Inspection on 31/05/05 for Darley Dale

This inspection was carried out on 31st May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Darley Dale 22/12/08

Darley Dale 18/12/07

Darley Dale 26/04/06

Darley Dale 21/01/06

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 Ruth Wilcox Announced Inspection 31st May 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Darley Dale Version 1.10 Page 3 SERVICE INFORMATION Name of service Darley Dale Address 35 Libertus Road Cheltenham Glos GL51 7EN 01242 513389 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs M OConnor Mrs M OConnor Care Home - personal care 13 Category(ies) of Old Age not falling within any other category registration, with number (13) of places Darley Dale Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18 October 2004 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. If a temporary nursing intervention is required, it can be accessed from community resources, as can all health care services. A chiropodist, dentist and optician can all visit the home if required. 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector undertook this announced inspection over 5 hours. Care records, the facilities to meet health and personal needs, and the standard of meals for the residents were inspected. Staffing levels and their development opportunities were looked at, as were the recruitment procedures adopted by the management. Health and Safety issues were inspected in the environment, with particular focus on safeguards for the residents; a number of documents relevant to the safe maintenance of the home were also seen. A tour of the premises took place, and staff were observed going about their duties whilst interacting with the residents. The care of three residents in particular was closely looked at. Nine residents and one visiting relative were 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 Acting and Deputy Manager, and two members of staff, each of whom was open to the inspection process, and was most welcoming and helpful. 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. 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 Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Darley Dale Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Darley Dale Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 & 6. The home’s Statement of Purpose and Service User Guide provide prospective residents with good information and details about the services the home provides, enabling an informed decision to be made. A contract document ensures that residents can be clear about the terms and conditions of their stay. EVIDENCE: The home has produced a Statement of Purpose and a Service User Guide that has been combined into one informative document, which is issued to all interested parties; this is called the home’s brochure. Each resident is issued with a contract for their care and accommodation at Darley Dale. The notice period for any changes to fees is currently identified as two weeks; this must be amended to identify a one month notice period of such changes. Intermediate care is not provided at this home. Darley Dale Version 1.10 Page 9 Darley Dale Version 1.10 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 standard(s) 7, 8 & 10. There is a care planning system in place, which provides staff with the information they need to satisfactorily meet residents’ health and personal needs. Personal support in this home is offered in such a way as to promote the residents’ privacy, dignity and independence. EVIDENCE: Each resident has a plan of care that is devised on the basis of an assessment of their needs, which is done in consultation with them, and which is regularly reviewed. Manual handling assessments are recorded for each person. Case tracking confirmed appropriate interventions are carried out by the home through contact with the District Nurse, in cases where a risk of developing a pressure sore is identified. The home does not have any formal assessment tool for this, and assessment is carried out by the District Nurse, with appropriate support equipment provided. The adoption of a designated Darley Dale Version 1.10 Page 11 assessment tool would be of some assistance to staff in assessing and recording any risks and trigger points for action more methodically. Records confirmed that residents are weighed, though this did not appear to have been done for some months; this should be done more regularly, particularly in cases where a nutritional risk is identified. Records showed that access to all health services and outside agencies is ensured, when and wherever needed. 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 Version 1.10 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 standard(s) 14 & 15. 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 reasonable standard of varied food to meet the residents’ nutritional needs, in accordance with individual likes and dislikes. EVIDENCE: 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. One visitor said that the staff at Darley Dale are very good at sharing information with them, and enabling them and their relative to discuss their care and associated issues. Darley Dale Version 1.10 Page 13 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. A record of food served to the residents is maintained, though the home must ensure that a record of any menu alternatives is also 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. Residents all said that the food is ‘very good, with plenty of it’. Darley Dale Version 1.10 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 standard(s) 16 & 18. 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. One person said that ‘staff do anything they can for you’. There was no record of complaints to inspect, as none have been received. The home has a written policy on abuse, and has a Whistleblowing procedure for staff to follow if they had any concerns. The Abuse policy is currently under review, in order that it is in full accordance with the Department of Health guidance, ‘No Secrets’. The local Adult Protection Unit’s ‘Alerter’s Guide’ is also available. Staff are not permitted to be involved in helping to make or benefiting from residents’ wills, and safe storage is available should any resident wish to place valuables with the home for safe-keeping. Darley Dale Version 1.10 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 25 & 26. Darley Dale provides a very homely and clean environment for the residents, however some attention is needed towards a small number of potential health and safety risks posed to the residents in the home. EVIDENCE: Although a number of radiators have been covered to provide a safe surface temperature for the residents, there remain a significant number that are not. In these areas staff have conducted and recorded a risk assessment in individual care plans, and though no serious risks are currently identified, the home would provide radiator covers as a priority in any areas where there is risk. Thermostats are fitted to each radiator so that temperatures can be controlled. Hot water is stored at appropriate temperatures to prevent colonisation of Legionella, though is not blended at outlets to ensure a safe temperature for the residents. The home must undertake and document risk assessments for all hot water outlets, and take any corrective measures where a risk of scalds is identified. Darley Dale Version 1.10 Page 16 As a precaution staff run bath water for all residents, and use a thermometer to check for safe temperatures before use. All windows on the first floor have a restricted opening. 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. There is only one odorous area, and this is subject to ongoing monitoring and review by the staff. This odour is contained and does not impact on the rest of the home. Darley Dale Version 1.10 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. 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 must be 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 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 personnel share responsibility for non-care tasks such as domestic and catering duties. All residents, and the one visitor spoken to, confirmed that staff are always very accessible and helpful. Darley Dale Version 1.10 Page 18 As the staff team is particularly stable, there has been no recruitment of any new staff for some time. The home was required to devise a written recruitment procedure, which fully incorporates all of the required preemployment checks; this has not yet been addressed. Information pertaining to the amended regulations for staff recruitment has been provided to the Acting Manager following this inspection, in order to assist him in writing a compliant procedure. Staff training records demonstrate that there are regular training opportunities for staff, with a range of training relevant to their roles being undertaken. Training booklets written in accordance with TOPSS standards have been sourced in order to provide a structured induction for any new staff that may be employed in the future. There is a commitment to the NVQ training, with two staff currently on the programme. Darley Dale Version 1.10 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 & 38. Management systems are in place, which are designed to safeguard the residents. Some additional management focus is required however, towards a small number of environmental health and safety issues, which could potentially pose risks to the residents and staff. EVIDENCE: An application to register the home’s Acting Manager with the Commission for Social Care Inspection is being processed at this time. Darley Dale is very much a family managed home, and the Acting Manager has been involved with it for many years; he is currently undertaking the NVQ level 4 Registered Manager Award with a local college. A central secure facility is available, in which residents can place personal money and valuables if they wish. There is currently no-one choosing to do this, and consequently there are no records to inspect. Darley Dale Version 1.10 Page 20 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, however a suitably skilled and competent person has not undertaken the servicing of the load bearing bath hoist. Following this inspection the Acting Manager resolved to make an arrangement for this to be carried out by such a person as soon as possible. The property is old, and the Acting Manager is not aware of when the electrical installation was last checked for safety; it is recommended that this be done on a five yearly basis. Chemicals in use are held securely, and there is a written Control of Substances Hazardous to Health policy. Data sheets for each chemical have not been obtained, and this must now be addressed. Darley Dale Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 2 COMPLAINTS AND PROTECTION x x x x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 x x 2 Darley Dale Version 1.10 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 5A(3) Requirement The homes contract document must be amended to include a four week notice period for any changes to fees. A record of alternative foods served to that indicated on the menu must be kept, which enables any person inspecting the record to determine whether the diet is satisfactory. A risk assessment must be conducted and recorded to identify any risks posed to individual residents from hot water, with corrective measures taken where necessary. The home must document a recruitment procedure to be followed, which is fully in accordance with this regulation. (previous timescale of 30 January 2005 not met). The home must make provision for any load bearing equipment to be serviced for safety by an appropriately qualified engineer. Data information sheets must be obtained for each chemical in use in the home. Timescale for action 31 July 2005 31 July 2005 2. 15 17(2) 4(13) 3. 25 13(4.c) 31 July 2005 4. 29 19, Schedule 2 31 July 2005 5. 38 13(5) 31 July 2005 30 September 2005 6. 38 13(4.c) Darley Dale Version 1.10 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. 3. 4. 5. Refer to Standard 8 8 25 25 38 Good Practice Recommendations It is recommended that the home adopts a formal assessment tool for assessing individuals risks of developing pressures sores. Residents weights should be monitored regularly, including monthly in cases where a nutritional risk is identified. It is strongly recommended that low surface temperature safety features be fitted to all radiators and hot pipes. It is strongly recommended that hot water is blended at outlets to ensure safe temperatures for the residents. It is recommended that the electrical installation undergoes a five yearly safety check by a qualified engineer. Darley Dale Version 1.10 Page 24 Commission for Social Care Inspection 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 Version 1.10 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. 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