Inspection on 21/03/06 for Darna House

This inspection was carried out on 21st March 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Darna House 23/08/07

Darna House 24/05/06

Darna House 25/11/05

Darna House 03/02/05

Darna House 03/11/04

Darna House 23/03/04

Darna House 02/12/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Darna House Groby Road Altrincham Cheshire WA14 2BQ Lead Inspector Elizabeth Holt Unannounced Inspection 21st March 2006 1:00 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 Darna House DS0000006707.V275650.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. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Darna House Address Groby Road Altrincham Cheshire WA14 2BQ 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) 0161 928 4342 0161 929 1914 Mr Simon Porritt Tracy Lynn Lidster Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users shall be aged 60 years or over and require nursing care. Staffing levels as specified in the Notice issued under Section 25(3) of the Registered Homes Act and dated 2nd May 2000 shall be maintained. 25th November 2005 Date of last inspection Brief Description of the Service: Darna House is a care home providing nursing care and accommodation for 20 residents. The home is a detached Victorian house situated on a tree-lined road in Altrincham. Bedrooms are on three floors with access to these by stair lifts. Accommodation is provided in both double and single bedrooms. The home is in close proximity to Altrincham town centre. The grounds include a large garden area. There is ease of access to public transport, the motorway, local shops and parks. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 21st March 2006. During the inspection time was spent talking to the registered manager, several of the residents and some members of staff. In addition residents files, records and other relevant documentation were examined. Since the last inspection the CSCI has not received any complaints about the service. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well: What has improved since the last inspection? Following the last inspection the home had redeveloped the medication policy, arranged medication training and were looking at ways to change the system for the administration of medication in the home. Since the last inspection the home has developed a new system for the care planning documentation. This has not yet been implemented however the manager hopes to start this new system within the next weeks. Residents and a visitor to the home spoke positively about the staff team and how “kind and considerate” they are. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 6 The home had reviewed their menu since the last inspection and introduced a new, more varied one. 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. Darna House DS0000006707.V275650.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 Darna House DS0000006707.V275650.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 Prospective residents were assessed before an offer of a place was confirmed, however not having the information available at the home may potentially put residents at risk. EVIDENCE: The manager confirmed that she carried out an assessment of needs of the individual residents. The manager explained that due to the layout of the building she was particularly selective to ensure the resident’s needs could be met by the home. The format for the resident’s needs assessment was examined and a discussion highlighted that this form should have scope for the provision of more detailed information. It was disappointing to see that the information for a newly admitted resident referred through Care Management arrangements was not available at the time of inspection. This information must be available prior to a new resident being admitted to the home to inform the care plan. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 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 10 The care planning documentation and risk assessments require improving to ensure all the residents’ health, personal and social care needs are fully met. Residents were treated as individuals who had their privacy respected. EVIDENCE: Two care files were examined at this inspection. There was no evidence that these files were drawn up with the involvement of the resident or their representative. A number of nursing problems had been developed in the care plan for a resident who had been in the home for one week only and information gathered pre admission had been included. Following a requirement made at the last inspection in relation to improvements required in the care planning it was pleasing to see that the manager had devised new documentation for the risk assessments and care plans. These had not yet been implemented. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 10 One resident requires a risk assessment in relation to there being no window restrictor on the bedroom window in this room. This was discussed with the manager at the time of the inspection. Following the requirement made at the last inspection for arrangements to be made for the safe administering and disposal of medicines received into the home. The manager had arranged for staff training to be held in April 2006 and had introduced a new medication policy and procedure. A new drugs trolley is on order to assist in the practical aspect of administering the medication in a home, which is on three floors. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 11 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 and 15. Since the last inspection improvements have been made to the range of activities available for residents and to the food provided. EVIDENCE: As required at the last inspection a new programme of activities had been organised. This included plans for an entertainer, buffet tea, farm lunch and a cheese and wine evening for example. The manager stated that other “impromptu” activities and discussions do take place including bingo games. The new care planning documentation includes a section on individual’s likes and dislikes and their lifestyle history. A discussion highlighted that this information, including activities an individual has participated in must be recorded in, their plan of care. Following the immediate requirement made at the last inspection a new, varied menu had been introduced. Residents spoken to during the inspection were complimentary regarding the food provided and one said; ”I am never hungry here, the food is tasty.” Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 12 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): These standards were not assessed at this inspection. EVIDENCE: As required at the last inspection the complaint procedure has been updated to include the name, address and telephone number of the Commission for Social Care. Following the requirement made at the last inspection for staff to training in the Protection of Vulnerable Adults, including the actions to be taken in the event of an allegation of abuse it was pleasing to see this training had been booked for the 28th March 2006. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 13 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): 26 The environment continues to be clean and pleasant. Some minor decoration was required to one bedroom. EVIDENCE: The tour of the home showed the bedrooms to be personalised and the home was clean. The manager stated that an ongoing programme of decoration was in place however bedroom 5 required repainting/papering. The inspector commented that this room may benefit from a mirror at the sink, as there were no mirrors in this room at all. The broken cord from the sash window in bedroom 6 must be mended. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 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): 30 Staff have access to training and learning they require in order to carry out their job competently. EVIDENCE: At the time of this inspection half of the staff had successfully completed NVQ level 2. One staff member was interested in commencing NVQ level 2. The home had accessed the new induction standards for all social care services and workers and planned to implement this induction programme when a new person starts. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 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, 33, 35 37 and 38 The manager is able to fully discharge her responsibilities fully and the home is run in the interest of the residents. The lack of weekly fire alarm tests and provider reports does not fully safeguard service users’ safety and best interests. EVIDENCE: The manager of the home fully understands her responsibilities; she is currently undertaking her NVQ level 4 qualification and hopes to complete this by December 2006. The manager was approachable and clearly knew the residents well. Darna House has yet to commence a full quality assurance monitoring system, which seeks the views of residents, relatives, staff and professionals regarding the service provision, and upon conclusion produces a report of the outcomes. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 16 A questionnaire has been developed however this had not been sent out to service users and /or relatives at the time of this inspection. One regular visitor to the home commented that she always found her friend to be happy and generally content with life in the home. Minutes of formal staff meetings were not available however the manager stated that issues were discussed with staff members following handovers. A recommendation has been made that formal staff meetings and minutes of these are held and recorded. The home owner visits the home approximately once a week. In line with the requirement under regulation 26 the registered provider should make an unannounced visit once a month and prepare a written report on the conduct of the care home. This visit should include interviewing some of the service users, their representatives, and staff working at the home in order to form an opinion of the standard of care provided in the home. The home does not hold personal allowances for individual residents however small amounts of pocket monies were held as necessary. A format for the formal supervision of the care staff was being developed but not yet implemented. Staff must receive regular formal supervision with the recommended frequency being 6 times a year. This should include: All aspects of practice Philosophy of care in the home Career development needs. Fire alarm system checks were generally carried out weekly, however the records showed this check had not been done since the 21.02.06. This must be addressed to ensure the system is working effectively. A fire lecture had been carried out by Greater Manchester fire within the last 12 months. Darna House DS0000006707.V275650.R01.S.doc Version 5.1 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X 2 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 2 Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? NO 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(1)(b) Requirement The registered person must obtain a copy of the full assessment of the service user prior to them being admitted to the home. Where possible the service user’s plan must be drawn up with the involvement of the service user, or representative. The décor to bedroom 5 requires renewing and the broken sash cord from the window in bedroom 6 must be removed. A full review of the sash windows should be carried out. Care staff must receive formal supervision, and this should be at least six times per year. Testing of the fire alarm must be carried out weekly. The registered person must provide a written report on a monthly basis to the Commission on the conduct of the care home. Timescale for action 18/04/06 2 OP7 15(1) 30/04/06 3 OP19 23(2) 05/05/06 4 5 6 OP18 OP38 OP38 18(2) 23(4)c(v) 26 19/05/06 10/04/06 30/05/06 Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Darna House DS0000006707.V275650.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!