Inspection on 19/07/05 for Daneside Mews

This inspection was carried out on 19th July 2005.

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 18/04/07

Daneside Mews 23/01/06

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 Joan Adam Announced 19 July 2005 09:00 th 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 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 F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Daneside Mews Address Chester Way Northwich Cheshire CW9 5JA 01606 351935 01606 331500 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Ann Bailey/Southern Cross Healthcare Services Ltd Mrs Catherine Johnson Care home only 34 Category(ies) of Dementia - 2 registration, with number Dementia - over 65 years of age - 32 of places Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2005 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 situated in the town centre of Northwich, making it well placed for various community facilities, and for access for visitors who may have to rely on public transport. The home provides single bedrooms with ensuite facilities, and a variety of communal lounges and dining areas. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over a two-day period. A tour of the home was carried out and care records, fire records and staff training files were inspected. Before the day of the inspection twenty-four comment cards for residents and their families were sent to the home. A detailed preinspection questionnaire was sent to the manager to complete. Comment cards were also sent to the G.P for the home and to placement officers with social services. Residents, visitors and staff were spoken to during the inspection. What the service does well: The needs of the residents continue to be met to a good standard and all of the people spoken with were satisfied with the care that they, or their relative, were receiving. A good variety of food is provided. The home has a regular group of staff that have worked there for some time and they are aware of the needs of the residents. Staff members are friendly and attentive to the residents. Social activities are varied and the residents spoken to were pleased with the way the home is run and the choices they can make. The home manager is experienced and competent. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 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. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,6 Assessment procedures before residents move into the home are thorough and allow family members to be part of the process of assessing needs. The home only admits those people whose needs are in keeping with the skills and knowledge of staff working within the home. EVIDENCE: Care plans of two recently admitted residents contained preadmission assessments. These had been carried out by the manager and were also supported by additional assessments carried out by other social care workers. Copies of these were kept in the resident’s files. The manager and other senior staff confirmed that the identified needs were discussed with family member as part of the admission process. One relative spoken with said that the manager had visited them prior to their relative’s admission to the home. Daneside Mews does not provide intermediate care. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 Care plans in general at the home are detailed but one plan of care looked at did not document the specific individual problem identified by staff. The health care needs of residents are met at Daneside Court. Staff members working at the home are aware of the needs of the residents. Residents at the home are treated with dignity and their privacy is respected. EVIDENCE: Five care plans were examined. These contained detailed assessments of areas of need, such as mobility, falls, moving & handling, continence, nutrition and general dependency. All were up dated and reviewed on a regular basis. Records were also made of support from and visits by other health professionals such as GP’s. One resident who was a diabetic had a detailed care plan in place and charts to enable blood glucose to be recorded. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 10 Residents that had waterlow scores (a measurement tool to assess skin integrity) identified as being at a high risk of developing pressure sores had care plans in place to enable action to be taken to prevent these, however, the problem section in the care plan had not been completed correctly. (See requirement 1) Care staff were observed to interact well with the residents. Relatives spoken with said that the staff were very good and that their relative was well looked after. Residents spoken with who were able to express an opinion said that the staff were very nice. A good social history had been written in the plans of care, most of these had been completed by family members. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 Residents living at Daneside Mews are able to make choices regarding daily routines at the home. The residents enjoy a good and varied choice of wholesome and well presented meals. EVIDENCE: Residents spoken with who were able to offer an opinion said that varied social activities take place at the home. One resident said that “ there is always something going on” A programme of activities was available on the notice board in the entrance hall and in the main corridors. Relatives said the activity programme was good and varied, however they would like more trips out for their relatives. A trip to Llandudno was arranged for Wednesday and when the inspector returned to the home following this some of the residents said that they had enjoyed their day out. The atmosphere throughout the home was warm, friendly and relaxed. Care plans included rising and retiring times and preferences regarding social activities, likes and dislikes regarding foods. Some residents were in bed until lunchtime by choice, this was recorded in their care plan and some residents went back to bed for a nap after lunch. The activities co-ordinator was at the home on the first day of the inspection and was seen to interact well with the residents, using gentle persuasion to Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 12 encourage residents to join in. One resident was seen to commence the game and changed his mind. Staff took time to assist him to another area of the lounge away from the activity. Bedroom doors at the home have locks fitted to maintain residents’ privacy if they so wish. Menus at the home offer choice and snack foods are available between meals if requested. Residents said the food was really good. One resident was seen to eat her breakfast and some time later came back to the table and was given a second breakfast at her request. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Complaints at the home are dealt with in accordance with the company’s complaints policy and residents and relatives know who to raise concerns with. The policies, procedures and management at the home protect the residents from abuse. EVIDENCE: There have been no complaints made to the home or to CSCI since the last inspection. A copy of the complaints procedure is available in the service users guide. However, the manager is not recording all concerns raised by relatives, such as items missing from residents’ bedrooms or items missing in the laundry, within the complaints log. It was felt that all concerns should be logged to enable the manager to monitor items that are missing and as good practice. (See recommendation 1) Residents and relatives spoken with said that they had no complaints and that they were aware of who to speak to if they were unhappy about any aspects of the home. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 14 A policy on the protection of vulnerable adults is in place. Members of staff spoken with confirmed that they were aware of the policy and the No Secrets guidance issued by the Department of Health. Staff have received fire prevention training in January 2005 and this was recorded in the staff training files. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,23,26 Residents live in a safe comfortable environment that is clean and pleasant. EVIDENCE: The home has a programme of redecoration in place and some of the main corridors had been painted. Care call points are located in bedrooms, bathrooms, toilets and communal areas. Residents rooms are well personalised with residents’ own furniture, photographs and ornaments. The home was clean and free from unpleasant smells. Residents and relatives spoken with said that the home was always clean but felt that the carpets in the upstairs corridor had been cleaned especially for the inspection. A commode that was being stored in a bathroom on the downstairs floor had enamel paint peeling off and needed replacing, the manager had this removed before the end of the inspection. All bathrooms at the home had bath thermometers in place and water temperatures were recorded prior to a resident being bathed. The home had Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 16 good practice in place of all toiletries, hairbrushes combs and toothbrushes being named for individual residents. There are safe enclosed gardens for the residents to use and some residents said that they enjoyed going out in the fresh air. One resident on the first floor said that he would like to use the garden on a more regular basis. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Resident’s benefit from a service that provides adequate staffing levels and well-informed and knowledgeable staff. EVIDENCE: Staff spoken to were aware of their various roles and responsibilities, had an understanding of the policies and procedures that directed their work and had a very good relationship with those they cared for. The staffing numbers at the home are adequate to meet the needs of the residents. Duty rotas were seen and staffing levels were being maintained. Care staff spoken with had detailed knowledge of the needs and personalities of the residents and spoke about training they had received over the last year. This included Adult Protection, Moving & Handling, fire, first aid, infection control and NVQ. Over fifty per cent of staff at the home have achieved level 2 NVQ in care. Staff at the home have had recent training on dementia care which they all enjoyed and felt that it has given them an insight into the needs of the residents in their care. The records of two recently appointed staff contained appropriate information to ensure that the residents are protected. New staff were provided with a formal induction that was in the form of a workbook, which is based on the recognised TOPPS induction. Staff will then complete TOPPS foundation course before undertaking NVQ level 2 in care. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,38 The management of the home maintain the safety of the residents living there. EVIDENCE: Residents living at Danesidew Mews and relatives visiting said that their opinions are listened to. Residents’ choices are recorded in the plans of care. The manager holds regular residents/relative meetings and a record of this is available on notice boards. Staff meetings are also held on a regular basis within the minutes taken and circulated to all staff. Staff working at the home have yearly appraisals and there was evidence of staff being formally supervised six times a year. A senior manager visits the home on a monthly basis, unannounced, and areas checked are health and safety, property and equipment and staffing issues. Discussion with residents and staff also take place. These visits and any resulting actions are recorded. A copy of the report is sent the CSCI office. Residents’ monies are stored individually and records of accounts are stored on Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 19 the computer. A printed copy is available for each resident. Accidents are recorded appropriately. Safety certificates were in place for items such as hoists and passenger lifts. The homes fire log showed that staff training in fire safety has taken place and been recorded. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 3 x 3 x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x 3 Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 21 no Are there any outstanding requirements from the last inspection? 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 15 Requirement identified problems must be specified clearly within the care plan. Timescale for action 31st August 2005 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 op16 Good Practice Recommendations all complaints made to the home should be logged. Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Daneside Mews F51 F01 S6631 Daneside Mews V231131 190705 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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