Inspection on 07/06/06 for Darley Hall

This inspection was carried out on 7th June 2006.

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 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 Ray Coonan Unannounced Inspection 7th June 2006 10:15 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.V293686.R01.S.doc Version 5.1 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.V293686.R01.S.doc Version 5.1 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.V293686.R01.S.doc Version 5.1 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 November 2005 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. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of six hours on the 7th June. The acting manager, Julie Bellamy, was present throughout the visit and one of the Home’s owners, David Treasure, was also present for some of this period. Most parts of the Home were seen during the inspection, including several residents’ bedrooms, and there was the opportunity to meet with many of the residents. There were also discussions with several of the Home’s staff on duty at the time. A variety of documentation was viewed including individual care plans, staff files and training records, health and safety records and other relevant policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 6 There remain several aspects of the maintenance of the premises and general environment that are below standard, with bathroom facilities in particular needing improvement. Consultation with residents requires a more structured approach. 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.V293686.R01.S.doc Version 5.1 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.V293686.R01.S.doc Version 5.1 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Insufficient assessment information was obtained prior to a resident coming to the Home. EVIDENCE: A sample of three care plans were examined during this visit, including two plans of residents recently arrived from another residential home in Derbyshire. There were inconsistencies in the amount and quality of information obtained prior to admission with one plan having a summary of needs from the previous home’s manager though on these 2 files there was no care plan or assessment information from social services due to the fact, it was explained, that there had been a change in care manager and the relevant information could not be found. The third file relating to the care needs of a Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 9 more established resident did have some pre-admission assessment information, though this had been an emergency admission and this information was limited. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had their personal and health care needs suitably assessed, planned and monitored at the Home. The individual wishes of residents were respected appropriately. EVIDENCE: Individual care plans were generally well organised and kept up to date. The manager has revived the key worker system at the Home and developed more care worker involvement in care plan maintenance whilst retaining a clear monitoring system of standards in this area. Staff spoken to showed a good level of awareness of individual resident needs and welcomed the opportunity to be more involved in the care planning process. Key workers would also attend reviews. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 11 There was evidence that the resident and /or their relatives were involved in the development of the plans and there were risk assessments routinely made in such areas as mobility, skin integrity and other aspects of personal care. These would also be reviewed regularly. Attempts were also made to obtain information on residents’ social background and their social and leisure needs/interests. The physical health of residents was further monitored and promoted with records kept of any contacts with community health services such as G.P., district nurse, chiropodist and optician. Nutritional assessments were made if relevant. Comments from residents were very positive regarding the care and attention received by staff and their attitudes were seen as friendly and supportive. Residents spoken to did not feel any sense of too many routines at the Home and indicated that their wishes as to how they spent the day were respected and that they went to bed and got up at times that were convenient to them. The Home has a specific room for the storage of medication, which is kept locked. This was suitably equipped for storing medicines including any controlled drugs. Stock levels were satisfactory and there were suitable processes for the disposal of unused medicines. Administration records were up to date. A regular system for auditing medication arrangements is in place with the pharmacist who also provides training input for those staff involved in the administration of medicines and the manager stated that she is due to attend an advanced medicine management training course later in the year. There were three residents who administered their medication. They had signed forms regarding individual responsibility for this and had secure storage facilities available. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 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 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. There were some mixed messages from residents about the frequency of activities though regular programmes are in place. Overall the Home had a relaxed atmosphere with family contact encouraged. Residents were generally happy with catering standards at the Home. EVIDENCE: A range of in house activities and entertainments are provided at the Home, such as bowls, skittles and dominoes. The ‘First Taste’ project visits the Home fortnightly and provides a variety of activities and help to arrange trips out. Some of the residents stated that they got somewhat bored at times and would like more stimulation, particularly trips out, though others did not want to get involved out of their own choice. There were one or two residents who accessed local amenities independently, but otherwise there was not a great deal of contact with the local community for the general resident group. There Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 13 was a degree of contact with local clergy. Records of sessions and participation by residents are kept. Records were kept on care plans of contact with family or friends and there were several visitors to the Home on the day of the inspection. One relative was spoken to at length and she indicated clear satisfaction with the services to her sister at the Home, felt staff were very helpful and kept her appropriately informed about the overall welfare of her relative. As stated in the previous section there was no sense of any undue emphasis on routines at the Home and efforts to consult with residents on a more meaningful basis has been made through the manager. Independent advocacy support is available and used at the Home. A few residents manage their own finances though most have assistance from relatives in this respect. Comments from residents were positive about the meals provided at the home. Menus were seen and these were generally nutritious with good variety and fresh produce used. Special diets were catered for. Residents confirmed that alternatives were available and each morning they were asked about their preferences for the day. Residents used either the small dining room or, if they wished, could have meals in their bedrooms. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from more structured systems for the recording of complaints and a more rigorous approach to the training of staff in the protection of vulnerable adults. EVIDENCE: The Home has a satisfactory complaints policy contained in their brochure, which was displayed in the entrance hall. It was noted that on one individual care file there was a copy of a recent letter of complaint from the relative of a resident. The manager stated the matter had been looked at and a return letter sent to the complainant though a copy of this was not available and there was no entry in the Home’s complaints book. The Home has relevant policies regarding abuse and protection and some information on local procedures is given to staff. Discussions with staff indicated that there were varying degrees of awareness of these issues and a lack of any recent training, with some staff not having received any specific input. The manager stated that she is booked to attend a two day course in September on the protection of vulnerable adults. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 21, 22, 23, 24 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There was no structured approach to the maintenance of the home and residents’ interests and welfare was not enhanced through a shortfall of fully suitable bathroom facilities and lack of accessibility to sitting and garden areas. EVIDENCE: Several matters have been addressed since the last inspection. Window restrictors have been fitted, lockable storage space in the form of small individual safes, has been provided in each bedroom and the laundry floor surface has been made good. It was stated that an assessment concerning the shower facility on the top floor indicated that this could not be suitably upgraded and that a whole new conversion is required. The owner has indicated that his preferred option would be to convert the existing bathroom on this floor, which is not used, into a new shower room. It was noted that the majority of residents on the first and top floors have to come down to use the bathroom on the ground floor, the first floor bathroom not having any Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 16 adaptations such as hoist facilities. It was also noted that individual bars of soap were being left in bathroom areas. There were several aspects of ongoing maintenance around the premises to be dealt with though there was not a clear works programme established in this respect. There were several areas that required attention to plasterwork and paintwork such as the ground floor bathroom and Room 4. There were also several matters of refurbishment such as replacing old worn chairs in lounge areas. The carpet in the small lounge was worn and thin and carpeting throughout the Home was in need of review. A sample of bedrooms were viewed and these were well personalised by residents, Furnishing here were generally satisfactory though again carpeting of these areas needed reviewing, for example bedroom 17. The Home has extensive grounds though these were not readily accessible. One wheelchair resident could not get out of the front door to sit with other residents as the ramp facility was not the right size and the exit from the lounge was not ramped. Those residents sitting outside the front had their space cramped by cars parking right up to the front door. A large pile of discarded rubbish including old chairs, mattresses as well as garden waste dominated the grounds to the side of the Home. The Home was generally clean though it was noted that there is not a fulltime cleaner. The laundry area was satisfactorily equipped and maintained though some negative comments were made by some residents regarding the maintenance and ironing of their clothes and this matter had been raised as a formal complaint by a relative. The Home has sluicing facilities though these need to be kept locked when not in use. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 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 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are benefiting from a more systematic approach to staff development, though some aspects of recruitment processes could be better organised. EVIDENCE: Staffing rotas were seen and showed that suitable staffing levels were being maintained. It was noted that several staff were working long daily shifts on a regular basis. A sample of staff files was seen during this visit, relating to two staff employed in the past four months. Staff recruitment procedures were in place though on one file only one written reference had been obtained. Criminal Record checks had been completed. Staff files were somewhat disorganised and there was no evidence of induction programmes though the manager stated that she is now planning to use the ‘Skills for Care’ programme and initiating this with recently employed staff in the near future. From discussions with staff and examination of records/programmes it is clear that the manager has started to develop a more systematic approach to staff development at the Home. Staff spoken to felt this had improved in the past six months and NVQ training was well promoted with some staff now starting Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 18 Level 3 courses. The manager is identifying needs with individual staff and looking to arrange regular input and refresher courses in the mandatory care training. Several staff had attended training in challenging behaviour recently. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are benefiting from an improved and more purposeful approach to the running of the Home though a more structured approach to monitoring the quality of services has yet to be developed. EVIDENCE: The current acting manager has substantial practice experience and has been managing the Home for about six months, though a formal registration application has not been sent to the Commission yet. However, it is understood that this will be forthcoming and she has recently started on NVQ level 4 training in care and management. Discussions with staff indicated that they felt appropriately supported and they confirmed that they received regular supervision time and appraisal. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 20 There were no formal quality assurance processes in place though the manager indicated that she intended to set up more frequent staff and resident meetings and was also developing a system of questionnaires to use with residents and/or relatives. Arrangements for the safekeeping of residents’ monies were secure and appropriate records of any financial transactions were in place. Health and Safety records and processes were examined at the last inspection visit to the Home in February and were satisfactory. The outstanding issues relating the checking of fire safety equipment and the alarm call system have now been dealt with and relevant certification was seen. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 1 2 3 2 X 2 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 1 X 3 3 X 3 Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 22 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 OP3 Regulation 14 (a) Requirement The Home must obtain full assessment information on all prospective residents prior to admission. The Home must ensure that complete records are kept of any complaints and subsequent responses. Timescale for action 31/07/06 2. OP16 22 31/07/06 3. 4. OP18 OP19 13 (6) 23 5. 6. OP19 OP21 23 23 All staff must have specific training in the protection of vulnerable adults 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. External sitting and garden areas must be made accessible and safe and tidily maintained. Suitably adapted bathroom/shower room facilities DS0000019970.V293686.R01.S.doc 30/09/06 31/07/06 31/08/06 31/10/06 Darley Hall Version 5.1 Page 23 7. OP29 19 8. OP30 18 9. OP31 8 (1, 2) must be available to residents on each floor. Staff files must be more organised and 2 written references must be obtained on all new staff. Staff must receive suitable induction training and appropriate records must be kept. A manager must be appointed and the manager must apply for registration with CSCI. Previous timescale of 30/8/05, 01/02/06 and01/04/06 not met. Timescale extended. As part of quality assurance programmes feedback must be actively sought from residents and relatives about the services provided e.g. by anonymous surveys. 31/07/06 31/08/06 30/09/06 10. OP33 24 30/09/06 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 OP22 OP33 Good Practice Recommendations The range of activities and recreational opportunities should be kept under review. An assessment for the installation of a loop system should be made. The manager should establish regular resident meetings. Darley Hall DS0000019970.V293686.R01.S.doc Version 5.1 Page 24 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. 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