Inspection on 21/01/06 for Darley Dale

This inspection was carried out on 21st January 2006.

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 18/12/07

Darley Dale 26/04/06

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 Ms Gillian Goldfinch Unannounced Inspection 21st January 2006 2:00 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 Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 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.V271344.R01.S.doc Version 5.0 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.V271344.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2005 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 and personal care for twelve 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. At the rear of the house is a large multi-purpose garden room. Service user accommodation is provided in single rooms, eight of which have en-suite facilities that contain a toilet and wash hand basin as a minimum. There are three communal bathrooms that provide assisted bathing facilities. Service users rooms are situated on both ground and first floor levels. There is a shaft lift for access between floors and stairs for the more able service user. Health care is accessed via community services. Service users can register with a local GP of their choice. There is a secluded garden area to the rear of the property where service users can sit in comfort and safety. There is a small parking area for staff, visitors and relatives to the side of the home. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately 4 hours on a Saturday afternoon in January 2006. Opportunity was taken to talk to the registered persons and staff on duty, to inspect assessment documentation, medication systems, activities, some aspects of the premises and quality assurance. Compliance with requirements made at the last inspection was checked. Four of the residents were spoken to in order to ascertain their views of the service they receive. What the service does well: What has improved since the last inspection? What they could do better: Fully implement the recommendation made for the fitting of low surface temperature features to all radiators and hot pipes. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 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. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 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 Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 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): 2 and 3 Each resident has a written contract with the home. Residents’ needs were assessed and they were able to visit the home to help them make a choice about whether they wanted to move there. EVIDENCE: An assessment document was seen which covered all areas of residents’ needs. The registered persons stated all prospective residents are admitted only on the basis of a full assessment. Individuals and their representatives are encouraged to visit the home before making a decision to move in. A requirement made at the last inspection to amend the contract document to include a notice period of four weeks had been met. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 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): 9 There were policies and procedures in place for the safe handling and administration of medication. EVIDENCE: Clear guidance was provided for staff through policy, procedure and training on receipt, recording, storage, handling, administration and disposal of medicines. The registered manager stated the pharmacist provided good support to the home. All staff responsible for the administration of medication had undertaken training in the safe administration of medicines. Medication used on a daily basis was being appropriately stored. Medications in need of refrigeration were suitably stored. Fridge temperatures were being monitored and recorded. Procedures were in place for appropriate storage and administration of controlled drugs. Records of the administration of medication were checked and found to be in order. Residents were able to take control of their own medication if they wished, within a risk management framework. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 10 There were records kept regarding the use of homely remedies. A recommendation made at the last inspection for the home to adopt a formal assessment tool for assessing individuals’ risks of developing pressure sores had been implemented. A recommendation made at the last inspection for residents’ weights to be monitored more regularly had been implemented. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 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): 12 and 13 Activities provided in the home cater to individual needs of the residents providing them with meaningful ways of spending their time. Residents were able to choose their daily routine. Visitors are encouraged and links with the community are maintained. EVIDENCE: Residents and staff confirmed that residents have the opportunity to exercise choice in relation to daily routines. They can choose whether to join in with social activities, where to sit and who to talk with. Those residents spoken to were strongly of the view that they were encouraged and enabled to make their own decisions about aspects of daily living. There was information on residents’ files about their individual interests. Leisure and recreational activities were focussed on an individual basis to suit their preferences and needs. The inspector did not see any visitors during this inspection. Information about the home indicated that visitors were welcome to visit. Residents confirmed that their visitors were always made most welcome and were offered refreshments. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 12 A requirement made at the last inspection relating to the record of food provided had been met. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 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 the following standard(s): These standards were not inspected as part of this inspection. EVIDENCE: Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 14 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): 19 The home provides safe, well-maintained accommodation for residents to live in. EVIDENCE: Darley Dale is an older building with a new extension that meets the needs of older people in a comfortable and homely manner. There is an ongoing programme of refurbishment and maintenance to ensure that the quality of the environment is maintained at a good standard. There is a ramp providing access to the garden area providing seating and outdoor heating. Residents spoken to stated much use was made of the garden in the better weather. The building complies with the requirements of the local fire service and environmental health department. The Fire Officer visited the home on 17/5/05; no requirements arose from the visit. The Environmental Health officer visited the home on 22/4/05; there were no requirements arising from the visit. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 15 A requirement made at the last inspection for a risk assessment to be conducted and recorded to identify any risks posed to individual residents from hot water, with corrective measures taken where necessary had been met. A risk assessment was in place and was being reviewed monthly. A recommendation made at the last inspection for low surface temperature safety features to be fitted to all radiators and hot pipes had not been fully implemented. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 16 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): These standards were not inspected as part of this inspection. EVIDENCE: A requirement made at the last inspection for the home to have a documented recruitment policy and procedure had been met. A copy was seen but it was not possible to inspect these in practice as there had been no staff appointments made since the last inspection. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 17 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): 33 The home has a quality assurance program that measures its success in meeting the aims, objectives and statement of purpose of the home. EVIDENCE: The home does not use a professionally recognised quality assurance system but has devised its own programme for ascertaining the views of all stakeholders in the home on the service offered. These views are audited and used as part of the development plan for the home. Residents spoken to confirmed that they were regularly asked and encouraged to offer feedback on the service received. This was ascertained through the use of anonymous questionnaires along with individual and group discussion. Samples of questionnaires used to seek the views of residents, families, friends and stakeholders in the community were inspected. These were without exception 100 positive about the service offered at Darley Dale. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 18 There was evidence of the regular review of policies and procedures. Requirements identified in CSCI inspection reports had been progressed within the agreed timescales. A requirement made at the last inspection for the home to make provision for any load bearing equipment to be serviced for safety by an appropriately qualified engineer had been met. A requirement made at the last inspection for the home to obtain Data Information sheets for each chemical in use in the home had been met. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 19 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X 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 3 X X X X X Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 20 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. Refer to Standard OP25 Good Practice Recommendations It is strongly recommended that low surface temperature safety features be fitted to all radiators and hot pipes. Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Darley Dale DS0000016420.V271344.R01.S.doc Version 5.0 Page 22 - 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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