showing that they have some control over their lives. EVIDENCE: A new activities co-ordinator has recently been employed and the staff spoken with described her as the best we have ever had. They said residents enjoy the activities she arranges, and she is able to encourage residents to join in. Some of her time is spent with 1:1 activities and some with small groups. Reminiscence, indoor games, music and crafts are some of the activities. Those people who do not wish to join in have the choice of going out to the shops or for short walks with her. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 13 On the day of the visit, the activities co-ordinator was not on duty, so there was not much happening in the home to keep residents occupied or stimulated and little interaction with the staff. The televisions in both lounges were playing the whole time during the inspection visit, with hardly anyone watching. There are no separate smaller lounges for residents who wish to choose a quieter area to sit in. Staff said the food is much improved over recent months. Food is prepared at Daneside Court, a nursing home on the same site, and delivered on trollies. There are two choices at lunchtime, and staff show the residents two plates of food from which they can choose, rather than asking them to decide the day before. On the day of inspection, the choices were roast lamb or sausages in onion gravy, roast and mashed potatoes, sprouts and cabbage. The dessert was rice pudding or fresh fruit salad. One relative wrote on a comment card “re meals – mum has gone from being a skeletal size 8/10 to a size 12. They really do try to tempt her with things she likes. Two small kitchen areas are situated next to the dining rooms, and these are stocked with snacks for residents who wish to eat at different times. Typically there are cereals, fruit, yogurt, cheese, bread for toast or sandwiches and tea cakes. The kitchen areas are in need of refurbishment, but the manager said this is planned for later in the year. Two relatives spoken with said they had seen the food on a number of occassions and thought it looked very good. One said that she had been able to enjoy having a meal with her relative in the home. They both confirmed that they could visit the home at any time. Staff were observed to give appropriate help to residents who required assistance with their eating, such as sitting with them, smiling, communicating and not being rushed. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for making complaints and protecting residents from abuse are satisfactory so residents are not at risk from harm or poor practice. EVIDENCE: The complaints procedure is available in the service user’s guide, a copy of which is in the hall and information regarding how to contact the CSCI is displayed. Residents and visitors to the home are encouraged to express any comments they have about the home, and regular relatives’ meetings are held. CSCI has not received any complaints about the home since the last inspection. The information sent to CSCI before this visit took place indicated that the home has received two complaints in the past year. The manager encourages families to discuss any issues or concerns they have with her and the staff, so that these can be put right immediately. None of the visitors spoken with had made any complaints, but both said that any minor concerns they bring up are quickly acted upon. The staff spoken with showed an understanding of adult protection procedures. A training course on protecting adults from abuse has recently taken place for staff to update their knowledge. There are policies and procedures in place for the protection of residents. Daneside Mews DS0000006631.V320782.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, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in comfortable surroundings but these now need some improvements to make sure they meet the residents’ needs. EVIDENCE: The people living at Daneside Mews all have large single ensuite bedrooms, which contain many of their own possessions, creating a homely effect. Ouside, there are pleasant garden and patios, with furniture for the warmer weather. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 16 The communal areas of the building were seen during during the inspection. There are only two lounges in Daneside Mews, each fairly large, accommodating up to 17 people each. There are no smaller rooms or lounges where residents can get away from others, or have some quiet time away from televisions and noise. There is a conservatory which leads off a lounge and dining room, but this is used as a smoking room at present. This room should either be totally enclosed so the adjacent lounge and dining areas are smoke free, or other arrangements made for residents to smoke in the home. This should be in line with new Government legislation regarding smoking in public places being introduced on 1 July 2007. There are four bathrooms, but only one is in use. Staff said this was because there is only one hoist in the building (another is on order). The bathrooms, including the one in use, were used for storage and dirty linen, as there are no other suitable storage areas in the home. There should be sufficient bathing areas for residents to have a choice of facilities, which are homely and comfortable and not being used for storage. There were no waste bins in the toilets for used paper hand towels, as staff said they were used inappropriately by some residents. Bins were put into toilets during the inspection visit but a long term solution to this problem needs to be sought. There has been some investment to the fabric of the home over the past few months. New carpet has been laid in the corridors and lounges and laminate flooring has been installed in the dining areas. The standard of cleanliness throughout the home is good, with no noticeable odours. Policies and procedures are in place for the control of infection and health and safety, protecting staff and residents. Daneside Mews DS0000006631.V320782.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have had training to help them develop their skills and provide safe care. Recruitment procedures are thorough enough to ensure that residents are protected. EVIDENCE: The staff group at Daneside Mews have been continuing with their training, and are working towards reaching the target of 50 trained care staff. To date, 6 of the 17 care staff group (35 ) hold a minimum of NVQ level 2. Eleven care staff have started their training. In-house training for staff continues on a regular basis according to need. The majority of staff have undertaken dementia care training provided by the Alzheimers Society, with one member of staff now trained as a trainer. The staff spoken with said their mandatory training was updated as required and all felt there was sufficient training available. The staff group felt well supported by the management of the home. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 18 Good policies and procedures are in place for the recruitment of staff. Four staff files were seen and each contained evidence of an interview, two references and the necessary POVA and CRB checks having been obtained before the staff member started working in the home. This provides a level of security and safety for residents. Equality and diversity within the home can be seen in the way the staff treat the residents as individuals with different needs. The home strives to meet these needs as appropriate, and provide the necessary care to enable each person to live their chosen lifestyle. However, some further staff training in this area would raise the staffs’ awareness of equality and diversity issues. Daneside Mews DS0000006631.V320782.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and supported by senior staff, ensuring the residents live in a well run home. EVIDENCE: The manager at Daneside Mews has a number of years experience as manager at the home and has completed the Registered Managers Award. Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 20 The quality assurance questionnaire system could be improved. The results of these surveys could be collated and a summary made available for the service users’ guide, detailing any actions that may or may not be needed. Joint relatives/residents meetings are held regularly, enabling people to voice an opinion about life at Daneside Mews. The home works to a good system for safeguarding residents’ money and clear records with receipts are kept. Policies and procedures for safeguarding residents’ money provide security. The information provided from the home before the inspection visit showed that equipment and installations at the home are serviced regularly. A handyman is employed at the home to attend to maintenance issues such as checking fire equipment, water temperatures and other health and safety matters, providing a safe environment for staff and residents. Daneside Mews DS0000006631.V320782.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 2 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 X 18 3 2 X 2 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 2 X 3 X X 3 Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP21 Regulation 23(2)(j) & (m) Timescale for action There must be sufficient 30/10/07 bathrooms in working order, and not being used for storage, to meet the needs of the residents. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Further information should be gained about each resident’s earlier personality, lifestyle, likes and dislikes from relatives and friends to build a ‘life-story’. This will enable staff to work with residents in a person-centred way. More appropriate arrangements should be made for residents who wish to smoke in the home. Consideration should be given to current good practice guidelines, which recommend that residents with dementia are cared for in small groups, and there should be a room where they can get away from other people, televisions and noise. The internal quality assurance surveys in place should be improved upon so that the home receives feedback from people that use the service and their relatives. 2 3 OP19 OP19 4 OP33 Daneside Mews DS0000006631.V320782.R01.S.doc Version 5.2 Page 23 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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