Inspection on 28/08/07 for Darnall View

This inspection was carried out on 28th August 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

Darnall View 19/09/06

Darnall View 15/12/05

Darnall View 01/09/05

Darnall View 07/09/04

Darnall View 22/06/04

Similar services:

Elmleigh Convent

Eastfield Farm Residential Home Limited

Cranwell Court Care Home

Fairview

Cottingham Hall

Cranmer Scheme

Fairburn Mews

Claremont House

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

CARE HOMES FOR OLDER PEOPLE Darnall View 37 Halsall Avenue Darnall Sheffield South Yorkshire S9 4JA Lead Inspector Susan Vardaxi Key Unannounced Inspection 28th August 2007 08:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Darnall View DS0000002954.V337544.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. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Darnall View Address 37 Halsall Avenue Darnall Sheffield South Yorkshire S9 4JA 0114 243 3323 0114 243 3323 none 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) Fisherbell Limited Vacant Care Home 23 Category(ies) of Dementia - over 65 years of age (23) registration, with number of places Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may admit persons between the age of 60 and 65 years of age. 15th December 2005 Date of last inspection Brief Description of the Service: The home is situated in the Darnall area of the city and provides care for twenty-three people over the age of 65 years who may have dementia. Accommodation is provided on two floors and including lounges, toilets and bathrooms, the dining area located on the ground floor provides a pleasant environment for people to eat their meals. There is some car parking space in the grounds. An activities person is employed to encourage people to maintain skills, hobbies and interests and a raised garden area to the rear of the home provides opportunities for people living at the home to grow their own produce. The weekly fees for the service in August 2007 are £345. Hairdressing, newspapers and private chiropody are not included The owners make people aware of the service in the service user guide, advertising and when enquiries are made. The role of the Commission is included in the service user guide. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place on the 28th August 2007 commencing at 8:45am over seven hours. The visit included talks with some people who live at the home, three visitors, four staff on duty, the cook and the owners. Some records were checked, practice was observed and a walk round the premises completed. Five comment cards were sent to people who live at the home, five to relatives, and one to health professionals seeking their views of the service. One was received from people living at the home, five from relatives and one from a GP who were generally satisfied with the care provided. The owner provided information in respect of the service prior to the visit. A random visit was made to the home in November 2006 when a complaint was made in respect of the service and requirements for improvements made had been dealt with at this visit. Two safeguarding incidents have occurred since the last visit, which were referred for investigation under the local authority’s multi agency safeguarding procedures; one is currently being progressed through care management procedures. The owners were present throughout the visit; they have assumed temporary joint management of the home in the manager’s absence. What the service does well: The home is cleaned, decorated and maintained to a high standard. Comments made by a relative on a survey received included “ The home is spotlessly clean. People looked comfortable and relaxed, the interaction between them and staff was good, staff were polite and respected people’s dignity. Generally positive comments regarding the staff were made on the survey forms received, relatives spoken with at the visit said they were satisfied with the care provided. A health professional’s comments received by the Commission stated “ the owners invest a great deal of time into the care and knowledge of residents”. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 6 A relatives comment includes “Staff are excellent, they go out of their way” “Very satisfied with care, people are treated with respect. People are treated as individuals.” The meal provided on the day of the visit was cooked and presented to a high standard and people were assisted appropriately. The home employs a laundry assistant, people’s clothing; bed linen and towels had been laundered to a high standard. What has improved since the last inspection? 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. Darnall View DS0000002954.V337544.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 Darnall View DS0000002954.V337544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The admission arrangements ensure that people’s needs be met. Intermediate care is not provided at the home. EVIDENCE: The owners said that they have revised the statement of purpose and service user to include that on completion of the extension to the existing building the home can provide care for 23 people. A copy was not available to check at the visit, the owners said they had sent a copy to the Commission, however when checked this had not been received, the owners said they would send a further copy to the Commission. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 9 Records seen showed that admission assessments had been completed prior to people being admitted to the home. The home does not provide intermediate care. Darnall View DS0000002954.V337544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Care plans are designed to meet peoples assessed needs and includes the action needed by staff to ensure people’s needs would be met appropriately. Health care arrangements ensure people are supported appropriately. EVIDENCE: Care plans and risk assessments seen had been completed appropriately and included the action needed by staff to ensure people’s needs are identified and met appropriately. A care plan seen showed that a relative and been involved in the care planning. A care plan was needed for people who had demonstrated aggressive behaviour to ensure staff knew the action to take to prevent situations arising or to deal with aggressive situations should they occur; the owner said it would be completed on the day of the visit. Records of health professionals visits included, GPs, district nurses, community mental health nurses and chiropodists. Comments on a survey made by a Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 11 health professional included “Care plans reflect the care that should be given” and “the owners invest a great deal of time into the care and knowledge of residents”. Nutritional assessments had been completed and records of people’s weights kept so that concerns i.e. weight loss/gain could be monitored and appropriate action taken if necessary. A person was seen on permanent bed rest, their care plan was appropriate to their needs, pressure-relieving equipment had been provided and the owners and relative spoken with said that pressure areas were intact. They looked clean and said they were comfortable, low music was playing in the room, a very pleasant environment had been provided. Fluid intake and turning charts were seen in the person’s room and had been completed by staff. The owners said they check the monitoring charts to ensure a continuity of care is being provided as needed. An owner said that a nutritionist had been contacted for advice to ensure the person receives an adequate diet. Comments received from two relatives included “Staff are always on hand “Staff are excellent they go out of their way” “ their relative is being well looked after, has peace of mind”. “Care after being in hospital is excellent”. Some medications and medication records where checked, generally records had been well maintained, some areas for improvements were observed which the owners said would be addressed immediately: Hand written entries on the medication records had not always been signed and countersigned by staff to confirm the details are correct. Pharmacy labels had been stuck on the medication records, which could become loose and transfer onto other sheets. An aperient prescribed to be given two tablets daily had been given once daily, the owners said that due to the person’s condition two tablets were not needed. Since the visit the owners have said that they have liaised with the GP who has agreed the change in the prescription for the aperient and the owners have arranged for staff to be trained in respect of the issues raised at this visit. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 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. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are encouraged to join in the social activities provided and retain links with relatives and friends. EVIDENCE: Staff were seen to be busy assisting people to get up when the visit commenced at 8.45am. Eleven people were seen sitting in the lounge waiting for breakfast to be served. The people looked relaxed and comfortable and their personal hygiene needs had been met. The people’s preferred times of rising and going to bed had been recorded, a person spoken with said they got up when they wanted to, they liked to get up early. The owners said an experienced activities person has been employed since the last visit who encourages people to join in social events daily. A visitor was seen having a game of dominos with their relative and two other people in morning and a member of staff was seen giving some people a manicure. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 13 Information provided by the owners prior to the visit shows that board games are encouraged and reminiscence sessions, outings and a summer fayre have occurred. Two of the five relatives’ surveys received felt that there should be more activities. A raised garden feature is currently being built behind the home and people will be able to grow vegetables or flowers. The owners said that the representatives from some religious denominations visit the home and advocates represent some people. A menu is available and choices of meals are provided. The people were joined in the dining room for lunch, a choice of lamb hotpot or fish cakes and chips was served, and pudding was bananas and custard or pineapple upside-down cake and custard. The meals were cooked and presented to a high standard. Table settings included tablemats, cruet sets and other condiments encouraging independence, people were observed offering assistance or verbal encouragement was given as needed. The owners said all “meat and vegetables are fresh and there are no budget restrictions for purchasing food, whatever people want they can have”. The cook confirmed this; she has relevant qualifications including a trainer’s qualification. The owners said that the local council has awarded them the local authority’s 5 stars rating for food hygiene; the certificate is displayed in the dining room. The interaction between staff and people living at the home was seen to be good; people were spoken to respectfully and offered assistance appropriately. Comments made on surveys by two relatives included “people are treated as individuals”. Comments made on the survey form by a health professional stated “Care staff attend to privacy and dignity taking into consideration the needs and safety of others” Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 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. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are protected by the homes complaints and safeguarding policies. EVIDENCE: A visitor spoken with said they would be able to make a complaint if needed and that it would be dealt with and not “swept under the carpet”. Two complaints had been made to the Commission since the last visit, a random visit had occurred as a result of the issues in one complaint and requirements were made for improvements in the service, it was observed that generally some improvements had been made at this visit. The second complaint was passed to the provider for investigation under the homes complaints procedures. The complaints book was seen and the action taken to investigate complaints and outcomes had been recorded. Two safeguarding incidents have occurred at the home, which were referred for investigation under the local authority’s multi agency safeguarding procedures. One involved a member of staff who was dismissed and their name referred to the Protection of Vulnerable Adults from Abuse (POVA list). Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 15 The second incident involving two people living at the home was being progressed through care management procedures at the time of this visit. Two ancillary staff members spoken with said they knew there was a whistle blowing policy, they were not sure of the content of the policy however knew that it related to reporting incidences of abuse. One member of ancillary staff was not sure if they had had adult protection training however was able to identify some forms of abuse. This was discussed with the owners who said training is being provided and would include ancillary staff. A senior carer spoken with said they had attended safeguarding training and this was recorded in records seen. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 16 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, 24, 25 and 26. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is cleaned to a high standard, well decorated and maintained and provides a pleasant environment for people to live in. EVIDENCE: The owners are arranging for a raised garden, patio and lawned area to be built at the rear of the home, which will be locked to protect people who would be at risk if they wandered onto the road. The areas of the home seen were cleaned, furnished and decorated to a good standard. All bedrooms were personalised with family photos, some had taken ornaments into the home. The fabrics and furnishings throughout the home are of a good standard and dining and lounge chairs appropriate for older people to sit in and get up from easily helping to retain independence with their mobility. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 17 A comment made on a survey completed by a relative stated, “ The home is spotlessly clean”. A person spoken with said they have a key to their bedroom ensuring their privacy is respected. A headboard made of fabric material had been provided following a risk assessment completed to ensure a person living at the home could not injure them self. People’s clothing, bed linen and towels seen had been laundered to a high standard, the home uses a special laundry cleaning system that the owners said staff are trained to use, certificates were displayed in the laundry to confirm this. The home employs a laundry assistant. All areas in the home were bright, fresh and very clean and tidy. There is no hand basin in the staff toilet; the owners said they would arrange for one to be fitted as soon as possible ensuring correct hygiene procedures be followed to prevent cross infection occurring. It was seen during a walk round the home that not all areas had signage displayed required at previous visits. This was discussed with the owners who said there had been difficulties in achieving this as people removed the signage from doors, an alternative was discussed which the owner said would be arranged as soon as possible so people could find their way around the home independently. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 18 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 and 30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staffing levels are satisfactory and training is being provided appropriate to peoples needs to ensure staff have the skills and knowledge to ensure needs would be met appropriately. EVIDENCE: The owners said they work in the home during the day and since the last visit have change the staffing levels to provide 4 carers including a senior carer in the morning and a laundry assistant, 3 carers and an activities person are on duty in the afternoon and evening and 2 carers at night. Carers working in the afternoon serve the evening meal; however, the cook said she prepares everything that is needed before she leaves the home. A member of care staff spoken with said the “home is busy and people can become restless in the afternoon and some people are bathed in the afternoon and felt that sometimes staffing levels were not always sufficient to meet needs. A person living at the home is currently being cared for who is on permanent bed rest requiring more that one member of staff to assist and another person who constantly wanders around the home needs supervising which can affect the number of staff needed to ensure needs are met and they are safe. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 19 Staffing levels were discussed with the owners who said they would keep staffing levels under review. Some staff files were seen and recruitment checks had been completed, there were some employment gaps on two records seen. The owners said this had occurred before they had taken over the temporary management of the home during the manager’s absence, the owners were able to check the absences at this visit as the staff concerned were on duty. Staff photographs were seen on the files checked which was required at the last visit. CRB checks had been completed prior to staff starting work and satisfactory references obtained ensuring people are protected. Staff training records seen showed that induction training had occurred. Mandatory training, dementia, falls awareness, safeguarding, medication, care planning had occurred since January 2007 and the owners are looking into training in respect of challenging behaviour. The owners said 2 carers have NVQ level 4, 5 carers have Level 3 and 4 carers have level 2 and 5 staff have been registered for levels 2 and 3 in care. An owner said they have achieved the NVQ D32 and D33 NVQ assessor’s awards. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 20 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 and 38. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The temporary arrangements for managing the home are satisfactory. EVIDENCE: The manager was not at the home at the time of the visit the owners are managing the home in his absence. The owners said they send out surveys quarterly to people’s relatives; one of the owners said the survey forms are currently under review to ensure the information received will provide a base which will ensure any shortfalls are identified and the service be improved if needed. The owners said staff Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 21 meetings are held approximately 3 monthly and relatives meetings are held annually. Records of the meetings held were not requested at this visit. Some people’s records and cash in people’s funds held on by the home were checked and found to be accurate. The Commission has received regulation 37 notifications, required at the last visit. The health and safety arrangements observed around the home were satisfactory to ensure people were safe, health and safety training had been provided. A hand basin is needed in the staff toilet, which has been addressed in standards 19-26 of the report. Some fire system checks were seen, fire drills had been held in January and July 2007 and some people living at the home had joined in. There were no records of running hot water temperatures, the owners said checks are completed and he will record them in future. The owner said he is liaising with the fire officer to ensure that a person whose door is locked is not at risk in the event of a fire occurring. Records of some accidents that had occurred had been recorded appropriately. . Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 22 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 3 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 3 X 3 X 3 X X 3 Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP19 Good Practice Recommendations Signs should be placed on doors as appropriate to the needs of the service users. Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Darnall View DS0000002954.V337544.R01.S.doc Version 5.2 Page 25 - 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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