Inspection on 25/11/05 for Darna House

This inspection was carried out on 25th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 21/03/06

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 25th November 2005 12:30 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.V262759.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. Darna House DS0000006707.V262759.R01.S.doc Version 5.0 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.V262759.R01.S.doc Version 5.0 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. 3rd February 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. The home is close to Altrincham town centre. There is a large garden with a wheelchair access via a wheelchair lift at the rear of the building. The accommodation is provided in single and double bedrooms. There is easy access to public transport, the motorway, local shops and parks. Darna House DS0000006707.V262759.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and it took place on the 25 November 2005. There were 16 residents accommodated at the time of the inspection visit. During the inspection time was spent speaking to the nurse in charge of the shift, the carers, residents and their relatives. The manager was off sick on the day of the inspection, however the registered provider was spoken to on the telephone during the inspection. Direct observations were made as to how the staff cared for and supported the residents. Examination of staff and residents records were carried out. Other records kept at the home were also looked at. Full insight into the care being provided to the residents at Darna House would be gained when this report is read together with previous reports, as the Commission for Social Care Inspection did not look at all the standards during this inspection. What the service does well: What has improved since the last inspection? What they could do better: The home could do better by ensuring that prospective residents are fully assessed before an offer of a place is confirmed. The care plans could be better if they are detailed and reviewed on a regular basis. The welfare of the residents could be more protected and promoted by ensuring that the risk assessments are detailed and fully completed. The medication procedure must be improved. The home could organise more leisure activities and social events. The home needed a new menu to include 3 Darna House DS0000006707.V262759.R01.S.doc Version 5.0 Page 6 full meals each day. The complaints procedure must include the telephone numbers of the Commission and the other significant agencies. All the staff should be aware where the policies and procedures are kept and learn more about adult protection. The home must ensure that records kept at the home are available for inspection at all times. 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.V262759.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 Darna House DS0000006707.V262759.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): 1, 3, 6. Not all prospective residents were assessed before an offer of a place was confirmed. Prospective residents were given the necessary information about the home to help them make a decision whether to use its service. EVIDENCE: There was a Service User Guide and a Statement of Purpose in place. Although the Statement of Purpose states that all prospective residents are assessed before an offer of a place was confirmed there was no evidence to indicate that this was being carried out. The home must ensure that pre assessments of prospective residents’ needs are carried out before an offer of a place is confirmed. Prospective residents were given the Statement of Purpose and also the service user guide. Residents were able to ‘test drive’ the home and meet the other residents to help them make a decision whether to use the service of Darna House. The home did not provide intermediate care. Darna House DS0000006707.V262759.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, 8, 9. The social and health care needs of the residents were recorded in the care plans, which allowed the staff to meet the needs of the residents. The medication policy and procedures were appropriate to meet the needs of the residents however they were not being carried out. EVIDENCE: The sample of the care plans examined contained risk assessments such as pressure sore risk assessment, nutritional risk assessment, and risk of falling. However, some of the risk assessments for managing falls were not fully completed. The care plans must be reviewed and updated. Care plans should be put in place for dealing with challenging situations. The daily records of the residents were not detailed or linked to individual care plans. The medication policy and procedures could not be located at the time of the inspection, however previous inspections indicated that there were procedures and policies in place. A copy of the Safe Disposal of Waste Medicines from Darna House DS0000006707.V262759.R01.S.doc Version 5.0 Page 10 Care Homes issued by the Commission for Social Care Inspection was available but had not been implemented. The home must implement the new policy. Poor medication practice was observed during the inspection and an immediate requirement was issued. The member of staff administering the medicines was taking pots to the residents, not named, and popped from the blister packs. None of the residents managed their own medication. Darna House DS0000006707.V262759.R01.S.doc Version 5.0 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, 13, 14, 15. The home continues to support the residents to maintain contact with their relatives, friends and representatives. Residents’ individual lifestyles were not being met. The home was not providing adequate meals. EVIDENCE: Relatives and friends of the residents are able to visit at anytime. There were evidence of relatives and friends visiting on a regular basis. There were very little leisure activities being organised by the home. One resident when asked what leisure activities she participated in said, “I sit here and watch the other residents sleeping, that is my leisure activity”. She continued, “ We do jigsaws from time to time. I dread the weekends because they are very quite, boring, and no one to talk to”. The home must have a planned activities programme and ensure that the residents are physically and mentally stimulated. The meals being provided were found to be inadequate. On the day of the inspection jam and bread, crumpets, or pate on toast were being offered at teatime. An immediate requirement was issued regarding the meals being offered at the home. A new menu has been put in place since the inspection visit. Darna House DS0000006707.V262759.R01.S.doc Version 5.0 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): 16, 18. Policies and procedures for managing complaints were in place. There are systems and arrangements in place to protect the wellbeing of the residents. EVIDENCE: There were procedures in place for dealing with complaints however they needed reviewing to include the telephone numbers of the Commission for Social Care Inspection and the other agencies. This is to enable the residents and their relatives to make complaints using the telephone. The complaints book could not be located at the time of the inspection. The complaints procedure was displayed at a prominent area. The Commission for Social Care Inspection had not received any complaints about the home since the last inspection. The home had policies and procedures for dealing with the Protection of Vulnerable Adults (POVA) however this could not be located during the inspection. The nurse in charge of the shift and a carer did not know where they were. POVA training was required as some of the staff were not sure how to deal with an allegation of abuse. Darna House DS0000006707.V262759.R01.S.doc Version 5.0 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): 19, 26. The environment appeared safe and well maintained. The home was clean and well decorated. EVIDENCE: The home was nicely decorated and the bedrooms were personalised. One of the windows did not have a restriction in place and an immediate requirement was issued. One of the residents did not have a bumper on her bedrail. All bedrails should have a bumper to protect the residents. The house and the grounds were kept clean and tidy. Darna House DS0000006707.V262759.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): 27, 28, 29, 30. The home’s recruitment policies and procedures supported and protected the residents. EVIDENCE: The needs of the residents accommodated at the home were met by adequate number and skill mix of staff. There was a roster available that detailed all persons working at the home. The person in charge at the time of the inspection visit said that there were CRB checks in place before prospective staff started working at the home. There was a training programme in place and the person in charge stated that staff had been trained in fire prevention and the safe moving and handling of residents. Staff files detailing information about each person could not be located at the time of the inspection. Darna House DS0000006707.V262759.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): 37, 38. It was not possible to make a judgement on these outcomes. EVIDENCE: The majority of the home’s records, policies and procedures could not be located during the inspection. It is important for the home to make sure that all policies and procedures are available and easily accessible to staff and residents. They must also be available for inspection at all times. The home appeared well maintained. Fire equipment checks were carried out on a regular basis but there was no evidence of routine checks on fire alarms, emergency lighting and fire exits. The person in charge also said that health and safety policies were in place however they could not be located on the day of the inspection. Darna House DS0000006707.V262759.R01.S.doc Version 5.0 Page 16 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 2 Darna House DS0000006707.V262759.R01.S.doc Version 5.0 Page 17 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 Requirement The registered person must ensure that prospective residents are fully assessed before they are admitted. The registered person must ensure that the health and personal needs of the residents are set out in the care plans. Strategies for dealing with challenging behaviours must be included in the care plans. The registered person must ensure that unnecessary risks to the health and safety of the residents are identified and so far as possible eliminated. Risk assessments must be completed in full. The registered person must make arrangements for the safe administering and disposal of medicines received into the care home. The registered provider must consult residents and provide activities and facilities for recreation. The registered person must provide adequate quantities of wholesome and nutritious food. DS0000006707.V262759.R01.S.doc Timescale for action 20/12/05 2 OP7 15 15/01/06 3 OP8 13 15/01/06 4 OP9 13 05/12/05 5 OP12 16 15/01/06 6 OP15 16 05/12/05 Darna House Version 5.0 Page 18 7 OP16 22 8 OP18 15 9 OP19 13 10 OP37OP38 17 The registered manager must ensure that the complaints procedure includes the name, address and telephone number of the Commission. The registered provider must make arrangements by training staff to prevent residents from being harmed or abused. The registered provider must ensure that all parts of the home that the residents have access to are free from hazards to their safety. The registered person must ensure that records required to be kept at the home are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. 15/01/06 28/02/06 01/12/05 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Darna House DS0000006707.V262759.R01.S.doc Version 5.0 Page 19 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.V262759.R01.S.doc Version 5.0 Page 20 - 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!