Inspection on 23/01/06 for Daneside Mews

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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 Jayne Telfer Unannounced Inspection 23rd January 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 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.V278159.R01.S.doc Version 5.1 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 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.V278159.R01.S.doc Version 5.1 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 19th July 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 DS0000006631.V278159.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a short, unannounced inspection. It looked at standards which were not examined during the previous detailed inspection. A tour of the home was completed, files and other documents examined. Staff and residents were both observed and spoken with. Discussions took place with the Registered Manager. What the service does well: What has improved since the last inspection? What they could do better: The Service User Guide could be written in a more user-friendly way. Care files could have less medical documentation. Care plans could be written in a clearer way using plain english. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 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.V278159.R01.S.doc Version 5.1 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 the following standard(s): 1 Daneside Mews provides detailed information to prospective residents about the home. EVIDENCE: Both the Statement of Purpose and Service User Guide contained all the information required. Both documents are written by Southern Cross Healthcare, the company who owns the service. On admission all residents are given a copy of the Service User Guide, and a brochure.It was discussed, with the Registered Manager, that the Service User Guide could be made more user-friendly. The Registered Manager agreed to speak with staff and other managers to discuss ways this could be achieved. See Recommendation 1. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 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 the following standard(s): 7, 9 Care plans are appropriately detailed and clearly reflect the needs of the individual resident. Medication policies and procedures exceed the current standards. EVIDENCE: Southern Cross Healthcare has recently introduced new care plan formats which staff at Daneside Mews are getting used to using. Care plans are detailed and reflect the need of individual residents. Plans are regularly reviewed. Staff said that some documents in the care files are irrelevant and medical, for example, ‘monitoring pupil size’, ‘turning charts’ and ‘fluid output charts’. These documents are, in general, unnecessary in a residential environment. It is recommended that staff remove these documents from files. Although care plans were detailed, in some cases the language used was complicated, and it is further recommended that plain english is used when describing care needs and plans. This would make plans easier to read and to use. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 10 A Team Leader oversees medication procedures in Daneside Mews, and checks all records daily. Medication is stored securely and appropriately. Daily temperatures of the medication room and refrigerator are recorded. The team leader showed a good knowledge about the medication procedures, including controlled drugs and homely remedies. Records examined included the controlled drug books, stock books, returns books and MAR sheets. All records were completed appropriately. Medication is stored in locked cupboards in a locked room. Medication supplies were appropriate, and any leftover of out of date medication was kept separate and returned to the pharmacy. Daneside Mews is in the process of changing to a new pharmacy in line with a corporate policy. Staff are offered regular and appropriate medication training. See recommendation 2 and 3. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 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 the following standard(s): 13 Residents are encouraged to maintain contact with friends and relatives and contact is kept with the local community. EVIDENCE: Many pictures around the home show events and trips which residents have participated in. An activity co-ordinator takes residents on day trips, out into the local community for meals, walks or just a cup of tea. Daneside Mews also hold fundraising events attended by the local community which raise money for the home. A residents` summer house was bought from the last fundraising event. There are no set visiting times at Daneside Mews, although staff ask that should a relative wish to visit after 9pm, they let staff know so that they can arrange to let them in. Family and friends are welcomed into Daneside Mews, and staff show a good knowledge of the individual family situations of residents. For example staff are aware of times when individual residents family members are likely to visit, ‘X’s son comes late on a Wednesday as he works late’. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 16 The complaint procedure is clear and displayed in the Home. Complaints are logged appropriately. EVIDENCE: Although this standard was inspected at the previous inspection a requirement to ensure all complaint were logged was issued. This has now been met and complaints are logged appropriately. The Registered Manager stated that staff tried to resolve any concerns immediately. If a concern or complaint could not be resolved by the individual staff member then the complaint was logged and the senior staff member would then get involved. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 24 Resident’s bedrooms were clean, safe and comfortable. EVIDENCE: All bedrooms at Daneside Mews are individual and have en-suite facilities. Rooms are clean, well maintained and contain adequate and good quality furniture and furnishings. Efforts are made to personalise bedrooms with pictures, photographs and furniture. All rooms are lockable, with the upstairs bedrooms kept locked when residents are not in them, so that residents cannot enter each others rooms without permission. Residents have their own room key, where able. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All core standards for this section were met at the previous inspection. EVIDENCE: Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Resident’s money is handled by Daneside Mews in an appropriate and regulated manner. EVIDENCE: There are clear procedures at Daneside Mews for handling resident’s money. Any money received is written into a receipt book, and a copy of the receipt is given to whoever handed the money over. A copy of the receipt is attached to the money and a further copy is kept in the receipt book. All money is kept in a safe in the office of Daneside Court – the Nursing Home side of Daneside Mews. All individual residents money is recorded on computer, so that it can be seen clearly what is received and how it is spent. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 16 No residents hold their own money, and no staff at Daneside Mews acts as an agent for any resident. The Registered Manager receives monies from relatives, solicitors and the local authority for individual residents. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 17 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 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 4 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X 4 X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 4 X X X Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP1 OP7 OP7 Good Practice Recommendations It is recommended that the Service User Guide is developed so that residents are able to understand it. It is recommended that irrelevant documentation is removed from care files. It is recommended that plain english is used when describing plans of care. Daneside Mews DS0000006631.V278159.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Northwich Local Office 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. 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