Inspection on 23/04/08 for Darley Hall

This inspection was carried out on 23rd April 2008.

CSCI found this care home to be providing an Adequate service.

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 Hall 21/04/09

Darley Hall 06/06/07

Darley Hall 07/06/06

Darley Hall 23/11/05

Darley Hall 23/06/05

Darley Hall 22/12/04

Darley Hall 01/06/04

Darley Hall 19/12/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Darley Hall Park Lane Two Dales Matlock Derbyshire DE4 2SD Lead Inspector Rose Veale Unannounced Inspection 23rd April 2008 09:30 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 Hall DS0000019970.V362871.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 Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Darley Hall Address Park Lane Two Dales Matlock Derbyshire DE4 2SD (01629) 735770 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) Mr David John Treasure Mr A Wright, Ms Glenis Pamela Wright, Alison Treasure Vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home accommodates one named individual named in the notice of proposal for the duration of their stay. Date of last inspection 6th June 2007 Brief Description of the Service: Darley Hall is a converted Georgian building, built around 1796 and set in extensive grounds. This established care home provides accommodation for up to 22 older people. The accommodation is on three floors, with access to the first and second floors via staircase or shaft lift. There are 17 single bedrooms and 3 shared. 10 bedrooms have en-suite facilities. There are two main lounge areas and a dining room on the ground floor. Services include personal laundry, meals, and personal care designed to meet individual needs. The fees are £375 - £405 per week, according to the needs and care required following individual assessment. This information was provided by the acting manager on 23rd April 2008. Information about the home, including CSCI inspection reports, is available in the main entrance area of the home, or from the acting manager. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection visit was unannounced and took place over 6½ hours on one day. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. There were 17 people accommodated in the home on the day of the inspection visit. People who live in the home, visitors and staff were spoken with during the visit. The acting manager was available and helpful throughout the inspection visit. One of the providers was available for part of the inspection. Some people were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. Records were examined, including care records, staff records, maintenance, and health and safety records. Most parts of the building were seen. The Annual Quality Assurance Assessment (AQAA) had been completed and returned prior to the inspection and information from this has been included in the body of this report. Surveys were sent out to people living in the home, their relatives, and staff. Information from the survey responses has been included in this report. What the service does well: What has improved since the last inspection? Improvements had been made to care plans and risk assessments so that people’s needs were more clear. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 6 Improvements had been made to the home, including a new special bath for people who would have difficulty in using an ordinary bath. Some areas had been decorated and some new carpets had been provided. 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. The summary of this inspection report can be made available in other formats on request. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 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 Hall DS0000019970.V362871.R01.S.doc Version 5.2 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. 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. There was a satisfactory assessment process so that people were generally confident that their needs could be met at the home. EVIDENCE: The care records of 3 people living in the home were seen. All the records had an assessment of the person’s care needs, including information from social services care managers and from relatives. Risk assessments were carried out and had been reviewed approximately every 6 months. Each person had a care plan produced from the assessment information. The Annual Quality Assurance Assessment (AQAA) said that people are assessed and risk assessments and care plans are in place before the person comes into the home – “to help maximise the residents independence”. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 9 Surveys were received from 2 people living in the home and from 2 relatives. Of the 4 surveys, 2 said the person’s needs were always met at the home, 1 said ‘usually’ met and 1 said ‘ sometimes’ met. People spoken with during the inspection visit were mostly satisfied that their needs were met. There were comments that there could be more activities provided for people in the home, (see Daily Life and Social Activity section). Standard 6 did not apply to this home as there were no people receiving intermediate care. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 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. 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. Although people were generally satisfied with the care provided, there were gaps and a lack of detail in care records so it was not clear that people’s needs and personal preferences were always fully met. EVIDENCE: Each of the 3 care records seen included a care plan covering the assessed needs of the person. The care plans had some details of personal preferences and preferred routines. The care plans lacked detail of how staff were to ensure privacy and promote dignity for people. All of the care plans had been reviewed monthly. 1 of the care plans had been recently re-written and updated as the person had lived in the home for several years. This had not been done with another care plan and so, although it had been reviewed monthly, the plan was not accurate in several areas. Also, this person had an assessment that the risk of developing pressure sores Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 11 was high but there was no care plan of the action to be taken by staff to address this. There were records of the visits of the doctor, district nurse, chiropodist and optician. People spoken with confirmed that they were able to see their GP when needed and that they had access to other healthcare services. The surveys also indicated that people usually had the medical support they needed. Two of the care plans had been signed by relatives of the person to show their agreement and involvement in care planning. Daily records were completed to show the care provided and any changes in the person’s health or general condition. The content of the daily entries was not always useful or informative, for example stating “No problems”. People spoken with and those responding to the surveys said that staff listened to what they said and that their needs were usually met. People said that staff respected their privacy and dignity. Staff were observed to have a respectful and appropriate approach to people. People commented that the staff were “wonderful” and “kind”, and that “we’re well looked after”. Staff spoken with were knowledgeable about the needs and preferences of people living in the home. Staff were able to give examples of how they ensured privacy and dignity for people. Staff spoken with and those who returned surveys were pleased with the training provided for them. Staff said they had sufficient training to meet people’s needs. All of the staff were involved in a distance learning course about caring for people with dementia. Medication was securely stored and was administered by the senior care assistants. All care staff had received training about the safe handling and administration of medication. The medication administration records seen were correctly completed. There was a risk assessment in place for one person who wanted to administer their own medication. There was no reference book for staff to consult about medication to ensure they had current and correct information. The AQAA said that care plans are updated monthly, relatives are involved in care planning, and that each person in the home has a keyworker. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 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. 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. The lifestyle offered in the home generally met the expectations and preferences of people living there. EVIDENCE: There was a range of activities provided in the home, such as music and movement, dominoes, bingo, flower arranging and arts and crafts. There were regular trips out and some people attended a weekly luncheon club. Each afternoon a member of staff was nominated to organise activities and records were kept of the activities offered. There were photographs on display of recent activities. People spoken with said they enjoyed the activities provided. There were comments from 2 people that there should be more activities offered. From observation and the records seen, there were limited activities available for people who had dementia or who were less able to communicate. There were links with local churches and the acting manager said that clergy visited regularly and on request. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 13 People spoken with said they were able to get up and go to bed when they wanted to. Preferred daily routines were noted in the care records, although in one case this was not up to date. People were pleased they could bring in their own furniture and belongings to personalise their bedrooms. One person said they chose the home because it was “homely” and another person commented on the “friendly and homely atmosphere”. Visitors said they were always made welcome and that they could visit at any reasonable time. At the previous inspection in June 2007 there was no permanent cook at the home and so the acting manager, deputy manager and other staff were doing the catering. Since then, a new cook had been found and the home were advertising for another cook to ensure adequate cover at all times. The acting manager continued to do some of the catering. People spoken with said they enjoyed the meals at the home. Both of the surveys from people at the home said they usually liked the meals. One person said they could have a choice if they did not like what was on the menu and that there was “always plenty of it!” The lunchtime meal on the day of the inspection visit looked appetising and was well received by people. The menu appeared varied and balanced. People were provided with individual jugs of cold drinks in the lounge so they could help themselves. People who were unable to help themselves were helped and encouraged by staff to have regular drinks. The AQAA said that the range of activities had improved since the last inspection, and that staff were better motivated and more committed to helping people with activities. Fund raising efforts had raised money to pay for a local organisation to provide arts and crafts, pottery and music and movement. The home had started meetings for people at the home and their relatives, and also quality assurance questionnaires. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 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. 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 were policies in place and good staff awareness so that people were protected and their concerns effectively dealt with. EVIDENCE: There was a complaints procedure displayed in the main entrance area and included in the service user guide. The complaints procedure did not have the correct contact details for CSCI. Records were kept of complaints made with details of the action taken and the outcome. The records were not always signed and dated. People spoken with said they would be happy to go to the acting manager or the provider with any complaints. One survey said that action was taken straightaway when any concerns were raised. One survey from a person living at the home said they did not know how to make a complaint. No complaints about the home had been received by CSCI since the last inspection. There was information available about local advocacy services. There was no information available in the home about the Mental Capacity Act 2006, and staff had not received any training about this. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 15 Staff had received training about safeguarding vulnerable adults. Staff spoken with were clear about what abuse was and the immediate procedures to follow. The acting manager had attended a two day training course with Derbyshire social services about safeguarding vulnerable adults. The AQAA said that the complaints procedure is accessible to people in the home and their families and is explained on admission to the home. All staff have a Criminal Records Bureau (CRB) disclosure as part of the recruitment process. Policies, procedures and staff training are all kept up to date. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 16 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): 19, 20 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 and grounds were not sufficiently well maintained to ensure a safe a pleasant environment that fully met the needs of people living there. EVIDENCE: There had been some improvements made since the last inspection. Some areas had been decorated and some new carpets had been provided. A new carpet was to be fitted on the day of the inspection visit. A Parker bath with whirlpool had been installed in the ground floor bathroom and this was said to be enjoyed by people in the home. One person commented that they had “never had a bubble bath like that before!” and found it relaxing. There were comments on the surveys and from people spoken with that the home was in need of general refurbishment, including the external grounds. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 17 From observation, there were many areas of the home where the décor was shabby, ‘tired’ and dated. There were extensive grounds to the home. People were able to sit in the area outside the front door of the home in good weather. The paths and driveway were uneven and would be hazardous for anyone with limited mobility to walk on. The security light outside one of the external doors, (the door from the laundry room), was not working and the one light on the driveway was said to be inadequate. There had been a recent incident with a prowler at night outside the laundry room door. The area outside the laundry door was unsightly and untidy. This area was not accessed by people at the home or their visitors. People in the home were allowed to smoke in the front porch. This did not comply with the smoke-free legislation introduced in England in 2007. Areas of the home seen on the day of the inspection visit appeared clean and were free from offensive odours. People spoken with said the home was always clean and fresh, and the surveys also indicated this. The acting manager had received training about the control of infection and said she was looking for a course for all staff to do. Staff spoken with were aware of good hygiene practices to ensure control of infection. The AQAA clearly identified the need to improve the internal and external environment of the home. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training and recruitment procedures were sufficient so that people were safe and their basic care needs were met. Staffing levels were not sufficient every day to ensure people’s needs were fully met. EVIDENCE: The staff rotas were seen and showed 3 care assistants on duty for the morning and afternoon shifts – from 8am to 8pm. There were 2 care assistants on duty for the night shift. The 2 surveys from people at the home said there were ‘sometimes’ and ‘usually’ staff available. People spoken with said staff were usually available, although there were times when staff were busy. Staff spoken with said that 3 care assistants for the morning and afternoon shifts was usually sufficient for the needs of people currently in the home. The staff rotas showed that on 3 afternoons per week the domestic assistant was included as part of the care staff. Staff spoken with and the acting manager said this did not work as it meant there were effectively only 2 care staff on duty for those afternoons. There were people in the home who needed 2 care staff at once to help them and so if both care assistants were Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 19 occupied, there was no-one to be with other people in the lounges. Also, with 2 care assistants it was more difficult to provide activities on these afternoons. The records of 3 members of staff were seen. The records included nearly all of the required information, such as Criminal Record Bureau (CRB) disclosures, POVA First checks, and 2 written references. One record had a form of identification for the member of staff, the other two did not. None of the records had a photograph of the member of staff. One of the application forms had no explanation of a gap in the employment history. Training records showed a range of training for staff. The new induction programme met Skills For Care standards, although no new care staff had been recruited since the last inspection and so this had not been put into practice. Staff had received training in manual handling with regular updates, safeguarding of vulnerable adults, fire safety, basic food hygiene, and safe handling and administration of medication. All the care staff were working on a distance learning course about dementia. More than 50 of the care staff had achieved National Vocational Qualification (NVQ) Level 2 or above. Most of the staff had not received first aid training or training about control of infection. The AQAA said improvements in training have been made over the last 12 months, and identifies the need for further improvement in training “to ensure that the residents get the best care possible”. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was well organised and effectively managed. However, there were some gaps in records, health and safety practices, and staff training so that the welfare and best interests of people were not well promoted. EVIDENCE: The acting manager had been in post for approximately 2 years but had not applied to be registered with CSCI. During the inspection visit, the acting manager confirmed that an application would be made as soon as possible. The acting manager had completed the Registered Manager’s Award. People spoken with said the acting manager was “approachable” and “well organised”, and said they had confidence that she would take action on any issues or Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 21 concerns. Staff said they liked the ‘hands-on’ approach of the acting manager. The acting manager had very little supernumerary time to carry out necessary administrative tasks and other managerial responsibilities. The AQAA was returned before the due date and included nearly all of the information required. During the inspection visit, the acting manager was able to provide information to complete the few gaps in the AQAA. The AQAA said “We now have residents meetings and quality assurance questionnaires from the staff and the residents”. “The manager really needs more time to do the administration side of things”. There was a quality assurance system in place that included meetings and surveys for people living in the home and their relatives, and surveys for staff. There was an ‘open door’ policy so that anyone could see the acting manager with any concerns or issues. The provider carried out monthly visits as required under Regulation 26. There was no annual report produced to analyse the findings of surveys and give details of action taken to address any issues raised. Records were seen of personal money held for people living in the home. The money was kept securely and the records included receipts and 2 signatures for each transaction. Information from the AQAA showed that equipment and systems were serviced or tested as recommended. The AQAA showed that most of the required policies were in place and had been reviewed in 2007. The fire log book was seen and showed that all equipment tests and system checks were up to date. As noted earlier, most staff had not received first aid training or training in the control of infection. People were allowed to smoke in the entrance porch to the home which did not comply with the smoke-free legislation introduced in England in 2007. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 22 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 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X X X 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP19 Regulation 23(2)(o) Timescale for action External sitting and garden areas 30/09/08 must be made accessible and safe and tidily maintained. This will ensure a safe and pleasant environment for people to use. (Previous timescales of 31/08/06 30/11/06 and 30/09/07 not met). External security lights must be 31/05/08 in working order to help ensure the safety of people living in the home and of the staff. There must be sufficient care 31/05/08 staff working in the home at all times to ensure that people are safe and their needs are met. All recruitment information and 30/06/08 documents must be obtained for each member of staff as outlined in paragraph 1 to 9 of Schedule 2. Specifically, proof of identity including a recent photograph and a full employment history with a satisfactory written explanation of any gaps. This will help to protect people through a fully robust recruitment procedure. Suitable arrangements must be 31/07/08 DS0000019970.V362871.R01.S.doc Version 5.2 Page 24 Requirement 2 OP19 13(4)(c) 3 OP27 18(1)(a) 4 OP29 19 (4) (b) 5 OP38 13(4) Darley Hall 6 OP38 12(1)(a) made for staff to be trained in first aid. This will help to ensure the safety and welfare of people living in the home. The home must comply with the 31/05/08 smoke-free legislation introduced in England in 2007. This will help to promote the health and safety of people living in the home. 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 2 3 Refer to Standard OP7 OP9 OP10 OP12 Good Practice Recommendations Care plans should have more detail of people’s personal preferences regarding care and routines to ensure their needs are fully met. There should be an up to date medication reference book for staff to consult so that they have current and correct information available. Care plans should include details of how staff are to promote the person’s dignity and privacy. The range of activities should be further developed to include more activities for people with dementia and/or communication difficulties. This will ensure all people living in the home have appropriate opportunities for leisure and social activities. The complaints procedure should be updated with the current contact details for CSCI so that people have correct information. There should be information available and staff training about the Mental Capacity Act 2006 to ensure people’s rights are promoted and protected. All staff should have training about the control of infection to ensure the health and safety of people is promoted. The acting manager should apply for registration with CSCI as soon as possible. The acting manager should have sufficient supernumerary time to ensure she can carry out the necessary administrative and managerial tasks for the smooth DS0000019970.V362871.R01.S.doc Version 5.2 Page 25 4 5 6 7 8 OP16 OP17 OP26 OP31 OP31 Darley Hall 9 OP33 running of the home. The quality assurance system should include an annual report to analyse information received and give details of action taken. This will ensure people’s views are taken seriously and action is taken to address any issues raised. Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Darley Hall DS0000019970.V362871.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!