Inspection on 22/07/08 for Darwin House

This inspection was carried out on 22nd July 2008.

CSCI found this care home to be providing an Good service.

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

Darwin House 09/09/09

Darwin House 04/09/07

Darwin House 06/09/06

Darwin House 18/01/06

Darwin House 30/06/05

Darwin House 12/02/05

Darwin House 16/08/04

Darwin House 17/06/04

Darwin House 11/05/04

Darwin House 24/02/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Darwin House Darwin Lane Sheffield South Yorkshire S10 5RG Lead Inspector Sue Turner Key Unannounced Inspection 07:45 22nd July 2008 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 Darwin House DS0000002955.V364180.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. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Darwin House Address Darwin Lane Sheffield South Yorkshire S10 5RG 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) 0114 230 1414 0114 230 6017 whitakerhilary@tiscali.co.uk Darwin House Limited Manager post vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th September 2007 Brief Description of the Service: Darwin house is a home providing personal care for 25 older people. It is situated in a residential area of Sheffield. The facilities are on three floors accessed by a lift. Seventeen single and five double rooms are available. Each of the bedrooms is provided with en-suite toilet facilities, five rooms have ensuite showers. A variety of communal lounge space, and communal library room and dining room are provided. A central laundry and kitchen serve the home. Sufficient bathing facilities are available. The home has pleasant landscaped gardens with seating for service users. The home has a car park. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of fees from 1st April 2008 were £550 £700 per week. Additional charges included newspapers, hairdressing and private chiropody. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This was an unannounced key inspection carried out by Sue Turner, regulation inspector. This site visit took place between the hours of 7.45 am and 3:30 pm. The manager is Hilary Whitaker who was present during the site visit and received feedback at the end of the day. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. We received eight from people living in the home, eight from relatives, four from professionals and four from staff. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Time was spent observing and interacting with staff and people. Five staff, three relatives and eight people living in the home were spoken to. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last key inspection in September 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 6 What the service does well: People living in the home said that the care they were receiving was good. They made comments such as: “Its very nice here”. “This is the best place in Sheffield and I’ve tried a few”. “The staff are nice, happy and affectionate”. “The food is excellent and I can’t complain about anything”. “I am very happy here, people are so very kind”. “I feel safe living here and I can lead a quiet life. It’s a peaceful place to live”. “Things are all done regularly and to time”. “It’s a happy home”. Comments received from questionnaires and from talking to relatives were positive and included: “I am very pleased with the home, the staff are very helpful and kind and we all get on well together”. “We’re very content, this is definitely the right place for mum”. “Staff are lovely and we have a wonderful relationship with each other”. “Staff are marvellous, kind, patient and tolerant”. “My mother is very well looked after (she thinks so, too)”. “Nothing is too much trouble”. Health professionals said: “Management are positive in seeking advice and information to establish improvements in systems and approaches to elder care”. “Quality environment and food services are of a high standard”. “From a medical point of view they appear to respond to the needs of individuals”. “The staff we have contact with are very helpful and reliable in following any instructions/advice that we may give them”. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 7 Care plans were in place for all. They set out all aspects of personal, social and health care needs. People’s health care was monitored and access to health specialists was available. People and relatives said that staff were always respectful towards them. People said that they had a choice of food and that the quality of food served was “good”, “marvellous” and “plentiful”. There was a complaints procedure and adult protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. Training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? The manager had been in post for twelve months. During this time she had worked extremely hard to make many improvements. Her enthusiasm was commendable and it was very evident that the staff team had responded positively to her style of management. At the previous inspection eleven requirements were issued. All these had been actioned. The board, managers and staff should be applauded for this. It was clear to see that people’s life’s had been enhanced. The Statement of Purpose (SOP) and Service User Guide (SUG) had been reviewed and updated. One person said that they had read several SOP and SUG’s to help them make a decision about which home to live in. They said: “When I read about Darwin House, I knew that’s where I wanted to live”. Prior to being admitted to the home each person was assessed by the manager. She had devised a new pre assessment form that covered all aspects of a persons care. This ensured that they were able to meet the needs of people admitted into the home. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 8 The care needs, wishes and preferences for each person were recorded in their care plan. Plans of care contained specific information on the staff action required to meet personal care needs. Care plans and risk assessments were being regularly monitored and reviewed, then signed and dated to confirm that this has been done. Handwritten entries on Medication Administration Record (MAR) sheets were signed by the person making the entry. A witness also signed to confirm the instructions were accurate. The home’s medication system had been changed. Staff said this was a much safer system. The pharmacist, who supplied the medication carried out checks to ensure that medications were being administered, stored and disposed of correctly. All staff had either received, or were booked in for updated/refresher training in adult protection and moving and handling. This helped to ensure that people were safeguarded. Staff had undertaken training in specialist subjects for example diabetes and dementia. This was assisting them to provide more personalised care to people. The quality assurance system had been improved and developed. People, their relatives and others had been sent questionnaires asking them their opinions of the service. From this an action plan had been drawn up to address any issues raised. Fire alarms were being tested each week. This assisted to protect people’s health, safety and welfare. What they could do better: The service provided at Darwin House is of a good standard and everyone involved with the home should be proud of this. So that people health, safety and welfare is not put at risk the door to the cellar should be kept locked and the key removed at all times. We acknowledge that the provider and manager continue to evaluate and monitor the service and make any changes necessary to ensure that the home continues to provide the good service that is presently offered. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 9 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. The summary of this inspection report can be made available in other formats on request. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 10 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 Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 5. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided sufficient updated and relevant information to inform people about their rights and choices. Trial visits were encouraged to enable people to look around the home, meet other people living there and give them the information needed to make informed choices. EVIDENCE: The home’s Statement of Purpose (SOP) and Service User Guide (SUG) were available, both in the entrance hall, for anyone visiting the home and a copy was also in each persons room. These included useful information about the home and the services offered. Both the Statement of Purpose and Service User Guide had been updated recently. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 12 One person said that they had read several SOP and SUG’s to help them make a decision about which home to live in. They said: “When I read about Darwin House, I knew that’s where I wanted to live”. Prior to admission taking place professionals and staff assessed people. The majority of people were self-funded and this meant that information was provided by the manager’s own assessment. This assessment had been revised and covered a much broader spectrum. It also included information about mental health issues. The AQAA started: A Needs Assessment is carried out prior to admission to the home to ensure that the home will indeed be able to meet any individual needs. Any information collated from the needs assessment would then form the basis for the care plan. We invite any prospective resident to come and spend the day with us in order for them to get a true feeling for their environment and to sample the services provided by the home. We also encourage trial visits as a means for the resident to get a realistic feel for the home and environment in general. People said: “I came on three separate visits so that I was sure this was the right place for me”. “I spent a day meeting people and trying the food”. “I enjoyed my holiday stays here, so I knew I would be happy living here”. Relatives said: “The consultant at the hospital said this was a nice home”. “We looked around 20 or 30 homes before we decided. There was no comparision. This is home from home”. This home does not provide intermediate care services. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A range of health care professionals visited the home. Medication procedures protected people’s health and welfare. The health and personal care needs of people were met in a way that respected their privacy and dignity. EVIDENCE: People living in the home had an individualised plan of care. Two peoples plans of care were checked. Care plans contained a wide range of information on many aspects of personal, social and health care needs. The AQAA stated: We hold a comprehensive care plan for each person. These are updated on a regular basis and checked by management every month. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 14 The care plans seen were not written in a person centred way. Plans seen focused more on the tasks necessary to care for the person. There was little information about what the person themselves felt their care needs were and how they wanted their specific needs to be met. Staff completed daily records. These were done at the end of each shift. There was very little information in the daily records. Those seen were short, brief comments that were repetitive. Records didn’t detail how people had spent their day, what meals they had taken, if any visitors were seen, any personal care tasks undertaken and any activities they had joined in. Daily records did not link with the information recorded in peoples care plans. There was evidence in the care plans seen that relatives had been involved with them. Relatives said: “Staff talk to me frequently about mums needs. I haven’t been involved in a formal review of her care plan, but this hasn’t been necessary”. “I am aware that mum has a care plan and that we can look at this. I have been asked to attend a review but have chosen not to”. Care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists visited the home as requested. Staff were regularly reviewing and updating individual risk assessments. People said: “Staff are fully aware of my care needs. The district nurse also supports me. I recently became very ill and the staff acted really quickly to get me into hospital”. “The staff assist me to get bathed twice a week, this is my preference, I could have more if I wanted”. “When I press the buzzer the staff come straightaway, they tell me I mustn’t worry about pressing it”. One relative said: “My mother is better in health and more content than she’s been in years”. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 15 The AQAA stated: We have moved pharmacy and operate the Monitored Dosage System (MDS), which is proving far superior to our previous system. Lloyd’s pharmacy come to the home on a regular basis and inspects our policies, procedures and practices. Medicines were securely stored around the home in locked trolleys within cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Controlled drugs (CD) were kept in a clinical room and within a double locking cabinet. A CD register was available. People spoken to said that staff administered their medication at appropriate times and one person who had chosen to self administer had been provided with a lockable drawer to keep their medications safe. Staff said that they had to complete competence training before they were allowed to administer medications. There was evidence that the manager and deputy manager were auditing medication administration procedures. If managers found that there was a gap in the medication records they asked staff to complete the record. This meant that staff were signing for medications that they may have given several days or weeks ago. This was unsafe practise as staff could not be sure that they would have given the medication after a time lapse. We discussed this with the manager. She devised a separate record sheet that identified when MAR sheets weren’t signed and gave the reason for this. This was a good way of continuing to monitor medication administration without putting people or staff at risk. People and relatives spoken with, and via their questionnaires, confirmed that the carers treated them with respect and provided personal care and support in a way that maintained their dignity and privacy and was sensitive to their individual needs and wishes. Staff were observed speaking to people in a respectful way and showed empathy and patience when providing personal care to them. People said: “When I came into the home the staff asked me if I would mind being cared for by the male carer. I thought this was very considerate of them”. “The staff would never come into my room without knocking”. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 16 One relative said: “People are happy and have dignity, stimulation and genuine care”. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A limited range of activities was on offer, further activities would promote choice and maintain peoples interests. Meals served at the home offered choice and ensured people received a healthy balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was offered hospitality and staff took time to make sure friends and family were made to feel comfortable whilst visiting their loved one. Some people said they preferred to stay in their room at certain times of the day and that the staff respected their decision. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 18 One person said: “We have our freedom here”. Relatives said: “We know we can visit at anytime, the staff always greet us with a smile”. “When we visit, mum rings downstairs for a tray of tea, staff always oblige”. People said that they enjoyed taking part in social activities within the home. Particular favourites were chair aerobics, bingo and quizzes. The activities coordinator had left and not been replaced. People said that they would like to do even more activities. Relatives said: “The home could improve by encouraging more social activities, although I have seen that opportunities are sometimes not taken up when offered which is personal choice”. “I would like to see more trips out taking place”. The AQAA stated: We host a church service within the home on a monthly basis conducted by a visiting Minister. We aim to make meals and meal times a pleasant and sociable event, we feel that this is a chance for our residents to socialise and spend quality time together. We offer armchair aerobics every Friday, and ‘bingo’ every Wednesday. We do try to encourage all our residents to participate in the activities provided by the home, however we will not force as we strongly promote autonomy and choice. We provide organised in-house activities, which include crosswords, general knowledge quiz, scrabble and cards. These activities are proving exceptionally popular with all our residents. We encourage and promote independence and offer support to our residents relatives and friends to encourage personal outings. We offer an excellent healthy and nutritional varied diet. We maintain a well-informed relationship with residents and their families and friends, and welcome their support in decision making. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 19 In May this year we held a 1920’s fashion evening this was an absolute success. We arrange evening entertainment for residents and friends, which are performed by professional entertainers. As a result of receiving the government grant and purchasing a people carrier we have been able to organise outings for our residents. We aim to continue to listen to people to establish what and where they would like to go. As we have now got the people carrier this has enabled us to take people out on excursions, so far we have been able to do the following: Pub lunch Drive in the country Support with medical appointments Garden party On the day of the site visit, we observed breakfast and lunch being served. People chose to eat breakfast in their room. This was nicely served on a tray with individual teapot, milk and sugar. People had a choice of cereals, porridge, prunes or grapefruit followed by bread or toast with preserves. People could also request a cooked breakfast; one person said they enjoyed a bacon sandwich each morning. Breakfast trays had a slip for people to request their choice of lunch. On the day of the visit the choices were chicken curry and rice or lamb hotpot with potatoes and fresh vegetables. A selection of desserts was offered from a trolley. At lunchtime the dining room tables were set nicely with fresh flowers, placemats, napkins, cutlery and matching crockery. The dining room was quite small and had a pleasant relaxed ambience. People said: “The food is fine I have no complaints”. “The food is excellent”. “There’s only one problem and that is the meals are too good, I’m eating too much”. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall and bedrooms. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. Relatives spoken to said that they felt very comfortable in going to any member of the staff or the manager, knowing that any concerns they may have would be addressed without delay. Two relatives said: “I speak to the manager or deputy if I have any concerns. They have sorted out minor issues I have raised with them.” Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 21 “If I had a complaint I would not hesitate to talk to the manager, but I have no complaints.” The home kept a record of complaints, which detailed the action taken and outcomes. The home had received one complaint/issue since the last inspection. The manager had responded to this and a positive outcome had been reached. We had not received any complaints about the home. Staff spoken to were clear how to respond and record any complaints received. The AQAA stated: We have a complaints policy and procedure and all complaints are taken seriously and acted upon without delay. Any complaint received is addressed as a matter of urgency and will be responded to in no more that 28 days. We protect people from abuse and operate a zero tolerance abuse policy. We arrange regular training sessions, carried out by outside professionals, to cover all types of abuse and ensure staff are up to-date regarding any form of abuse. We also have in-house training to re-in force the issues and zero tolerance to abuse. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was maintained to a very high standard. The environment was very clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and people’s bedrooms were well decorated and personalised. Controls of infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: The home is surrounded by very pleasant gardens, which have a variety of shrubs, flowers and an ornamental pond. Many rooms overlook the grounds and people said they got great pleasure from looking out of their windows and sitting outside in the nice weather. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 23 The home was very clean and tidy. Lounge and dining areas were domestically furnished to a good standard. The manager had a programme of refurbishment and redecoration that ensured that the home was very aesthetically pleasing and free from hazards. The manager said that the provider would carry out any work that she deemed necessary for the comfort and well being of the people living in, working and visiting the home. Bedrooms checked were comfortable, homely and reflected peoples personal tastes. People said their beds were comfortable and bed linen checked was clean and in a good condition. In peoples rooms there was a telephone. The telephones were easy to use and handle. People could make outgoing and receive incoming calls. The cost of the telephone was included in the fees. Since the last inspection, a new call system had been installed. The manager said this had been of great benefit to people. All staff had their own pager and the staff response time was monitored on the computer. This had helped to monitor any shortfalls in the way in which staff responded to people. No unpleasant odours were noticeable in the home and relatives said that the home was always kept “immaculately clean” and “spotless”. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Staff had undertaken training in infection control. The AQAA stated: Darwin House believes that people should expect their quality of life to be enhanced by the provision of their own safe, well-maintained and comfortable environment. We believe that every person has the right to live their life with privacy, dignity, independence and choice and that the quality of the home environment is a key factor in this regard. We provide a safe, well-maintained and welcoming environment, both indoors and outdoors. All our equipment has regular maintenance checks to ensure safety, i.e. lifting aids, electrical equipment, fire extinguishers, smoke alarms etc. All our guest rooms are individually decorated and maintained to a high standard. We encourage people to personalise their rooms with their own furniture, pictures, paintings and ornaments, thus maintaining a feeling of home and well being. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were provided to meet the needs of people. The recruitment information obtained for staff was sufficient to adequately protect the welfare of people. Staff had completed training that ensured they had the competences to meet people’s individual needs. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained to meet the needs of people. Staff were very willing to cover any holidays and sickness. The manager said that they continued to have difficulties securing the employment of an evening chef/cook. This had an impact on the remaining staff, as it had been necessary for others to cover this role. The manager was continuing to actively employ to this post and was also recruiting bank staff to cover any shortfalls. The manager had undertaken a review of staff training and had identified the shortfalls. Mandatory training had been booked and further training in specialised topics for example diabetes and falls prevention was being delivered by the Sheffield Partnerships for Older Peoples Projects (POPP’s) team. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 25 Staff interviewed said that when they started work they received induction training in the first two months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, First Aid and Fire. 70 of the care staff had achieved NVQ Level 2 or above in Health and Social Care. A number of care staff had also commenced the training. This met the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Four staff surveys were returned, when asked are you being given training, which is relevant to your role? All four said, “yes”. Staff said: “We have been provided with all the essential training”. “I have never done this work before and found the induction training very useful”. Three staff records of employment were checked. POVA checks had been made and CRB checks had been obtained for the staff members. There were shortfalls in the information that should have been gathered during the recruitment process. Two people had not given their full employment record and this had resulted in references not being obtained from their previous employer. The significance of obtaining references from people’s last employer was reiterated to the manager. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The managers’ leadership approach benefited people and staff. Quality assurance systems meant that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. In the main people’s health and safety had been promoted and protected. EVIDENCE: The manager at the home was in the process of registering with us. She was undertaking a management qualification and had many years experience of working with older people. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 27 Since the last inspection the manager, with the support of the provider, had worked hard to action the requirements made and this was evidenced by the many developments made within the service. The manager was hard working, competent and carried out her role to a very high standard. She was clearly very committed to ensuring that people living in the home were consistently well cared for, safe and happy. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. Vanessa de Roeck is the responsible individual (RI). She visited the home several times a month and spent time speaking to people, staff and relatives. Each month she completed a report about the quality of the service provided. These reports were seen. They were thorough and informative. Following these visits the manager and RI complied an action plan that was addressed each month. The manager had sent out surveys to people and their relatives, asking them their opinions of the home. The information returned had been collated into a report. The results were very positive. When asked, “Are you satisfied with the service provided to your relative”, 79 of people said “yes” and 21 said “yes very satisfied”. When asked does your relative appear happy and well cared for 100 of people said “yes”. Regular resident, staff and relative meetings were arranged. Minutes from these were seen. There was evidence that appropriate actions had been taken following peoples comments at these meetings. The AQAA stated: We have put into place a quality assurance questionnaire that goes to the residents, their families, visiting professionals and staff, once we have received all responses we then organise meetings with the residents, their families and staff. This has proved to be very positive and productive. The home handles money on behalf of some people. This was checked for three people. Account sheets were kept, receipts were seen for all transactions and monies kept balanced with what was recorded on the account sheet. Formal staff supervision, to develop, inform and support staff took place at regular intervals and staff said that they found this useful and beneficial. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 28 Fire records evidenced that fire alarm checks took place each week. Staff said that they had received fire training and fire drills. The fire service had carried out an inspection of the home and made a number of recommendations. The manager said that all the recommendations had been actioned. Following this the manager had updated the fire risk assessment. The manager said that no further actions were necessary. Environmental Health had awarded the home a very good four-star rating following their last inspection visit. When we arrived at the home the door to the cellar had been left unlocked. A notice on the door stated that it must be locked and the key removed at all times. Behind the door there was a very steep stone stairway that could be a serious health and safety risk to anyone entering. Staff locked the door when asked. The AQAA stated: We ensure that regular checks are carried out on gas appliances, electrical appliances and outside professionals to check the aids and lift used within the home. We have an appointed Health & Safety Officer who is responsible for all health and safety matters and ensuring that we comply with our legal responsibilities. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 29 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 3 X 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X 4 X 4 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 3 X 2 Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 30 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 OP38 Regulation 13 Timescale for action So that people health, safety and 22/07/08 welfare is not put at risk the door to the cellar must be kept locked and the key removed at all times. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP7 OP7 OP9 OP12 OP27 OP29 Good Practice Recommendations Care plans should be written in a more person centred way. Daily records should give more detail. For example how people have spent their time and if they have received any personal or professional visitors. Staff should sign MAR sheets at the time of medication administration. If there are gaps in the MAR sheets staff should not sign them retrospectively. An activities worker should be recruited so that the programme of outings and activities is enhanced. There should be an evening cook/chef employed so that other staff are not being relied upon to cover this post. To fully protect people written references should be obtained from staff’s previous employer. Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Darwin House DS0000002955.V364180.R01.S.doc Version 5.2 Page 32 - 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!