Inspection on 13/06/05 for Darsdale

This inspection was carried out on 13th June 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

Darsdale 12/02/09

Darsdale 06/09/06

Darsdale 22/11/05

Darsdale 03/03/05

Darsdale 17/08/04

Darsdale 16/03/04

Similar services:

Applegarth

Thornham Grove

Hunter`s Lodge

Conifer Lodge

Manor Court

92 Black Prince Avenue

Agnes House

The Manor House

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

CARE HOMES FOR OLDER PEOPLE Darsdale Chelveston Road Raunds Northants NN9 6DA Lead Inspector Kathy Jones Unannounced 13 June 2005 @ 17:00 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 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. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Darsdale Address Chelveston Road Raunds Northants NN9 6DA 01933 622457 01933 389399 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Northamptonshire Association for The Blind Mrs Valerie Grant Care Home Only (PC) 30 Category(ies) of Sensory Impairment -Over 65 (SI(E)) 30 registration, with number of places Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user identified in a letter dated 16th June 2004 (subject of variation application Number V000014542) with a sensory impairment and under the age of 65 years of age may be accommodated in the home. Date of last inspection 03/03/05 Brief Description of the Service: Darsdale is a residential care home providing personal care for 30 older people over the age of 65 years. The home is registered for service users who have been diagnosed with a sensory impairment. Darsdal is owned by Northamptonshire Association for the Blind which is a charitable organisation. The home is set in large and pleasant grounds on the outskirts of the small town of Raunds. There are bedrooms on both the ground and first floors of the building. A lift provides access to the first floor bedrooms. All Residents have accommodation provided in single rooms and twenty four of the rooms have en-suite toilets. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried during the evening of a weekday. The inspection involved review of records relating to the assessment and planning of care needs. Discussions with three Residents and observations of the daily routines and care provided were made. The Inspector also met with the Senior Carer on duty to discuss care provided. Discussions with other Staff were limited due to them being busy with the evening routine in meeting the needs of Residents. No comment cards were received from Residents prior to this inspection. Inspector’s conversations with Residents and observations confirmed that they wouldn’t be able to complete the comment cards independently due to their sensory impairment. One comment card was received from a relative/visitors prior to the inspection and the Inspector had a telephone conversation with a relative. A pre-inspection questionnaire was submitted, which provided the Inspector with some additional information to inform the inspection. As the Manager was not on duty at the time of this inspection the Inspector telephoned her following the inspection to discuss issues identified during the inspection and also to clarify and confirm information in the pre-inspection questionnaire. What the service does well: Staff were observed to be respectful of Residents privacy and dignity throughout the inspection and to have a good relationship with Residents. During the inspection Staff were observed to be to be engaging in some friendly and light hearted conversations with Residents. Appropriate and swift action was taken to protect Residents following concerns raised and referral made through adult protection procedures. Over half of the Staff team have now achieved a National Vocational Qualification (NVQ) at level 2 and the Deputy Manager has achieved NVQ 4. Regular monthly unannounced visits are carried out by members of the committee. Copies of these reports are forwarded to the Commission for Social Care inspection and appear to be a very open account of the visit. The reports show that standards of care are discussed with Residents and Staff which provides the committee responsible with a good overview of Residents views. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 6 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. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 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 standard(s) 3, Standard 6 is not applicable as the home does not provide intermediate care. The assessment process provides assurances that the needs of people admitted to the home can be met. EVIDENCE: Records for a recently admitted Resident were sample checked which identified that an assessment had been carried out by the home prior to admission. Copies of other relevant assessments such as the community care assessment carried out by the Local Authority and a copy of the care agreement with the funding body had also been obtained. The gathering of this information enabled the home to have a good understanding of the Residents care needs. A sample check of the assessments alongside the care plans confirmed that relevant information had been transferred to the care plans to inform Staff as to the care needs to be met. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 Although good systems are in place for care planning, Residents are at risk due to responsibilities for implementing the care plan not being specifically allocated and monitored. EVIDENCE: The care planning systems have improved significantly with relevant information regarding the individual’s care needs gathered during the assessment process being included. The care plans provide Staff with important information regarding the needs to be met and include details of tasks the Resident is able to manage independently which reduces the risk of their independence being taken away. Care plans show that as more information has come to light following admission regarding Residents needs or needs have changed then this has been added to the care plans. From the information seen care plans appeared to be up to date and reflective of Residents current care needs. Details of Residents preferred method of communication are clearly identified at the front of care files which is particularly important due to Residents different sensory impairments and varying methods of communicating. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 10 Records showed that District Nurses are involved where necessary in the provision of wound care to Residents and that, instructions are in place for Staff as to how to maintain and care for any unbroken skin areas. Food and fluid monitoring charts were in place for a Resident who was poorly and was being cared for in bed. The records in place identified that either fluids were being offered very infrequently or that they were not being recorded. On the evening of the inspection the record indicated that the Resident had not received any fluids since 11am that morning, some seven and a half hours earlier. Discussion with the Senior on duty identified that no specific member of Staff is allocated responsibility for monitoring individual Residents increasing the risk of this being missed. To reduce the risk of dehydration the Senior was going to allocate a specific member of Staff on the shift to monitor the fluid intake of the Resident who was poorly and discuss a change in practice with the Manager the following day. Observations of the practice for administering medication confirmed that care was taken to ensure that medication remained safely stored and that medication administration records were checked and appropriately signed. A requirement was made following the previous inspection regarding the predispensing of medication into small pots. This practice has now ceased reducing the risk of incorrect administration of medication to Residents. Staff were observed to be respectful of Residents privacy and dignity throughout the inspection. Personal care is carried out in the privacy of Residents rooms and Staff were seen to knock on Residents doors before entering the room. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 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 standard(s) This section of the standards was not reviewed during this inspection. This section of the standards was not reviewed during this inspection. EVIDENCE: This section of the standards was not reviewed during this inspection. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 Action is taken in accordance with Adult Protection Procedures on allegations of abuse in order however recruitment procedures need to be more robust to protect Residents. EVIDENCE: The Commission for Social Care Inspection have received no complaints about Darsdale since the last inspection. The Registered Manager has advised that they have received one complaint since the last inspection regarding the low temperature in the home during the night. The Manager confirmed that the problem has been addressed and that the aim is for a comfortable temperature to be maintained throughout the twenty four hour period bearing in mind some Residents will be up during the night. A comment card received from a relative states that they are not aware of the complaints procedure. The Registered Manager has advised that copies are sent out with information about the home when a Resident moves in and that a copy is displayed in the hallway of the home though accepts that this may have been removed for a while during re-decoration. During a conversation with a Resident some concerns were raised about a recent incident, which had given some cause for concern. The Registered Manager has followed up the concerns, and appropriate action has been taken to protect Residents through referral to Social Services as part of the protection of vulnerable adults procedures. In order to protect the interests of Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 13 Residents and the Staff member subject to the allegations arrangements the Staff member has been suspended until an investigation has been carried out. As detailed under the staffing section some of the kitchen staff were found to have been employed without criminal record bureau clearances being obtained. This creates a potential risk to Residents. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 21 and 22 The home was clean, comfortable and the improvements that are being made are appropriate to the specialist needs of Residents. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 15 EVIDENCE: A limited tour of the premises, which consisted of lounges, two toilets, a bathroom and a Residents bedroom identified that these areas of the home were clean. Improvements to the premises have been made which include redecoration and refurbishment of bathrooms and toilets. Bathrooms and toilets now have equipment and space, which is more appropriate for Residents, needs and have been refurbished to a good standard. Silver edging strips have been added to the main stairs to make the edges clearer for Residents who are partially sighted. Most areas of the home are now identified by hand rails and door frames being painted in strong contrasting colours to assist partially sighted Residents with orientation. Staff advised that this work in continuing. Some tactile signage has been introduced to identify bathrooms, toilets and the lift. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30 Staff receive appropriate training to meet the needs of Residents however recruitment procedures need to be more thorough to provide better protection for Residents. EVIDENCE: The Manager was not on duty during this unannounced evening inspection therefore Staff records were not available. Information regarding staffing has been sample checked from other available sources. The pre-inspection questionnaire submitted by the Registered Manager identifies that just over half of the Staff team have obtained a National Vocational Qualification (NVQ) at level 2 or above. This training that has been undertaken by Staff is all relevant to working with and meeting the needs of Older People. One member of Staff has obtained NVQ 4, which includes management. Information obtained through the pre-inspection questionnaire, review of the staff notice board and discussion with Staff confirmed that there is an ongoing programme of training related to meeting the needs of Residents. Staff receive specific training in working with and communicating with people who are Deafblind. During the inspection a member of Staff was seen to be communicating effectively with a Resident who is Deafblind. A list of Staff responsibilities has been drawn up which clearly identifies areas of responsibility for each role. This is a positive step in helping to ensure that Staff are fully aware of their individual responsibilities in meeting Residents needs. Following the inspection the Manager has confirmed that Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 17 responsibilities for monitoring Residents who are poorly have been included. A comment received during a telephone call with a relative suggests it would also be beneficial to allocate responsibility for keeping relatives informed regarding changes to health. Residents spoken to confirmed that the majority of Staff are kind and caring. Concerns raised regarding one incident have been referred for investigation. During the inspection Staff were observed to be to be engaging in some friendly and light hearted conversations with Residents and Residents appeared comfortable in the presence of Staff. Information supplied in the pre-inspection questionnaire identified that criminal record bureau checks have not been applied for in respect of some of the kitchen Staff. In a telephone conversation following the inspection the Manager has confirmed following checks that this is the case. In order to protect Residents she will ensure that the criminal record bureau checks are applied for as soon as possible and carry out a risk assessment to consider how best to minimise the risk to Residents in the meantime. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38 Appropriate action is being taken in addressing health and safety issues highlighted and minimising risks to Residents. EVIDENCE: Two methods of recording accidents were in place. Accidents for all Service Users are recorded in a bound book and then individual records are made and kept on Service Users files. Keeping the records in the bound book does not allow Residents rights of access while protecting the confidentiality of others or comply with data protection requirements. Copies of reports of monthly visits conducted on behalf of the Registered Provider are being forwarded to The Commission for Social Care Inspection on a regular basis. The purpose of these visits is to assess the care provided to Service Users and report back to the Registered Person in order that they are kept fully informed of the standards of care. Reports show that the visits are being made by members of the committee and include appropriate discussion Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 19 with Staff and Residents regarding quality of care. The implementation of a full quality assurance system was not discussed during this unannounced inspection, as the Registered Manager or the Deputy responsible for Quality Assurance were not present. Allocation of responsibility for quality assurance is a positive step as a robust quality assurance system is essential for maintaining and improving standards of care received by Service Users. The Pre-inspection questionnaire provides dates that relevant safety checks were carried out which include checks on fire safety equipment, electrical equipment and servicing of the lift. There is no record in the home of when an electrical wiring check last took place and following discussion with the Manager she has confirmed that she will request that checks are arranged to ensure the safety of the wiring system and reduce the risk to Residents. The Fire Officer has visited the home since the last inspection and the Commission for Social Care Inspection have received confirmation that the recommendations for fire safety are being implemented, which will provide greater protection for Residents in the event of fire. Recent training provided for staff includes fire safety, health and safety, movement and handling and hoist training and food hygiene. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x 3 3 x x x x STAFFING Standard No Score 27 x 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x 2 2 Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? 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 8 Regulation 12 (1) (a & b) Requirement Timescale for action 04.07.05 2. 29 3. 29 4. 38 Residents must receive fluids regularly and where a risk of dehydration is identified records must be kept of all fluids offered. 12 (1) (a Satisfactory criminal record 04.07.05 & b), 19 bureau clearances must be (1) (a,b,c) obtained for all staff prior to starting work in the home. 12 (1) (a Details of how the risk to 04.07.05 & b), 19 Residents is going to be (1) (a,b,c) minimised while carrying out criminal record bureau checks on kitchen staff where not already obtained are to be forwarded to the Commission for Social Care Inspection. 13 (4) (a An electrical wiring certificate 30.07.05 & c), 23 must be obtained to confirm that (2) (c) relevant safety checks have been carried out. 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. Darsdale Refer to Standard 8 Good Practice Recommendations Where there is a risk of dehydration a specific member of C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 22 2. 37 staff is allocated responsibility for encouraging fluids on each shift. Accident records should be revised in order to comply with data protection legislation. Darsdale C51 C08 S12760 Darsdale V231105 130605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Northamptonshire Area Office Newland House, First Floor Campbell Sqaure Northants, NN1 3EB 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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