Inspection on 06/06/07 for Darley Hall

This inspection was carried out on 6th June 2007.

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 Hall 21/04/09

Darley Hall 23/04/08

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 Angela Kennedy Key Unannounced Inspection 6 June 2007 10:50 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.V337204.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.V337204.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.V337204.R01.S.doc Version 5.2 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. 11 October 2006 Date of last inspection Brief Description of the Service: Darley Hall is a converted Georgian building, built around 1796 and set in its own extensive 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, located on the ground floor. Services include personal laundry, meals, and personal care designed to meet individual needs. The fee scale for 2007 was: Residential rates per week = £340.00 - £400.00 Respite = £395.00 per week. All rates are dependent upon the needs and care required following individual assessment. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately five hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with residents and their representatives. The inspection was focused on assessing compliance with defined key National Minimum Standards. The acting manager was available throughout the inspection visit and the provider was available at the end of the visit when verbal feedback was provided. On the day of the visit three people who lived at Darley Hall were spoken with and one visitor to gain their views of the service. Two members of staff were also spoken with to gain their opinion of the service and the training opportunities available to them. What the service does well: What has improved since the last inspection? All staff at Darley Hall have now undertaken training in Safeguarding Adults with the local authority. This training will enhance the staff teams Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 6 understanding regarding abuse and the protection and reporting of any incidents or suspected incidents of abuse. As part of quality assurance programmes, feedback is now actively sought from the people living at Darley Hall and their relatives and representatives about the services provided. New carpets had been fitted to several areas of the home such as the area by lift, and hallway to kitchen and small lounge. A new carpet had also been purchased for one of the bedrooms. A new roof had also been fitted on the building. 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.V337204.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.V337204.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of people living at Darley Hall were assessed prior to admission to ensure the staff team and the services provided to them would be able to meet their needs. EVIDENCE: Eighteen people were living at Darley Hall on the day of this inspection visit. Therefore two peoples care files were read, to look at the assessments that had taken place before they moved into Darley Hall. As an assessment of the support and care required for each person must be done before admission to ensure the service is suitable for that individual in supporting and meeting their needs. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 9 Both of the care files seen had needs assessments in place that had been done before each individual had moved into the home. Both people had assessments that had been undertaken by care managers from the local funding authority, and assessments were also in place from the local health authority regarding nursing and health needs. Needs assessments were now undertaken by the service and this was seen in one persons care file that was relatively new to the service. The information contained within this assessment contained useful information regarding this persons health, personal and social needs and the level of support they required. Discussions took place with one person whose care files were seen and this person was able to confirm that they had been involved in the information provided within their needs assessment, and stated that the staff team were able to support their needs well. This individual was familiar with the service before they resided there, and therefore confirmed that they had all of the required information that they needed about Darley Hall, in order for them to make an informed choice about living there. Within the two care files seen care plans were in place that had been generated from each individual’s needs assessments. Darley Hall DS0000019970.V337204.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): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further development is required to ensure all areas of need and support are addressed. In general medication practices are good but these will be further enhanced once all areas of practice are appropriately risk assessed. EVIDENCE: The care files of two people were looked at. The care plan of one person who had recently moved into Darley Hall was generally well detailed and addressed most areas of health, personal and social needs. Information regarding this persons wishes regarding dying and death provided information on their choice of interment, but no further information was recorded as to their wishes regarding their care in the event of dying with regard to how their death was to be handled and how their spiritual and cultural needs were to be met. If it is the wish of an individual not to discuss Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 11 these matters then this should be documented, dated and signed and reviewed on a regular basis. This would demonstrate that every effort is made to address the wishes of each individual regarding all areas of their care. Nothing had been recorded regarding this individual’s preferred daily routine. This person was spoken with at some length and it was apparent from discussions with them that they generally did have a daily routine which they liked to follow, which involved them going out each day in the nearby local communities to have a walk around and do some shopping. This person also discussed the activities that they chose to do to ‘keep them active’ both physically and mentally. Therefore information such as this would demonstrate that the service promotes autonomy and independence for individuals and does not impose its own routines on individuals whenever possible. All health care needs and health professional visits for this person had been recorded; this included any treatment given and review/follow up appointments. One other person ‘s care plan and risk assessments were looked at. Some areas of the care plan provided sufficient information to enable the staff team to support their needs. However some areas did not provide a lot of information, for example one part of the care plan that looked at daily life and social activity only stated one specific activity that this person did, and the nature of this activity was reliant on this individual’s relative. Further information would address any other interest or activities that this person enjoys and any activities this individual did not enjoy or wish to participate in. Another area of this persons care plan stated the person’s refusal regarding a particular hygiene practice. There was no information for staff on how this was to be managed and recorded, such as verbal prompting and encouragement. Although there was recorded evidence that indicated that care plans had been reviewed regularly, one part of the care plan seen for this person required up dating in March 07, this related to this persons social relationship’s. As noted in the other persons care plan nothing had been recorded that related to their religious and cultural interests and beliefs, or their routines of daily living. The medication practices were examined and in general were satisfactory. A specific room was used for storing medication, which was kept locked. This was suitably equipped for storing medicines including any controlled drugs. Records were maintained regarding disposal of unused medicines. Administration records were up to date and no errors were noted in recordings. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 12 A regular system for auditing medication arrangements was in place with the local pharmacist who also provided training for those staff involved in the administration of medicines. The manager stated that all of the care staff team had undertaken training to enable them to administer medication. However it was confirmed that at the present time these staff were not administering medication, as this was the role of the senior care team. However consideration should be given to ensuring staff trained to administer medication are provided with the opportunity to do so, with senior supervision if required to ensure they maintain their competence. There were two people who administered their own medication. They had signed forms regarding individual responsibility for this and had secure storage facilities available. However risk assessments were not in place that demonstrated that these two individuals had the capacity to administer and securely store their own medication. Once these risk assessments have been completed this will demonstrate that these two people are able to store their medication safely and administer their medication as directed by their doctor. Comments from residents were very positive regarding the care and support provided by the staff team. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Darley Hall were able to participate in activities and outings. Contact with family and friends was maintained and positive comments were made regarding the meals provided, although the present catering arrangements have the potential to impact on the management of the service. EVIDENCE: A range of activities were provided at Darley Hall such as bingo, quizzes, movement to music and reminiscence, trips out, dominoes, flower arranging (every other Wednesday), singers, scrabble, a musical quiz CD, clothes sales and luncheon club on a Friday which some residents attended. A voluntary organisation visited Darley Hall each month and provided a variety of activities for the people living there and helped to arrange trips out As stated in standards 7- 11, one person spoken with discussed how they went out independently in the local community. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 14 Everyone spoken with said they were quite happy with the range of activities offered to them some said they joined in and others said that they preferred not to participate in some activities but were happy to go on any outings planned. Visiting hours were open for people to receive their visitors, however the acting manager did state that anyone visiting after 9pm was asked to telephone in advance as for security purposes the doors would be locked after 9pm. It was confirmed by the people spoken with that they were able to receive their visitors either within their private accommodation or within the communal areas, as they preferred. Advocacy services were advertised on the notice board in the entrance hall of the home. One person living at Darley Hall was using the services of an independent advocate. This demonstrates that individuals are helped to exercise choice and control over their lives. Comments from people living at Darley Hall were positive about the meals provided. Menus were seen and these were generally nutritious with good variety and fresh produce used. Special diets were catered for. The acting manager confirmed and people living at the home confirmed that alternative dishes to the main meal were available if preferred, and each morning they were asked about their preferences for the day. Meals could be taken either in the small dining room or, if preferred in individuals private accommodation. At the time of this inspection visit Darley Hall were without a permanent cook. Catering was being provided by the acting manager and deputy manager who both had catering qualifications. Additional staff also provided support at weekends. It was confirmed by the acting manager and the provider that efforts were being made to recruit a cook as soon as possible. Consideration should be given to the hours the acting manager spends on catering activities, to ensure these do not have a detrimental impact on the management of the service. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Darley Hall can be confident that their concerns will be taken seriously and acted upon promptly. The training provided to staff and the procedures in place safeguard the people living at Darley Hall from abuse. EVIDENCE: Darley Hall had a satisfactory complaints policy contained in their brochure, which was displayed in the entrance hall. One complaint had been received at Darley Hall since its last inspection in October 2006. The complaint was relating to the standard of meals provided and had been made by someone living at Darley Hall. This complaint and the actions and outcome had been recorded in the complaints record book. The person who made the complaint was available to speak with and they confirmed that their complaint had been dealt with promptly. This person also stated that they were happy with the standard of meals now provided at Darley Hall. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 16 No safeguarding adults referrals or investigations have taken place since the last inspection. Policies relating to abuse and protection were in place at Darley Hall and this included the local authority policy on Safeguarding Adults. Staff at Darley Hall had undertaken training with Derbyshire County Council in Safeguarding Adults and the acting manager has attended a 2-day training course provided by Derbyshire County Council. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 17 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): 19,21,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improvements have been made to the environment these require further development to ensure a range of bathroom facilities and access to the garden areas are available to everyone living at Darley Hall. EVIDENCE: Some improvements have been made since the last inspection. A new bathroom suite with fixed hoist has been installed on the first floor. There have not been any changes to the bathing resources on the top floor as the provider is awaiting a grant from the local county council, although it was confirmed by the provider that this had been informally agreed to date Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 18 Following a visit from the Environmental Health Officer work was being undertaken to meet with the requirements left. New carpets had been fitted to several areas of the home such as the area by lift, and hallway to kitchen and small lounge. A new carpet had also been purchased for one of the bedrooms. A new roof had also been fitted on the building. The provision of a suitable ramp to the front entrance of the Home in order to improve wheel chair access has yet to be addressed. A clear maintenance programme for the Home has not been developed and sent to The Commission as required. This was discussed with the provider who stated that this would be done and a copy sent to the commission. All areas of the home seen appeared clean. The laundry area was satisfactorily equipped and maintained. Night staff were responsible for the laundering of clothes. The cleaning was undertaken by care staff also, it was however confirmed that one member of the care team worked half of their hours as domestic staff. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The skill mix and numbers of staff on duty ensures the needs of people living at Darley Hall can be met. The training provided ensures staff are competent within their roles. The records maintained regarding recruitment require further development to ensure the people living at Darley Hall are protected EVIDENCE: The staffing rotas were looked and demonstrated that three staff were on duty in the mornings and afternoon and two staff were on duty throughout the night. Staff spoken with felt that the numbers of staff on duty were able to meet the needs of the people living at Darley Hall. Some of the people who lived at Darley Hall whose opinions were sought also indicated that sufficient staff were available to support them. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 20 Sixty percent of the staff team at Darley Hall had achieved a National Vocational Qualification at level 2 or above in care. A further two staff just started this training. The recruitment files of three staff were looked and in general these were satisfactory containing all of the relevant recruitment documents required. It was noted however that one staff file seen had only one reference in place, rather than the required two. The acting manager confirmed that she would ‘chase’ this up. The mandatory training for the staff team was up to date and some staff had also undertaken training that was specific to the needs of people living at Darley Hall such as, dementia, care of the dying and Parkinson’s Disease. All of the staff spoken with felt that the training opportunities provided at Darley Hall were good Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Darley Hall benefit from a more inclusive approach to the running of their home. The safety of individuals will be further enhanced one sufficient staff are trained in all safe working practices. EVIDENCE: The acting manager had not as yet applied for registration with the Commission. It was stated that the provider was waiting for acting manager to complete the Registered Manager’s Award, which has now been achieved. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 22 The provider confirmed the application to register, as the manager for Darley Hall will now be sent to the commission. The staff spoken with confirmed that the acting manager was fair and easy to talk to with an open door policy. Questionnaires were sent out last November to the people living at Darley Hall and the staff team and the findings and any actions required were fed back to the provider. A residents committee has been put in place that meets every 4 months; minutes of meetings were maintained including any actions taken from the discussions held. Families and representatives of people living at Darley Hall were also involved in the committee. Records were maintained of any monies held on behalf of people living at Darley Hall and receipts were given for any monies put into individual’s accounts. Only 1 signature was kept of monies being withdrawn, it was therefore advised as a good practice recommendation that two signatures are sought, preferably one being that of the account holder and one of the staff member dealing with the transaction. COSHH (Care of Substances Hazardous to Health) assessments are undertaken by an independent company who also provide all cleaning products and equipment to Darley Hall. This further enhances the safety of the people living at Darley Hall. Information provided within the pre inspection questionnaire showed that only one member of staff was qualified to provide first aid. This was discussed with the acting manager and provider as there should be a qualified first aider on duty at all times. Other information within the pre inspection questionnaire relating to the Health and Safety records and process, confirmed that satisfactory measures were in place to maintain the safety and welfare of the people living at Darley Hall, the staff team and visitors to the home Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 23 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 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 24 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 OP31 Regulation 8 (1, 2) Requirement A manager must be appointed and the manager must apply for registration with CSCI. (Previous timescale of 30/8/05, 01/02/06 01/04/06 and 30/09/06 and 30/11/06 not met. Timescale extended). Care plans must be kept up to date and all areas of the care plan must be completed to ensure all areas of need and support are addressed. Risk assessments must be undertaken on any person wishing to self-administer their medication to demonstrate they have the capacity to do so. The Home must produce a programme for routine maintenance and renewal of the premises, addressing matters of decoration, furnishing and refurbishment, as detailed in the main body of the report, in a timely manner. A copy of this programme must be supplied to The Commission. DS0000019970.V337204.R01.S.doc Timescale for action 30/09/07 2. OP7 15 30/09/07 3. OP9 13 (2) 30/08/07 4. OP19 23 30/09/07 Darley Hall Version 5.2 Page 25 (Previous timescale of 31/07/06 and 31/10/06 not met) 5. OP19 23 External sitting and garden areas 30/09/07 must be made accessible and safe and tidily maintained. (Previous timescale of 31/08/06 and 30/11/06 not met). Suitably adapted bathroom/shower room facilities must be available to residents on each floor. Timescale of 31/12/06 not met. Timescale extended A person must be appointed to maintain the catering needs of the service and reduce the hours the acting manager spends on this task each day. All recruitment documents must be obtained for each member of staff as outlined in paragraph 1 to 9 of Schedule 2 A qualified first aider must be available at all times. 31/10/07 6. OP21 23 7 OP15 10 (1) 30/08/07 8 OP29 19 (4) (b) 30/08/07 9 OP38 13 (4) 23 (4) (e) 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP11 OP22 Good Practice Recommendations Individual’s wishes regarding terminal care should be recorded to ensure their wishes and spiritual needs are met. An assessment for the installation of a loop system should be made. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 26 3. OP35 Two signatures should be sought at each financial transaction that involves the monies of persons living at Darley Hall. Darley Hall DS0000019970.V337204.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V337204.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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