Inspection on 26/04/06 for Darley Dale

This inspection was carried out on 26th April 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 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 Nick Jones Key Unannounced Inspection 26th April 2006 10:00 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.V291656.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. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 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.V291656.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st January 2006 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 thirteen older people. There are currently nine people living in the home. 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. Residents’ accommodation is provided in single rooms, eight of which have ensuite facilities that contain a toilet and wash hand basin as a minimum. There are three communal bathrooms that provide assisted bathing facilities. Residents 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. 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. The home makes available copies of the Service User Guide and CSCI inspection reports to prospective residents. The monthly fees charged by the home range from £1318 to £1601. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector undertook this unannounced key inspection over 6 hours on the first day and three hours the following day. Nine residents and two visiting relatives/friends were met and spoken to directly to obtain their view of the care and services they receive in the home. There was direct contact with the home’s Manager and Deputy Manager, and two members of staff, all of whom were open to the inspection process, and were most welcoming and helpful. A number of records were viewed including resident’s care plans and risk assessments, health and medication records and appointments, recruitment records and health and safety procedures. The care and records of three residents in particular were closely looked at. A tour of the premises took place, and staff were observed going about their duties whilst interacting with the residents. What the service does well: An informative brochure is available so that prospective residents and their families can learn about the home before choosing to live there. The home welcomes visits by prospective residents and their friends and family. This home provides an inclusive, homely and relaxed environment for the residents. The emphasis here is very much on the home being noninstitutionalised, and run in the interests of it being a ‘home’ for the residents, with consideration to choices and privacy. There is a small stable team of regular staff who work alongside the home’s Manager and Deputy, who are resident on the premises. The management and staff are very accessible to the residents and to any visitors; staff welcome families and friends into the life of the home. A good standard of home-cooked food is provided, with consideration to individual likes and dislikes. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 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. Darley Dale DS0000016420.V291656.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 Darley Dale DS0000016420.V291656.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process used in this Home ensures that staff are aware of the resident’s needs prior to admission and therefore can adequately meet these once the resident has been admitted. Intermediate care is not provided at this Care Home. EVIDENCE: One new resident has moved to the home since the previous inspection. Records for this resident were viewed and found to contain needs assessments written both by Social Services and the manager of the home. There were details of two visits made by the service user before moving to the home. This was once with a friend and once with staff from the home the resident was moving from. The manager stated the resident had been offered a copy of the Service User Guide and the most recent inspection report which had been Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 9 declined. He also stated that two friends of the resident had visited the home unannounced to view the home. They were made welcome, toured the building and talked to staff and residents. This was confirmed in conversations with the resident. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care records were, on the whole, detailed, well written and reviewed on a monthly basis to ensure residents’ needs and wishes were met. Healthcare professionals support the residents and appropriate records were made of their visits, which ensures health is maintained. Staff support residents in a manner that maintains their privacy and dignity. There were however an example where contact with health professionals did not take place to ensure the health and dignity of service users. The system for medication storage and administration are good with clear and comprehensive arrangements in place to ensure residents’ medication needs are met safely. EVIDENCE: Each resident has a plan of care and risk assessments that are devised on the basis of an assessment of their needs, which is done in consultation with them, Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 11 and which is reviewed on a monthly basis. The review of one service users’ care plan should have resulted in seeking advice and guidance from health care professionals. The manager acknowledged that this would be undertaken as a priority. The manager stated in a phone conversation two weeks after the inspection that the GP had visited and referrals were made to other healthcare professionals. Contact has also been made with the placing authority informing them of the changed needs of the resident. They are in the process of allocating a social worker to attend a review of the resident’s placement. Manual handling assessments are recorded for each person. Case tracking confirmed appropriate interventions are carried out by the home through contact with District Nurses. The home has an assessment tool, where a risk of developing a pressure sore is identified, in assessing and recording any risks and trigger points for action. Records showed that access to all health services and outside agencies is ensured, when and wherever needed. There was one resident where this has not occurred as described above. Residents are weighed on a regular basis and details recorded. The weight loss of one resident, as recorded, should have resulted in consultation with health care professionals. The medication system was inspected and all were being stored appropriately and were organised with only the stock required at that the time being stored. Records were kept correctly with no gaps in administration. A selection of staff training files were inspected and certificates were seen in accredited training for medication administration. All of the residents spoken to confirmed that staff are respectful, kind and attentive to their needs, and that they are thoroughly mindful of their privacy. Staff were observed going about their duties and interacting with residents in a friendly, relaxed and respectful way. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. The consideration and respect that is shown by staff towards residents ensures that residents are able to exercise control and choice in their daily lives. The home offers a good standard of varied food to meet the residents’ nutritional needs, in accordance with individual likes and dislikes. 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 Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 13 were strongly of the view that they were encouraged and enabled to make their own decisions about aspects of daily living. This was observed during both days of the inspection. Some residents access community facilities independently and with friends or family. Two residents described going out with a community voluntary group on day trips. 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 met a relative and a friend of a resident on the second day of the inspection. They stated ‘ this is a very nice home; you can always talk to the manager, deputy manager and the staff’. Residents are free to spend their time how and where they wish. All of those spoken to confirmed that staff are fully respectful of their personal choices and wishes. Residents are fully supported to retain their independence in so far as personal abilities will permit, and this includes handling their own affairs and finances. Residents are evidently able to exercise choices in their own rooms, with the introduction of their own items in order to personalise them. Although residents are not offered a choice routinely regarding their meals, daily menus are prepared with consideration to each person’s likes and dislikes. Residents and staff confirmed that an alternative meal is offered if there is anything that any resident does not like. Menus viewed and food seen showed residents receive a varied and nutritious diet. A record of food served to the residents is maintained. Service of the lunchtime meal was observed, which was in the spacious lounge/dining room. The meal was calm and unhurried, and staff were providing assistance where needed. Some residents chose to eat in their rooms and staff provided assistance where needed. Residents said that the food is ‘very good’, ‘great’ and ‘very nice’. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: There is a clear complaints procedure that is easily accessible to all in the home. All residents spoken to confirmed that staff were very approachable, and were always ready to listen to any views they may have. The home has a written policy on abuse, and has a Whistleblowing procedure for staff to follow if they had any concerns. Safe storage is available should any resident wish to place valuables with the home for safe-keeping. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 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 the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides safe, well-maintained accommodation for residents to live in. A homely and clean environment is provided for residents however some attention is needed towards a small number of potential health and safety risks posed to the residents in the home. 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. The lounge and some Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 16 bedrooms have been recently re-decorated. Bedrooms have had their radiators fitted with low surface temperature covers. The remaining bedrooms will have the same work completed over the next few months. This should include covers for the radiators. None of these are risk assessed as presenting a current risk. The kitchen has had a new fridge, freezer and cooker installed in January this year. There is a ramp providing access to the garden area which includes seating and outdoor heating. Residents spoken to stated much use was made of the garden in the better weather. The home was found to be largely clean, hygienic and free from odours. The needs of one resident has changed and requires the bedroom fixtures and fittings to be replaced appropriately to remove a persistent and strong odour. The home is cleaned to a good standard, with laundry and clinical waste handled appropriately for the prevention of cross infection. Gloves and aprons are provided for staff. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skill mix are adequate to meet the needs of the residents currently living in the home, the vast majority of whom have low dependency levels. A recruitment procedure has been devised, which will ensure that there are full and appropriate safeguards in place to ensure the protection of residents in the event of new staff joining the home. The arrangements for the training and professional development of staff are good, enabling them to have an understanding of their roles. EVIDENCE: There is a small and very stable team of staff at Darley Dale. Each person knows their routine shift pattern, and a record of shifts worked is maintained. At least two staff are on duty at all times, with two staff providing sleep-in night cover. The home is small and family run, and the inclusive arrangements mean all staff share responsibility for non-care tasks such as domestic and catering Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 18 duties. All residents, and the two visitors spoken to, confirmed that staff are always very accessible and helpful. As the staff team is particularly stable, there has been no recruitment of any new staff for some time. The home has written recruitment procedures, which fully incorporates all of the required pre-employment checks. Staff files contain all appropriate records and checks. Staff training records demonstrate that there are regular training opportunities for staff, with a range of training relevant to their roles being undertaken. There is a commitment to NVQ training, with two staff currently undertaking NVQ 2 in Care. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced Registered Manager who has worked at the home for many years. The home has a quality assurance programme that measures its’ success in meeting the aims, objectives and Statement of Purpose of the home. This is now just overdue for an annual review. Systems are in place to ensure residents’ financial interests are safeguarded. Management systems are in place, which are designed to safeguard the residents. These, however, should be reviewed to ensure that the changing needs of residents are identified and acted on appropriately. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 20 EVIDENCE: Darley Dale is very much a family managed home, and the Registered Manager has been involved with it for many years; he is currently undertaking the NVQ level 4 Registered Manager Award with a local college. The deputy manager has also completed the Registered Manager Award. The management systems should be reviewed to ensure the changing health needs of residents are identified and acted upon. A central secure facility is available, in which residents can place personal money and valuables if they wish. Residents confirmed they have been offered the use of this facility. There was evidence that health and safety issues are addressed in this home, with written policies, procedures and risk assessments, provision of necessary equipment and staff training. All necessary maintenance of equipment is undertaken in a timely fashion. This included the servicing of a bath hoist and the lift. Fire safety equipment and systems are regularly tested and serviced. 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. Residents spoken to confirmed that they were regularly asked and encouraged to offer feedback on the service received. 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. These were all undertaken over a year ago and this exercise should now be repeated to ensure the home has an up to date record of the views of residents and others involved with the home. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14(2)(a)( b) 15(2)(b) (c) 13 (1)(b) Requirement Timescale for action 30/06/06 2. 3. OP7 OP8 4. OP26 16 (2)(k) Assessments of residents’ needs must be reviewed and revised when their circumstances change. Residents’ care plans must be 30/06/06 reviewed and amended when the needs of the resident change. Advice from health care 30/06/06 professionals must be sought when the health care needs of a resident show a significant change. Appropriate fixtures and fittings 30/06/06 must be provided to a bedroom to keep it free from offensive odours. The current bed, mattress, chair and flooring must be replaced. Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 23 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 Refer to Standard OP25 OP33 Good Practice Recommendations It is strongly recommended that low surface temperature safety features be fitted to all radiators and hot pipes. The surveys introduced by the home to gain feedback regarding the service from residents, relatives, friends, and other involved professionals should be undertaken on an annual basis. Management systems should be reviewed to ensure the changing health needs of residents are identified and met. 3. OP38 Darley Dale DS0000016420.V291656.R01.S.doc Version 5.1 Page 24 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.V291656.R01.S.doc Version 5.1 Page 25 - 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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