Inspection on 23/06/05 for Darley Hall

This inspection was carried out on 23rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Hall 21/04/09

Darley Hall 23/04/08

Darley Hall 06/06/07

Darley Hall 07/06/06

Darley Hall 23/11/05

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 DE4 2FB Lead Inspector Andrew Bailey Unannounced 23 June 2005 10.00am 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 Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Darley Hall Address Park Lane Two Dales Matlock Derbyshire DE4 2FB 01629 735770 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) Mr and Mrs D J Treasure Mr and Mrs A Wright CRH - Care Home 22 Category(ies) of OP Old Age - 22 places registration, with number of places Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None stated Date of last inspection 22 December 2004 Brief Description of the Service: Darley Hall is a Georgian building, built around 1796 and set in its own grounds. This established care home provides accommodation for up to 22 service users. The accommodation is on three floors, with access to the first and second floors via staircase or shaft lift. Seventeen bedrooms are single occupancy and 3 bedrooms can be utilised for shared occcupancy. Ten bedrooms have en-suite facilities. There are two main lounge areas and a dining room. Services include personal laundry, meals, and personal care designed to meet individual needs. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately 6 hours. A tour of the building took place. Discussions were held with five service users, two relatives and with three staff/management. A number of records were examined, including care plans (as part of the case tracking process, which is used to facilitate assessment of the home from the service users perspective). An assessment was also made of progress by the registered persons to address requirements made at previous inspections of this service. What the service does well: What has improved since the last inspection? Steps have been taken to organise maintenance/restorative works on the roof of the premises. These works are due to commence in a few months. The exterior woodwork has been repainted and this has improved the appearance of the exterior of the building. Care planning systems have been reviewed with staff reporting that the care files are now up to date, with relevant assessments in place. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 6 What they could do better: There are some longstanding requirements from previous inspections that remain outstanding. A number of new requirements have also been made following this inspection. There is an expectation from CSCI that the registered providers will respond positively to the findings in this report and provide an action plan, complete with realistic timescales within which they intend to address the shortfalls. The Commission will consider taking further action if requirements fail to be acted upon by the registered providers. This may involve escalating levels of enforcement action. There must be steps taken to remedy the shortfalls with the environmental issues, including upgrade of a shower room to enable persons with physical disability to use the shower, and provision of a dedicated sluicing facility. Care planning documentation is generally satisfactory, but this can be further improved with more attention given to detail, such as greater applying greater consistency in ensuring that documents are dated and signed following reviews. Staff must receive training in adult protection to ensure that service users continue to be protected from abuse and neglect. There must be completion of staff training in safe working practices, with periodic updates arranged to further promote the health and safety of service users. The previous registered manager has now left the home. A manager must be appointed by the owners, and a application must then be submitted for registration of the manager with CSCI. Further steps must be taken to seek service users views of the home, for example by use of satisfaction surveys, with summary feedback then made available to current and prospective service users. This will provide further evidence that service users can have a real impact on the way that the home is run. Please contact the provider for advice of actions taken in response to this Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 3 Written documentation sets out the basis of the contractual agreements between service users and the registered providers. Pre-admission procedures are in place to ensure that new service users are admitted on the basis of a full assessment of their needs. EVIDENCE: The majority of the service users had contractual arrangements, which had been organised via social services (part or fully funded care). There was evidence from sampling that one of the self-funded service users (no social services contractual involvement) had been issued with a written contract/terms and conditions. A service user spoken with also confirmed that a contract had been issued. Pre-admission assessment documentation (present in the care plan files) was examined in respect of three service users and there was confirmation that appropriate pre-admission assessment procedures had been undertaken for these service users. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 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 The documentary standards of care plan entries are generally satisfactory. Further attention should be given to ensure that all plans are consistently reviewed within the required timescales and that they are dated, signed and always appropriately detailed. EVIDENCE: Service user care planning documentation was generally completed to a satisfactory standard. Overall, the records were comprehensive and included relevant risk assessments (including assessment of the risk of falls). However, there was an example found where a service user had signed in respect of the custody and self-administration of medicines, but it was unclear from the documentation what the outcome of the risk assessment was i.e. selfadministration of some or all of prescribed medication. The custody/selfadministration of medications form had also not been dated, making review arrangements difficult establish. There were also some care plans examined where a member of staff had not signed against the recorded dates of the periodic reviews. These documentary omissions lessen the value of these documents in legal terms and can hinder the effectiveness of the review processes. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 11 It was noted that reviews had generally occurred at six-month intervals, whilst the National Minimum Standard identifies once a month. There was little documentary evidence in the care plan files examined to support that service users had been fully involved in the formulation of the care plans i.e. the care plans had not been signed by the service user (or representative where appropriate). However, some of service users spoken with stated that they had been consulted about care issues. This helps to demonstrate that a partnership in care exists between care staff and service users, but written agreement should sought where possible in order to provide further validation of the process. The majority of the service users spoken with confirmed that staff are respectful of their privacy and dignity in their daily interaction with the service users. There were comments from two service users that a minority of the staff are possibly not fully attuned to the needs of the elderly, in terms of the way that they may sometimes verbally address service users. This was brought to the attention of management during the inspection feedback session (anonymity of the service users was maintained). Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 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) 12, 13, 14 & 15 A social & leisure programme is organised, including outside trips. Overall feedback from service users is that the food is of a good standard, with alternatives to the menu items available. EVIDENCE: There is a social & leisure programme, including outside visits, with events advertised on the main notice board. There is not a specifically designated member of staff identified in a coordinating role and this could be a worthwhile development to ensure the needs of all service users are considered. There is no individual record made of activities e.g. record logs. One of the service users voiced that there should be more board games. An open visiting system is in place and relatives stated that they were made welcome at the home. There was corroboration from service users that the home is run along informal lines, with the personal choice of service users considered. Therefore, service users are able to exercise as much control over their lives as possible. There was advocacy information available within the home (displayed in the entrance area). Use of advocates was confirmed, with two of the service users receiving this assistance. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 13 Most of the service users spoken with were very pleased with the quality of the catering service. One person felt that individual choice was not taken into account sufficiently. The midday meal was being served during the inspection and this appeared to be of a good standard. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 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 complaints procedure in place, with written information about this prominently displayed in the entrance area and in the information issued to service users. There needs to be further training for staff in adult protection. EVIDENCE: The complaints procedure is prominently displayed in the home and contained within the written information available to service users and visitors. Service users and relatives feel that their views are taken into account by the friendly and accessible management. One of the owners has regular contact with the home and any concerns about service users are identified as part of the statutory visits made to the premises. There had not been recent specific training for staff in respect of local adult protection procedures. Consequently, there was no confirmation from staff that they were fully up to date with how these procedures work. In order to ensure that staff have the necessary awareness of adult protection issues a requirement has been made for staff to receive appropriate training. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 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) 19, 20, 21, 22, 24, 25 & 26 There are environmental issues to address, some of which have been on going for some time. However, there are certain issues that impact directly on service users that should not involve major outlay to deal with. EVIDENCE: Work is planned to commence in the coming months to ensure that the roof is watertight. The exterior of the building has been re-painted and the overall appearance of the aspects of the building regularly on view to the public and service users is satisfactory. The grounds are maintained and provide an attractive setting for the home. A previous requirement to provide domestic style lighting in the dining room has not yet been addressed. Neither has a requirement to upgrade the second floor shower room. This facility does not provide satisfactory access for service users with physical disability Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 16 There are outstanding requirements to provide locks on bedroom doors and lockable storage facilities in bedrooms. Lack of these facilities can limit the independence and privacy for service users. One of the toilets (ground floor) for use by service users did not have an accessible toilet roll holder. A first floor toilet did not have grab rail provision on both sides of the toilet, thereby being of limited use if the handrail was on the opposite side to that required for an individual. Requirements have been made to provide these. The upper floor window restrictors should have a maximum opening of 100mm. Some of the sash window openings exceed this and a requirement has been made to ensure service user safety. The laundry floor finish is not impermeable and the walls are not readily cleanable. A requirement has been made to address this (as an infection control measure). The home does not have a dedicated sluice. The National Minimum Standards stipulate that a sluice should be provided and a requirement has been made accordingly. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 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 The staffing is proportionate to the needs of the number of service users currently accommodated in the home. The written policies and procedures to be followed for the recruitment of staff are out of date and need reviewing. EVIDENCE: The home is currently running at less than full occupancy and the staffing levels reflect this. The levels of staff are in accordance with the number and needs of the service users accommodated at the home. An umbrella body is utilised to process Criminal Records Bureau (CRB) checks for staff and a Protection of Vulnerable Adults check now forms part of the process. However, the written policies and procedures to be followed in recruitment of staff are out of date and do not mention Criminal Records Bureau/ POVA checks. Staff spoken with had the required employment checks carried out e.g. CRB Disclosure. The induction and foundation programmes were not examined at this inspection, but it was ascertained that not all of the training required identified at the last inspection had been completed e.g. first aid training. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 18 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, 33 & 38 The registered manager position is currently vacant, with acting arrangements in place. There are regular visits to the home by one of the owners and the required written reports of the visits are made. Not all staff had received the necessary safe practices training. EVIDENCE: The registered manager left about five weeks prior to this inspection. There were acting arrangements at the time of this unannounced visit. A requirement has been made to appoint a manager and for CSCI to receive an application for registration. There was evidence that the registered providers are carrying out their responsibilities in respect of visits to the home. Service users and relatives commented that one of the owners who regularly visits the home maintains a genuine interest in the welfare of the service users. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 19 There was no evidence that a recent anonymous satisfaction survey had been undertaken. Therefore, there was no written feedback on satisfaction levels to inform potential service users, or for the management to act upon, if it was necessary. Records of servicing examined were up to date (electrics, gas and fire services examined), indicating that the main services are regularly inspected. Staff had undertaken safe working practices training, but this was not comprehensive. For example, there had not been training in respect of infection control, the majority of staff had not received first aid training, and some staff awaited food hygiene training. The safety and welfare of service users will be further promoted when staff complete this safe practices training. Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 2 2 x 2 2 2 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 2 x x x x 2 Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 21 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 7 Regulation 14, 15 Requirement All care plan entries, including reviews and risk assessments must be unambiguous (e.g. selfadministration of medication) and assessments must be dated Care plans must be reviewed at least monthly and must be dated and signed There must be documentary evidence of service user involvement in the formulation of care plans Staff must receive adult protection training Domestic lighting must be installed in the dining room (previous requirement timescale of 30 September 2004 not met) The upstairs shower room must be upgraded to allow easy access for residents with disabilities (previous requirement - original timescale of 30 November 2004 not met extended at Dec 2004 inspection to 30 June 2005) All toilets must have an accessible toilet roll holder Hand rails must be provided on both sides of toilets used by Timescale for action 31 July 2005 2. 3. 7 7 15 (2) (b) 15 (1) 31 July 2005 31 August 2005 31 October 2005 30 September 2004 30 June 205 4. 5. 18 20 13 (6, 7, 8) 23 (2) (p) 6. 21 23 (2) (j) 7. 8. 21 22 23 (2) 23 (2) (n) 30 June 2005 31 July 2005 Page 22 Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 service users 9. 24 23 (2) (m) The programme of providing locks on bedroom doors and lockable storage space must be completed (previous requirement - timescale of 30 March 2005 not met) Window restrictors above ground floor must be adjusted to provide a maximum opening of 100mm Laundry floor finish must be impermeable and the wall finish must be cleanable A sluicing facility must be provided The written recruitment policy and procedure must be updated A manager must be appointed and the manager must apply for registration with CSCI Feedback must be actively sought from service users about the services provided e.g. by anonymous surveys Staff must receive training in all safe working practices, including first aid, food hygiene and infection control 30 March 2005 10. 11. 12. 13. 14. 15. 25 26 26 29 31 33 13 (4) (a) 13 (3) 13 (3) 19 8 (1, 2) 24 (1, 2, 3) 13 (3, 4) 16 (2) (j) 31 July 2005 30 August 2005 31 October 2005 31 July 2005 30 August 2005 30 August 2005 30 September 2005 16. 38 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 12 Good Practice Recommendations An activites (social & leisure programme) log should be maintained Darley Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby DE1 3QT 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 Hall C52-C02 S19970 Darley Hall V230987 230605 Stage 4.doc Version 1.30 Page 24 - 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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