Inspection on 18/12/07 for Darley Dale

This inspection was carried out on 18th December 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

Darley Dale 22/12/08

Darley Dale 26/04/06

Darley Dale 21/01/06

Darley Dale 31/05/05

Darley Dale 18/10/04

Darley Dale 08/06/04

Darley Dale 08/12/03

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Darley Dale 35 Libertus Road Cheltenham Glos GL51 7EN Lead Inspector Mrs Kathryn Silvey Key Unannounced Inspection 18th & 28th December 2007 10:15 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 Darley Dale DS0000016420.V355044.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. Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Darley Dale Address 35 Libertus Road Cheltenham Glos GL51 7EN 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) 01242 513389 Mrs Mary Rebekah O`Connor Mr John Francis O`Connor Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th November 2002 Brief Description of the Service: Darley Dale is a small family run care home on the west side of Cheltenham town; it is situated close to local amenities, bus services and the main railway station. The house is Victorian and has been extended to provide accommodation for thirteen older people. The ground floor has a large dining/lounge area with the kitchen adjacent to it. Laundry facilities are situated outside in the small courtyard. Accommodation is provided in single rooms, eight of which have en-suite facilities. There are three communal bathrooms that provide assisted bathing. Bedrooms are situated on the ground and first floor. There is a shaft lift for easy access between floors. The home has a secluded rear garden where people can sit, and a small parking area near the entrance at the side of the home. The home provides copies of the Service User Guide and the latest CSCI inspection report for people to see before admission. The weekly fees charged by the home are the same as the current Community Adult Care Directorates (Social Services) level for older people, there are currently no extra payments for care or ‘top ups’ required. The manager will provide the information on request. Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced inspection took place over two days with one inspector. All of the eleven people accommodated were spoken to during the inspection. Visitors and staff on duty were spoken to. The accommodation was seen, including the kitchen and laundry facilities. Records were looked at, which included care plans, medication, recruitment, staff training and fire safety. We (the Commission) received four surveys completed by relatives and six from people living in the home. One completed staff survey was also returned to us. An Annual Quality Assurance Assessment (AQAA) of the home completed by the registered manger was sent to the Commission. What the service does well: People have a detailed assessment before they move into the home so that the manager can be sure their needs can be met in the home. Information is provided about the home and the fees charged, and people can visit the home and join in with meals before they move in. People also fill in a survey about moving into the home to help the manager identify any improvements to the procedure. The home meets the needs of the people well and there are care plans that help the staff with this, and identify when healthcare professional support is required. The records seen indicate that different healthcare professionals visit the home to support people. People made the following comments; ‘It is very homely here I have made friends’, ‘the staff are kind and helpful’, ‘the staff cannot do enough for me’, ‘I could not find a better place’, ‘I am very happy in the home’, ‘everything seems satisfactory. The people living in the home are independent and enjoy their individual activities and going out to the local shops. The home provides activities people enjoy for example; A carol service at Cheltenham Race course, a meal at a local restaurant, garden parties to celebrate birthdays, barbeques in the garden, visiting the managers home, coach trips, film DVD’s and sing-a-longs. Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 6 The home provides good food mainly prepared using fresh produce. People in the home are able to add their suggestions to the menu when discussions are held during residents meetings. The staff know peoples likes and dislikes and alternatives to the planned menu are provided. Five surveys sent to us said that people always liked the food in the home and one said they usually like it. One person said they would like more curries and more spice in their food, but also said ‘the food is very good and very nicely presented’. Peoples concerns are listened to and everyone we spoke to said they felt able to raise anything with the staff. The staff we spoke to knew about the protection of vulnerable adults and how to recognise abuse The bedrooms were well maintained and personalised with photos and pictures, which made the rooms look homely. The staff are well trained and most have or are completing NVQ’s in care. An outside agency completes most mandatory training and staff spoken to said they were supported when identifying their own training needs at regular staff meetings. The home is run by well qualified and experienced managers who know the people well and employ a stable family staff group that are committed to meeting peoples’ needs. People living in the home and relatives are surveyed regularly to find out what they think of the home to help ensure that it is run in people’s best interests. The people are protected by regularly reviewed health and safety related polices for staff to follow, and the appropriate servicing of equipment used in the home. What has improved since the last inspection? What they could do better: The medication was managed incorrectly for several people who could have been at risk, and an immediate requirement was issued which was completed within twentyfour hours. This helped to ensure people were safe, however, Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 7 there were some other more minor corrections required and a regular audit by the manager is recommended to ensure that there is good medication practice at all times. The staff we spoke to knew about the protection of vulnerable adults and how to recognise abuse, but would benefit from more formal training to help ensure that procedures and policies are followed. Some radiator thermostats were inaccessible to people who may require different temperatures when in their own rooms, it was recommended that a regular check is made to ensure people have access to the control or staff help them be comfortable in their bedrooms. The home’s recruitment procedures were not followed correctly, which could mean people were at risk. More information must be recorded to ensure that recruitment is robust when employing family members. 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. Darley Dale DS0000016420.V355044.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 Darley Dale DS0000016420.V355044.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. People move into the home after an assessment of need has been completed, which helps to ensure that their needs can be met and their admission is well planned. The information given to people about the home was not up to date. EVIDENCE: The Service User Guide is given to all new people, but requires updating with the new information about contacting the Commission. We discussed the Statement of Purpose with the manager, and as the family share the communal accommodation, this should be in the information given to people. The family, that run the home, includes a small child. We (the Commission) saw two well recorded pre-admission assessments completed by the manager when people initially visit the home. Generally Community and Adult Care Directorate, CACD (Social Services) complete a Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 10 detailed assessment and care plan for people before admission. The manager stated that healthcare professionals are contacted by the home for any further information when required. The home has had three new admissions recently and the records seen were good, the people spoken to were satisfied with the information and the assistance they received when moving into the home. One person said that the manager gave them a survey to complete about their move into the home and asked if the procedure could be improved. This person had visited for lunch before moving into the home, and was pleased with the home. Some people we spoke to did not have a Service User Guide. We recommended that the manager ensure that everyone has the guide as soon as it has been updated. The Service User Guide is given to all new people, but requires updating with new information about the Commission and contact telephone numbers. Darley Dale DS0000016420.V355044.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 care plans seen were well recorded and regularly reviewed to help ensure that people’s needs are met, and health care professionals support people in the home when required. Medication was managed incorrectly, but this was immediately put right, however, some further updating needs completing. EVIDENCE: We looked at three care plans in detail and the people were spoken to independently. The care plans seen were good with needs identified well, however, one plan required more detailed actions to help ensure staff knew what to do. The care plans were reviewed monthly but there was little information about what had happened in the last four weeks, and not much space to record a meaningful review. We recommended that the manager ensure that there is space to record a more detailed review of people’s problems or needs. The risk assessments were good. People are weighed Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 12 monthly to identify any nutritional risk but this was not recorded in the care plan. Daily records are written in the homes diary and there is a monthly review recorded using the information in the diary. We recommended that all information about people be recorded in their own daily record, including any activities enjoyed. The staff in the home remains the same and people have a personal service as they are well known. People made the following comments; • The staff cannot do enough for me • I could not find a better place • I am very happy in the home • everything seems satisfactory. There was evidence that healthcare professionals visit the home, and the community psychiatric nurse was seen during the inspection. Records seen stated that the continence advisor visits, currently there is no need for the district nurse to visit anyone in the home. One person told us that an occupational therapist was coming to do an assessment. We looked at the administration of medication in the home and there were several failures that required immediate action. The manager completed the requirements within 24 hours to ensure that medication was handled safely to help protect people living in the home. The home administers medication to all but one person who manages her own. The manager agreed to provide lockable storage for this person to ensure safe storage. The storage for all other medication was secure, however, care should be taken to store internal and external medication separately to avoid contamination and for safe administration. A prescribed cream had been left in a person’s bedroom, this must be safely stored at all times particularly as there is a young child living in the home and other people that may access a bedroom. The medication records seen were complete with the exception of the allergies record, and a photograph of all people for administration recognition purposes. The home had a medication administration policy and procedure that required updating to include, a ‘homely remedy’ procedure and what to do with medication when a person goes out for the day. The home had medication information sheets kept for medication in use, however, this required updating as there were three new people in the home. The manager has agreed to record a weekly audit of the medication to ensure that the recent failures do not occur again. The supplying pharmacist audits the medication every six months, and the doctors complete a medication review for erveryone annually. We saw the medication training certificates for the staff provided by an outside agency and dated in 2005. The same provider has arranged an update to medication training for everyone in February 2008. Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 13 Darley Dale DS0000016420.V355044.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 good. This judgement has been made using available evidence including a visit to this service. Most people living in the home are independent, and they were satisfied with the activities provided and with the freedom they had within the home. Family and friends keep in contact with the people in the home and are made welcome. People like the food in the home and alternatives to the menu are provided when required. EVIDENCE: The AQAA information provided to us from the manager states that the home is relaxed and carefree where people do not have to join in with activities, and are encouraged to make their own decisions about how they spend their day. We spoke to everyone living in the home individually many of whom were independent and able to go out alone to the local shops. Most people were content with what the home provided and enjoyed their individual activities, which included reading, crossword puzzles, crochet and helping the staff with washing up and laying the tables. One person goes out with her daughter to play Bridge. Activities enjoyed by the people in the home include; • A carol service at Cheltenham Race course Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 15 • • • • • • a meal at a local restaurant a garden party for someone’s eightieth birthday barbeques in the garden visiting the managers home coach trips film DVD’s and sing-a-longs. One person said they would like more activities, for example more board games. We spoke to a carer who said that she knew what activities people liked, and that staff often take people for walks and play bingo with them. The home regularly holds two different religious services to help meet peoples spiritual needs. We looked at the homes menu, which was well recorded and although a choice was not included the staff knew people’s likes and dislikes and they were recorded in their care plans. There were recent additions to the menu as a result of a meeting with people requesting alternatives. A separate record was kept when alternatives to the planned menu were provided, and people spoken to agreed that sometimes they choose something different. Special diets can be catered for and people are weighed monthly to help risk assess them nutritionally. The home uses fresh fruit and vegetables weekly to help provide a balanced and nutritious diet. One person said that fresh fruit was not available in the home, therefore it is recommended that a bowl of fruit is always available for people to choose from. The manager informed us that all staff that prepare food have completed a basic food hygiene course. Five surveys sent to us said that people always liked the food in the home and one said they usually like it. One person said they would like more curries and more spice in their food, but also said ‘the food is very good and very nicely presented’. At the last Environmental Health Officer’s visit on 15/03/07 everything in the kitchen was satisfactory. Darley Dale DS0000016420.V355044.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 good. This judgement has been made using available evidence including a visit to this service. Peoples concerns were dealt with satisfactorily as they arise and they know how to make a formal complaint when required. People are protected from abuse, as there were good procedures to help the staff recognise abuse and report it. People said they felt safe living in the home. EVIDENCE: Three relative surveys said they knew how to make a complaint and two said they did not know. Five people surveyed knew who to talk to and how to make a complaint and one did not know. We spoke to everyone in the home and all felt able to speak to the staff if they had a complaint or concern. One person identified a concern to us and the manager agreed to try and ensure that this concern was looked at again. Concerns are usually recorded but none were seen. There had been no formal complaints since the last inspection. We saw the homes complaints procedure, which required some updating to include the regional CSCI office details. We looked at the homes protection of vulnerable adults procedure, ‘whistle blowing’ procedure and the staff disciplinary procedure. It was recommended Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 17 that the manager include the local Adults at Risk team’s communication details for support and information about any issues that may arise. The home has information for staff in The Alerter’s Guide, to help them recognise and report abuse, but they need more formal training in this important aspect of protecting vulnerable people. We spoke to a carer who was completing NVQ level 3 in care and knew how abuse was recognised and how to ‘whistle blow’. Darley Dale DS0000016420.V355044.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and clean, and risk assessments were recorded to help ensure that people live in a safe place. EVIDENCE: We looked at eleven bedrooms, the communal lounge/dining room and a bathroom, the kitchen and laundry facilities. Since the last inspection the lounge has new patio doors and the room had been refurbished to include new carpet. The lounge also has a new large flat screen television. Many of the bedrooms had been redecorated and had new carpets fitted. The manager plans to install a new kitchen within the next twelve months. The manager told us that the laundry area outside was going to be refurbished within the following six months, to make it easier to keep clean. Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 19 A bathroom, numbered room 6 had, a cracked toilet cistern, however, we were told a new bathroom suite was to be fitted there in January 2008. The home was well maintained and clean throughout, an odour problem had reduced in one bedroom due to a change in flooring and furniture, which was a requirement from the last inspection. The bedrooms seen were well personalised with photos and pictures. Some people also had facilities for making hot drinks in their room. Not all radiators were guarded to help prevent burning accidents, however, the staff have completed risk assessments. It is recommended that individual risk assessments for the new people, admitted recently, be reviewed for the safety of all hot surfaces. Some radiator thermostats to regulate the temperature were inaccessible to people who may want an alternative temperature. One person was cold, and the radiator thermostat did not appear to be working as it was on maximum. The Commission recommends that a regular audit of the radiators be completed to ensure they are working well and people can chose the temperature of their bedroom. People commented that the home was always clean and their laundry satisfactorily completed. Darley Dale DS0000016420.V355044.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. People’s needs were well met by the number and skills of the staff provided as many people were independent and their dependency level was described as low. The homes recruitment procedures were not followed correctly, which could mean that people were at risk. However, the home employs family members who are well known to them. National Vocational Qualification training in care had been completed or was being completed by all the care staff, which helps to ensure that staff are competent. EVIDENCE: During the first day of the unannounced inspection there was no staff rota available. However, this is a requirement and the manager had recorded the planned staff hours at the next visit ten days later. There should be a rota for every week and any changes recorded. There are two people on duty throughout the day and two care staff sleep in and are on call. There should be a recorded risk assessment for night care to ensure that people needs do not require a carer on awake night duty. Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 21 The deputy manager has NVQ level 4 in care, two carers are completing NVQ level 2 and one has NVQ level 2 and is completing NVQ level 3. The provider helps with the catering and there is one domestic who also helps in the kitchen. The domestic employed is a family member but did not have a completed Criminal Reference Bureaux check, or a Protection Of Vulnerable Adults ( POVAFirst), which must be completed. In a small family run home there is always close contact by all the staff with the people that live there, therefore it is recommended that the CRB is at the Enhanced level. We looked at the homes recruitment policy, which contained clear information. One new carer had been recruited a year ago and we looked at the record. There were no references, and no employment history as the carer had not worked since leaving school, and was a close family member. The manager must try and obtain references and agreed to do so. The carer’s CRB was not available in the home and the manager was asked to keep all new CRB’s until after we had seen them, then they can be destroyed. We saw the homes new induction booklet, which looked comprehensive, however, the manager should access the Skills for Care website and ensure that the six new induction standards are covered for new recruits. It is recommended that the registered manager has Internet access to the CSCI Professional website, which has good information to help keep the manager up to date with new regulations, guidance and policies/procedures. We spoke to a carer on duty that had worked at the home for a year. She was knowledgeable about the people cared for and said she also had to complete cleaning and laundry duties. The carer had started NVQ level 2 training and said it was going well. The staff have meetings occasionally where any problems can be discussed. The minutes from the last two staff meetings in June and September 2007 were seen, and training issues had been recorded. Another carer spoken to was completing NVQ level 3 in care training and had also completed a ‘communication skills’ course. Both carers spoken to knew about ‘whistle blowing’ to help protect people living in the home. We saw the staff training certificates for fire safety, food hygiene, health and safety, medication and first aid completed in June 2007 by an outside agency. The new carer had not completed any manual handling training and the manager stated that some staff require an update, which was planned for the new year. One carer had completed manual handling training in 2007 and an ‘Alerters Training’, which was about protecting vulnerable adults. The manager is planning to organise dementia care and end of life care training for staff. Darley Dale DS0000016420.V355044.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by well qualified and experienced managers who know the people well and employ a stable family staff group that are committed to meeting peoples’ needs. People living in the home and relatives are surveyed regularly to find out what they think of the home to help ensure that it is run in people’s best interests. People are protected by regularly reviewed health and safety related polices for staff to follow, and the appropriate servicing of equipment used in the home. EVIDENCE: We spoke to the registered manager and the deputy manager who are husband and wife, and live in the home. The managers have NVQ level 4 in Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 23 Care qualifications. The registered manager is experienced and the same family has run the home for many years. There is a stable staff group within the family and commitment to providing a well run homely care home. The home has its own quality assurance system and surveys the residents and their relatives’ bi-annually. Relatives are provided with a stamped addressed envelope to give an anonymous reply if they wish. We looked at the surveys and all the comments were positive about the home and the care provided. We also saw many complimentary letters from relatives pleased with the care of their loved ones. We also saw a survey a new person had to fill in about their experience of moving into the home. This is good practice and will help to alert the manager to any shortfalls in the admission procedure. People spoken to about moving into the home were satisfied that they had been able to visit and make a choice and that the home was meeting their needs. We saw a record of the residents meeting on 27 November 2007, which indicated that people were satisfied with the activities provided in the home, and had also made new suggestions for the supper menu. People living in the home or their relatives organise their personal monies. The home’s procedure folder was looked at and most procedures had been reviewed, including the health and safety policy, but some required minor updates. There were good fire safety records and the fire safety officer visited the home in November 2007, where everything was satisfactory. The home operates a fire evacuation policy for everyone. The shaft lift records indicate that it has been serviced quarterly. There were no accidents recorded, however, the home has a published record for use when required. The need to inform us of any accidents and incidents under Regulation 37 was discussed and information was given to the manager to aid the process. The AQAA stated that all equipment had been serviced or tested as recommended by the manufacturer in 2007. There is a policy for managing infection control in the home and it is recommended that the home obtain a copy of the Department of Health guide ‘Essential Steps’ from the web site. Two people living in the home were from Germany and were able to talk to each other occasionally in their own language, and staff could communicate well with both people. Diversity issues were discussed with one person who felt the home tried to ensure that food requests were met and felt well supported by the manager, and was able to keep in contact with relatives in Germany. Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement The registered person must ensure that all medication issues are completed to ensure that handling and administration of medication is completed safely. This includes; Providing safe storage for people that self medicate. Storing external and internal medication separately, keeping prescribed cream locked in the medication cupboard, completing allergy records on medication records, providing a photograph of all people for identification purposes, updating the medication procedures to include a homely remedy policy and procedure. The registered person must ensure that recruitment procedures are followed and the correct information is obtained for all staff employed to safeguard people. To include an employment history, a CRB check and references. Timescale for action 10/02/08 2. OP27 19 (1) 20/02/08 Darley Dale DS0000016420.V355044.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 OP1 Good Practice Recommendations It is recommended that the home’s Statement of Purpose is updated to include that the staff living in the home, which includes a small child, share the communal accommodation with the people in the home. This information should be in the summary of the updated Service User Guide and all people should have a copy of the Guide. It is recommended that there is more space in the care plans to record a more detailed review of people’s problems or needs, and that all information about people be recorded in their own daily record, including any activities enjoyed. It is recommended that the home has up to date information about all medication administered in the home. It is recommended that a regular audit of medication is completed to ensure that correct procedures are followed for safe practice. It is recommended that there is a bowl of fresh fruit available for people to choose from at any time. It is recommended that staff have more formal training in the protection of vulnerable adults. It is recommended that individual risk assessments, to include hot surfaces, are completed for the new people, admitted recently. It is recommended that a regular audit of the radiators be completed to ensure they are working well and people can chose the temperature of their bedroom. DS0000016420.V355044.R01.S.doc Version 5.2 Page 27 2 OP7 3 OP9 4 OP9 5 6 7 OP15 OP18 OP19 8 OP19 Darley Dale 9 OP27 It is recommended that there is a recorded risk assessment for night care to ensure that peoples needs do not require a carer on night duty awake. It is recommended that the home has a copy of the Department of Health guide ‘Essential Steps’ for guidance in managing infection control. 10 OP38 Darley Dale DS0000016420.V355044.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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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