Inspection on 23/11/05 for Darley Hall

This inspection was carried out on 23rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 23/06/05

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 Janet Morrow Unannounced Inspection 23rd November 2005 03:45 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.V268796.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 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.V268796.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One DE(E) place for the service user named in the notice of proposal letter dated 28 October 2005. The home accommodates one named individual named in the notice of proposal for the duration of their stay. 23rd June 2005 Date of last inspection 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 occupancy. 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 DS0000019970.V268796.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over 2.5 hours. Two residents, one relative, the proprietor and proposed manager were spoken with. A tour of the building was undertaken. Care records were examined. Written information supplied by the home provided information for the inspection. What the service does well: What has improved since the last inspection? What they could do better: Little progress had been made on requirements issued at the previous inspection, particularly in relation to the premises. This meant that two bathrooms were unusable and not all toilets had handrails. The laundry floor needed refurbishment. A sluice facility should be provided. All these items are outstanding from previous reports. Staff urgently need training in adult protection and to understand procedures to be followed in the event of any incidents. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 6 Care plans must have details on how to minimise assessed risks and action must be taken to prevent risk of pressure sores. There should be evidence, such as a signature, to show that residents have been consulted about their care and the way it is provided. Lockable storage space should be provided in bedrooms. A manager must be appointed and then an application for registration with the Commission for Social Care Inspection should be made. Fire training should be updated, particularly for night staff. 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 Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 There was sufficient admission information available to establish that the home could meet residents’ needs but failure to act on information had the potential for individual needs not to be met. EVIDENCE: One resident’s care file was examined. This contained assessment documentation that showed the home had established that it could meet the individual’s needs. However, the information detailed had not been acted on and there was therefore the potential for needs to be unmet. One relative interviewed stated that they felt their relative’s needs were being met and that the care was ‘generally satisfactory’. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 Lack of attention to detail in care planning has the potential to put residents at risk. EVIDENCE: One residents’ care file was examined. There was a care plan in place that covered all the key aspects of daily living and health needs. There were risk assessments in place that covered risk of pressure sores and nutritional assessments. However, there was insufficient information to establish that specific needs were being addressed. For example, there was an assessment that established a high risk of pressure sores but there was no detailed information on how to deal with this and no pressure relieving equipment had been provided. An immediate requirement notice was therefore issued to rectify this. There was no evidence on the care plan, such as a signature, to indicate that consultation about care had taken place. There were records of visits by health professionals such as General Practitioner, optician and chiropodist. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 10 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): 13 An open visiting policy ensured that residents maintained access to the community. EVIDENCE: Visitors were able to visit at any time. One relative interviewed stated that they were always made to feel welcome and that they were able to have private visits. A resident spoken was able to make their own choices about visits and outings and went out into the community as they wished. They confirmed that there was flexibility in the routines of the home. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 11 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): 18 A lack of knowledge about adult protection procedures had the potential to put residents at risk of harm. EVIDENCE: The pre-inspection information stated that the home had an adult protection policy in place but it did not have a copy of the Derby and Derbyshire Local Authority Social Services procedures. The management were unclear about the procedures and no action had been taken on a recent incident. The management were instructed to take action at address this incident during the inspection. There was no adult protection training detailed in the pre-inspection questionnaire provided by the home. An immediate requirement notice was therefore issued to obtain a copy of the procedures and for staff training. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 12 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, 20, 21, 22 and 26 There had been little progress on addressing some of the repairs and building work required, which had the potential to compromise residents’ safety and comfort. EVIDENCE: There were parts of the home that were in a poor state of repair. For example, ceiling and plasterwork on the upper floor was damaged and the floor in the laundry was unsatisfactory. Two bathrooms were unusable due to alterations being needed, there was no sluice facility and the toilet in one bathroom had no handrails. There was no lockable storage space provided in residents’ bedrooms. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 13 These were raised as issues at the previous inspection in June 2005 and although the proprietor stated that there were plans to make good these alterations, little progress had been made. An immediate requirement notice was therefore issued to ensure that the work is completed by the end of January 2006. The bathroom that was used had a suitable bath hoist and one toilet had a raised toilet seat, which was an aid to those with physical disabilities. Communal space in the lounges and dining areas was clean and comfortable. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 14 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): 28 There were insufficient qualified staff to ensure residents were in safe hands. EVIDENCE: The written information provided by the home stated that two of twelve care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. Although there were plans for three staff to undertake level 3 training, the home would not meet the target of 50 of staff achieving a level 2 qualification by 2005. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 15 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 and 38 Management systems needed improvement to ensure the health and safety of those in the home. EVIDENCE: The home did not have a registered manager. The proprietor had informed the Commission in writing that he wished to put forward a proposed manager and that an application for registration would occur in the near future. The written information supplied on the pre-inspection questionnaire showed that the fire equipment maintenance check was out of date. Other equipment such as bath hoists were checked in July 2005, the emergency lighting in January 2005 and the electrical wiring in January 2005. Moving and handling training for staff had taken place in the last twelve months and further training for staff in food hygiene and first aid was booked for February 2006. However, Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 16 the pre-inspection information provided showed that fire training was out of date, with the last session being in September 2004. Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 17 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 2 3 1 2 X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 18 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 OP7 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 Previous timescale of 31/7/05 not met. Now immediate Care plans must be reviewed at least monthly and must be dated and signed Previous timescale of 31/7/05 not met There must be documentary evidence of service user involvement in the formulation of care plans Previous timescale of 31/8/05 not met. Staff must receive adult protection training Previous timescale of 31/10/05 not met. Now immediate 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 DS0000019970.V268796.R01.S.doc Timescale for action 01/12/05 2. OP7 15 (2) (b) 01/02/06 3. OP7 15 (1) 01/02/06 4. OP18 13 (6, 7, 8) 23 (2) (j) 01/12/05 6. OP21 01/02/06 Darley Hall Version 5.0 Page 19 7. OP21 23 (2) 8. OP22 23 (2) (n) 9. OP24 23 (2) (m) 10. OP25 13 (4) (a) 11. OP26 13 (3) 12. OP26 13 (3) 13. OP29 19 14. OP31 8 (1, 2) 15. OP33 24 (1, 2, 3) to 30 June 2005) Timescale of 30/6/05 not met All toilets must have an accessible toilet roll holder Previous timescale of 30/06/05 not met Hand rails must be provided on both sides of toilets used by service users Previous timescale of 31/07/05 not met The programme of providing lockable storage space must be completed (previous requirement - timescale of 30 March 2005 not met) Previous timescale of 30/03/05 not met Window restrictors above ground floor must be adjusted to provide a maximum opening of 100mm This requirement was not assessed on this occasion. Timescale extended Laundry floor finish must be impermeable and the wall finish must be cleanable. Previous timescale of 30/8/05 not met A sluicing facility must be provided Previous timescale of 31/10/05 not met The written recruitment policy and procedure must be updated This requirement was not assessed on this occasion. Timescale extended. A manager must be appointed and the manager must apply for registration with CSCI Previous timescale of 30/8/05 not met. Timescale extended Feedback must be actively sought from service users about the services provided e.g. by anonymous surveys This requirement was not DS0000019970.V268796.R01.S.doc 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 Darley Hall Version 5.0 Page 20 16. OP38 13 (3,4) 16(2)j 17. OP8OP4 12 (1) (a) 18. OP18 13 (6) 19. OP38 23 (4) (d) assessed on this occasion. Timescale extended Staff must receive training in all safe working practices, including first aid, food hygiene and infection control This requirement was not assessed on this occasion. Timescale extended The home must make proper provision for the health and welfare of residents and ensure that assessed needs are met. There must be arrangements to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. There must be arrangements in place for staff to receive suitable training in fire prevention. 01/02/06 01/01/06 01/12/05 01/02/06 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. Refer to Standard OP12 OP8 OP18 Good Practice Recommendations An activities (social & leisure programme) log should be maintained This recommendation was not assessed. Pressure relieving equipment should be provided where assessments indicate this is necessary. A copy of Derby and Derbyshire Local Authority Social Services adult protection procedures should be obtained and staff should familiarise themselves with these procedures. Staff should undertake National Vocational Qualification (NVQ) training. Fire training should take place at least annually and twice yearly for night staff. 4. 5 OP28 OP38 Darley Hall DS0000019970.V268796.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office 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 DS0000019970.V268796.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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