Inspection on 19/06/07 for De Lacy House

This inspection was carried out on 19th June 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

De Lacy House 09/06/09

De Lacy House 10/06/08

De Lacy House 12/06/06

De Lacy House 07/03/06

De Lacy House 26/10/05

De Lacy House 22/03/05

De Lacy House 08/10/04

De Lacy House 04/03/04

De Lacy House 18/11/03

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE De Lacy House De Lacy House 42 De Lacy Way Winterton North Lincolnshire DN15 9JX Lead Inspector Stephen Robertshaw Unannounced Inspection 19th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address De Lacy House DS0000033109.V343816.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. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service De Lacy House Address De Lacy House 42 De Lacy Way Winterton North Lincolnshire DN15 9JX 01724 733755 01724 735083 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) www.northlincs.gov.uk North Lincolnshire Council Position Vacant Care Home 30 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (24), of places Physical disability (6) De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the Intermediate Care Services provided to promote short-term intensive rehabilitation are sited in a designated area. That the mixed age range of 18-65 years and over 65 years applies only to the six places registered for Intermediate Care Services. Date of last inspection 12th June 2006 Brief Description of the Service: De Lacy House is owned by the local authority and situated in Winterton. Part of the building includes the Poirier Suite, a designated rehabilitation unit with six en-suite bedrooms. Clinical support for the service is via the Primary Care Trust Intermediate Care Service Team consisting of a GP, qualified nurses, occupational therapists and physiotherapists. The suite has a kitchen, sitting room and a dining room. Other events that had been reported to the Commission since the last inspection have also influenced this report. The main part of De Lacy House has twenty-four beds and delivers personal care to older people, four of whom may have needs associated with dementia. The home also offers a day care service for up to six people. De Lacy House is a purpose built unit with four lounges and a large dining room. One of the lounges has a ‘Loop System’ installed to aid those service users who have a hearing impairment and one of them is designated for activities used by day care services. All the bedrooms are single. The home has ten single toilets, two assisted bathrooms and one shower room. A further bathroom is situated in the section designated for day care services. The home surrounds a courtyard patio area that has shrubs and plants and a covered area at one end. A further patio area is outside the separate entrance to the Poirier Suite. The home has ramps to all entrances. There are gardens to the front, side and rear of the building and adequate car parking facilities. According to information received from the home their weekly fee is £421.97. Items not included in the fee are personal toiletries, hairdressing, chiropody services and newspapers. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 5 Previous inspection reports are made available in the entrance to the home. The local authority’s adult services have recently been awarded Investors in People. Several of the homes care staff and management were interviewed as part of the assessment process for the award. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was unannounced and took place on the 19th May 2007. The inspector was in the home for approximately six and a half hours. The evidence included in this report was gathered through a variety of different ways. This included the documents seen at the home at the time of the site visit, the home’s Annual Quality Assurance Assessment that was returned to the Commission before the site visit took place, contact with service users, their families and friends and outside professionals involved in their care. Surveys were also sent out to twenty of the service users and twenty of the homes staff. Only one of these surveys was returned to the inspector before the completion of this report. The inspector interviewed the manager and three of the care staff working at the home and also spoke with eight of the service users. What the service does well: What has improved since the last inspection? The service has employed a new manager to the home. This means that there is now somebody in position that is responsible for how the services are delivered to individual service users. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 7 The home now always receive a copy of the service users assessment before they are admitted in to the home to make sure that the staff have the knowledge and skills to care for them. The activities in the home are more frequent than they used to be, and provide interesting and stimulating activities for the service users. The courtyard of the home has been cleared to make it a safer area for the service users to access. 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. The summary of this inspection report can be made available in other formats on request. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 8 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 De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users have their needs assessed before they are admitted in to the home to ensure that they can be met there. EVIDENCE: The inspector case tracked the care of three of the service users living at the home and observed all of the written documentation that related to their care. The home has a statement of purpose and service user guide. These documents detailed the services that are available in the home and also described the numbers of staff and management that are available to prospective service users. All of the files observed by the inspector included the terms and conditions of their residency of the home. Two of the three files observed by the inspector De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 10 included the signature of the service user or their representative on their contracts. One of the files did not include a signature. The manager of the home explained that the service user did not have the capacity to sign the document for themselves and the home were waiting for the service users representative to sign their document for them. All of the service users files that were seen by the inspector included an assessment of their needs that had been completed prior to their admission in to the home. The inspector observed care files from each category of the homes registration and this included a long-term care service user, a shortterm care service user and an intermediate care service user. The assessments detailed how their needs should be met. The assessment for the short term service user was very brief and did not clearly identify how the service users needs affected their daily lives and the individual support that they would require in the home to meet their health and personal care needs. This would make it difficult for an appropriate care plan to be developed from it. The home also has provision for an emergency overnight provision for one service user. The service user should be re-assessed before the lunchtime the following day with the exception of weekend admissions. Then the service user should be transferred if appropriate to a more suitable service that can meet their needs. The staff spoken to by the inspector stated that service users are not always discharged from this provision as soon as the home’s policy dictates. A visitor to the home stated that there relative should have been discharged on the day of the site visit, however their social worker (community based) had not made the arrangements for the discharge. The home’s records showed that the respite period was for a further week. The visitor stated that the staff in the home were very supportive and the difficulties in the discharge was not through their practices. Service users and visitors spoken to by the inspector stated that in the case of long-term and short-term service users were given the opportunity to visit the home before they made a decision to move their to have their needs met. This included attending day care at the home and longer trial periods including overnight stays and joining in the home’s activities. The service users that are admitted for intermediate care do not always have the benefit of visiting the home before they are admitted to it. This is due to the fact that they are either admitted straight from hospital or are admitted to the home as an alternative to being admitted in to hospital and therefore a trial period to the home is not always available to them and due to the nature of their needs there is no other service available to them in the local area to choose from. The home has the capacity to meet the needs of the living there and service users and visitors to the home confirmed this to the inspector. One visitor De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 11 stated that the staff and management were ‘excellent’ and that the staff ‘were very helpful and understood what they needed to do’. The service users that receive intermediate care at the home are in an area that is separated from the remainder of the home. This part of the service also has access to physiotherapy and other healthcare professionals on a regular basis. An intermediate care service user stated to the inspector that since they had been at the home their health and physical abilities had ‘improved’ and they were looking forward to being ‘discharged back home’, they also included that this was because people had recognised that there would be no ‘great risks’ to go home and live independently again. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the service users needs are met through the services provided at the home in ways that are acceptable to them. EVIDENCE: The inspector observed the care plans for three of the service users living at the home. The care plans identified how all of the assessed needs for the service users must be met. The care plans for the long and short-term service users did not include any detail that they had been evaluated on a regular basis to make sure that they were still relevant to the individual service users. However they were supported through daily dependency rating sheets that simply identified a number on a scale for the individual service user’s dependency. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 13 The care plans were supported where appropriate with risk assessments and moving and handling assessments. However these had not all been evaluated to make sure that they still supported the needs of the service users. The intermediate care service users health screening assessment had not been completed by the appropriate healthcare staff. It was therefore not available to determine an appropriate care plan for the service users in relation to their personal health care needs. In relation to their intermediate care this could cause problems in their development. All of the care files seen by the inspector included detailed information of when service users had any contact with professional healthcare workers. This included physiotherapists, GP’s, community based nurses, dentists, opticians and hospital consultants. The care plans also included an assessment of the service users nutritional needs. One service user told the inspector that when they have professional visitors they are always ‘in private’ unless they wanted ‘support from the care staff’. The staff that administer medication to the service users had all received accredited medication training and generally the only staff administering medication to the service user are senior members of staff. The inspector observed medication being administered to service users and all legislation and good working practices were followed. This included giving service users time to take their medication and remaining with them to make sure that the tablets had been swallowed. The majority of the intermediate care service users administer their own medication whilst they are in the home. On admission all service user have a risk assessment completed to see if they can safely administer their own medication. The inspector also observed the medication room. This was clean and tidy and was well organised. The medication records were accurately recorded and were up to date. Controlled drugs were appropriately stored and recorded. All of these practices help to maintain the health and safety of the service users. Direct observations supported the evidence that the service users privacy, dignity and respect is upheld at all times in the home. A service user said to the inspector that ‘I am very happy here, I am well looked after and only have to do things that I want to do’. Visitors to the home spoken to by the inspector also confirmed that they believed that the service users were treated with dignity and respect. Staff also stated that it was important to them that the service users were made to feel ‘comfortable’ in the home and this included making sure that they ‘were treated with the respect and dignity that they deserved’. The care plans did not include the last wishes of the service users in the event of their deaths. It is important to gain this information as early as possible as in the event of a service user’s death it is often very difficult for their families and friends to have to make these decisions. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 14 The individual service users’ care files include daily diary entries describing the events that the service users had been involved in and the mood of the service users during the day. These notes were very inconsistent. Some of the records were very lengthy and informative whereas others only included brief documentation for example the food that the service user had eaten. The manager of the home stated to the inspector that she was aware of this and care file training was going to be introduced soon to the staff group and this would include the need to consistently record information in individual service users’ care files. This would then help to build up any patterns of behaviour for individual service users. Some of the records in the home included health care abbreviations. This means that the records are not always clear and easy for others to understand. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 15 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): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users are provided with meaningful and stimulating activities to ensure that their daily lives in the home are full and they receive activities that they are interested in. EVIDENCE: Since the last inspection the home now employs an activity co-ordinator for fifteen hours a week. The service users stated that the frequency and the actual activities made available to them were appropriate to their needs. On the day of the site visit a choir made a pre-arranged visit to the home to perform for the service users. The inspector observed several of the service users watching the choir and noticed that they were enjoying the performance and joining in with the songs that they remembered. Staff were observed going round the service users in the room and making sure that the individual service users were enjoying the entertainment. Before the performance started the care staff were also observed approaching individual service users to remind them of the activity and to support them to the room where it was taking place and clarifying if they wanted to attend or not. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 16 On a Friday evening the home invited family of service users and people living in the community to a communal ‘bingo night’. This is used to help the home build up good relationships with its neighbours. Routines in the home are very flexible a service user confirmed to the inspector that ‘I get up form bed when I want to, and go to bed when I want’. Staff interviewed by the inspector also confirmed that the service users are supported to make decisions for themselves in relation to how they lead their everyday lives at the home. One member of staff stated ‘the service users are supported to develop their independence as much as possible’. The inspector spoke with four visitors to the home and they all confirmed that they are made welcome at the home at any reasonable time. One visitor stated ‘it doesn’t matter what time you come to the home, the staff always make you welcome’. They also stated that they could see their family and friends either in ‘their own rooms’ or in the communal areas. The inspector ate lunch with several of the service users. There was a choice of meal and the meals were very well presented and were very tasty. The service users sat with the inspector stated that the meals at the home were ‘always very good’ and that ‘you always get a choice’. The care staff also commented to the inspector that the meals provided at the home were always very good. Some of the staff eat the meals at the home and therefore have a first hand experience to assess the quality of the food being provided. Some of the service users in the dining room were not very tolerant of more vocal service users. The care staff very good at supporting both elements of the service users to make sure that they all remained comfortable while they ate their meal. The inspector also looked around the homes kitchen. This area was very cleaned well organised. The kitchen staff confirmed that a choice of meal is provided at all meal times in the home and any special diets are catered for. The only special diets at the time of the inspection were for low fat, low sugar and softened meals. Appropriate dignified support was observed by the inspector to be offered to individual service users to make sure that they completed their meals in a safe and healthy manner. Service users care files included an assessment of their nutritional needs. The manager also confirmed to the inspector that the care staff have obtained a phrase book to support their communication with a service user whose first language is not English and accesses the home for respite care. The service users’ family and friends also support the communication with the care staff in the home. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 17 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): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users are protected from possible abuse at the home. EVIDENCE: The home has a clear and easy to follow complaints procedure. There had been no complaints recorded at the home in relation to the service. This evidence was also supported through the homes Annual Quality Assurance Assessment (AQAA). Service users and visitors spoken to by the inspector stated that they knew how to make a complaint if they wished to. The records of complaints and concerns in the home also supported that no formal complaints had been registered. One area the manager commented on in the home’s AQAA was that the service ‘listens and learns’. The staff training programme includes complaints procedures and whistle blowing. Staff interviewed by the inspector stated that they understood what the whistle blowing policy was and how it should be used if they suspect any colleagues of abuse. There was also a copy of the whistle blowing charter in the home. All of the staff in the home receive safeguarding adults training. This is provided through the local authority’s training department. There had been no De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 18 cases referred to the Safeguarding Adults team. Staff interviewed by the inspector were aware of what constituted suspected abuse and understood how to report any allegations or suspicions of abuse. Staff training records supported that they had received protection of vulnerable adults training. The home’s quality assurance programme also provides the opportunity for service users to make their views known and provides empowerment to them through this process. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the environment is suitable for the needs of the service users. EVIDENCE: As part of the site visit the inspector made a tour of the premises. The building was well maintained and the decoration was in good order. New carpets have been fitted in the home’s corridors. The management of the home are in discussions with the carpet suppliers as the carpets are badly marked and they were guaranteed against any stains. New electric doors have been fitted to the front of the building to increase the security of the home. An electric door has also been fitted to one of the De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 20 bathrooms to make it more easily accessible for service users to use it independently. CCTV also covers this entrance to the home. The bathrooms and toilets were very clean and tidy. However there were some concerns in relation to infection control as piles of linen towels were openly on display in the bathrooms, communal nailbrushes were on the sinks and bottles of shampoo were left on the side of the baths. This could cause problems for service user if they ingested the contents of the bottles. This is a possibility as some of the service user in the home have dementia related care needs. A new bathroom with a walk in shower has also recently been provided at the home. All of the required maintenance and service records were available for all of the equipment used in the home. There is a choice of communal areas that are made available to the service users. Service users spoken to by the inspector said that they were very happy with the quality of the environment that had been provided for them. A service user stated to the inspector that ‘its very nice here and very clean’ this was also confirmed by a visitor to the service who said the home is always clean and new looking’. Three service users invited the inspector to visit their rooms. These varied on how much the service users had personalised them dependent of their placement for long-term care, short-term care or intermediate care. The maintenance records in the home identified when any work was required and was carried out in any of the individual rooms. This was also supported through the home’s maintenance and development plan. The manager of the home added that the home was under continual development as the management were learning through experience of the different service users and their needs. The service user stated that their personal rooms were suitable to their needs and were of an appropriate size for them. The home has two mobile hoist units one is electrically operated and the other is manual. The senior staff were identifying another electrical hoist to support the care of the service users and the management had approved this. The heating and lighting in the home is domestic in character. All of the radiators in the home had been fitted with protective covers to make sure that service users were not injured through coming in to contact with a hot metal surface. The home has a laundry and all of the machines available are programmable to sluicing and disinfection standards. The home does not employ laundry staff. The homes care staff carries out the laundry duties. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 21 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): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the staff understand the care needs of the service users and are able to appropriately support them at the home. EVIDENCE: The inspector observed the staff personnel and training files for three of the care staff employed at the home. He also interviewed three care staff and spoke with four others. The home has clear rotas that show when staff will be available on duty. There were no staff working in the home that were under the age of eighteen years. The home does not employ laundry staff. The care staff complete all of the laundry. The service users beds are also made by the care staff if they cannot do this for themselves. The staff spoken to by the inspector stated that these duties meant that they were restricted in any one to one key worker times with individual service users and believed that their time could be better spent with the service users. The manager of the home stated that there is currently a staffing review being undertaken in the home and it is possible that a member of staff may be employed to work in the laundry and the domestic staff may take some responsibility for making the serviced users beds. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 22 Serviced users and visitors spoken to by the inspector stated that they believed that there were always enough staff available in the home to meet the needs of the service users. Previously a high number of agency staff have been used at the home. In the last three months there has only been one shift where an agency worker was employed at the home. The home also has a bank of care workers that it can utilise to cover staff sickness, holidays and vacancies. Staff training records show that they receive induction training that is linked to the common standards. A part completed induction record was observed by the inspector and was discussed with member of staff involved. The care staff and management are working towards their commitment to a minimum of 50 of the homes care staff to have achieved NVQ 2 (National Vocational qualifications) or equivalent. NVQ’s are also made available to the domestic and kitchen staff in the home. All staff that access the kitchen had received a minimum of basic food hygiene training, however some of this training had not been renewed as it should have. The fire training, infection control and moving and handling training were out of date for the majority of the care staff. There were plans in the home to make sure that all of the staff’s mandatory training was brought up to date and was then regularly monitored for renewal or refresher training. The manager confirmed to the inspector that this had already been identified by the management and a training plan was being implemented to overcome these shortfalls. However all of the service users and visitors to the home that were spoken to by the inspector supported that the staff have all of the knowledge and skills to support the care of the individual service users. The inspector’s observations and interviews with staff also support this information. The employment procedures for the home support equal opportunities and the protection of the service users. The inspector observed the records for three of the staff working at the home. These provided evidence that the staff received personal and professional references and Criminal Rerecords Bureau safety vetting before they are employed to have any contact with the service users. The care staff, kitchen staff and domestic staff all wear uniforms to identify them and protect their own clothes. All of the staff also wear name badges to identify them individually. The senior care staff in the home do not wear uniforms. Two senior staff stated that this means that when they support care staff with service users personal needs then their clothes can become infected. A visitor to the home stated that sometimes it was difficult to identify who senior care staff were and who were other visitors were when they were De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 23 visiting the home. The inspector raised this issue with the acting manager of the service who stated that as far as she was aware this had always been the custom and practice in the home. However she stated that she would look in to this issue and discuss it with the care staff and senior staff and would consider providing new uniforms to the senior staff if this would be more appropriate. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 24 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): 31,33,34,35 and 37 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the management of the service understands and supports the needs of the service users, the staff and the service itself and provides a good environment to live and work in. EVIDENCE: Since the last inspection the registered manager of the home has left the service. The temporary management support to the home has been replaced by an acting manager who has been employed by the local authority to manage the service. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 25 The acting manager of the home has worked for the local authority for twenty years. Her previous positions included working in the authorities Quality assurance team. The acting manager is currently waiting for her CRB to be returned so that she can complete her registration with the Commission. Her qualifications include BA Honours in Applied Social Sciences, a Post Graduate certificate in Managing Social Care, a Post Graduate Diploma Leading in Health Award and is a qualified NVQ work base assessor. The manager stated to the inspector that the staff and management in the home has improved and various procedures were being put in to place to support the developments in the home. This included employing an activity coordinator and providing in house trainers for moving an handling courses. The management make sure that regular staff and service user meetings are held at the home. This allows these groups to air their views on how services are delivered to them at the home and how they could be improved. The management of the home have also developed a service action plan that details any major maintenance that needs to be carried out in the home in a twelve-month period. The acting manager was aware that the mandatory training for the care staff needs to be improved and stated that this training was going to be implemented in the near future. Care staff spoken to by the inspector were aware of some of the mandatory training that had been planned for them. An open door policy is adopted by the management of the home. The acting manager had only been in position since may 2007 and therefore the inspector was not able to determine at this point if the managers style is open, supportive and inclusive. However discussions with visitors and care staff supported that the manager is friendly and approachable. The quality assurance and monitoring system in the home is effective and appropriate to the needs of the service. However due to the difficulties in the management of the home and the recent new appointment of the acting manager the quality assurance programme has not been accessed since January 2007. The acting manager of the home stated that this was one of her priorities to re-establish the system to recognise any strengths and weaknesses in the current service provision. The service users are encouraged to manage their own finances, however some of the longer term care users have pocket money accounts held at the home. These were sampled and the records were up to date and had been accurately recorded. However the home also has a ‘comfort fund’ for the service users. Money for this fund are raised through social events held in the home and the funds are used to develop activities for the service users. The records for this fund were not accurately recorded although the manager could De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 26 account for the excess monies that were held in a locked tin. The inspector recommended that the comfort fund is fully audited and the records need to be accurately recorded. Staff formal supervision has not been undertaken in the home for a considerable length of time. The manager stated that some responsibilities for supervision had been delegated to the senior care staff and the supervision was beginning to happen. The Manager also confirmed that annual appraisals were also being arranged for all of the staff and some of these had already been completed. The staff records seen by the inspector supported that supervision has been planned for all of the staff and their annual appraisals if not already completed and been planned. The care staff spoken to by the inspector confirmed that they had been given dates for their forthcoming formal supervision. With exception of the supervision records all of the records required by regulation and for the protection of service users were in position and were up to date and had been accurately recorded. All of the aides and equipment in the home had up to date service and maintenance records. This included the fire systems and moving and handling equipment. There was also up to date insurance in position. The home did not have a copy of the gas and electrical systems safety certificates. The manager confirmed to the inspector that these records are kept by the local authorities property services department however she was unable to validate if they were up to date. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 18 3 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 4 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 2 3 3 De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 28 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. 1.. Standard OP3 Regulation 14.2a,b Requirement The registered person must make sure that all moving and handling and health screening assessments are assessed and appropriate care plans are developed from them. Theses must be evaluated on a regular basis to make sure that they are still appropriate to the needs of the service uses. The registered person must make sure that the individual service user care plans are evaluated on a regular basis to make sure that they are still appropriate to the needs of the service users. This also includes the evaluation of any associated risk assessments. The registered person must make sure that all infection control practices and procedures are upheld in the home to support the health and safety of the service users. This includes removing or securing the linen towels in the homes bathrooms. The registered person must provide all of the care staff with DS0000033109.V343816.R01.S.doc Timescale for action 30/07/07 2. OP7 15.1,2a 30/07/07 3. OP21 OP26 13.3 30/06/07 4. OP30 18.1c (i) 30/11/07 De Lacy House Version 5.2 Page 29 5. OP36 18.2 the required mandatory training and specialist training in relation to the needs of the service users to make sure that the staff have the necessary knowledge and skills to safely care for the service users. (Previous timescales of 30/04/06 and 31/01/07 were not met). The registered person must 30/12/07 make sure that all of the care staff receive the minimum of six formal recorded supervision period per year (pro-rata). This is to monitor their knowledge and skills to support the needs of the service users. (previous timescale of 30/04/06 partially met)31/08/08 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. Refer to Standard OP1 OP3 OP7 OP11 Good Practice Recommendations The registered person should make sure that the homes statement of purpose and service user guide are updated to include the details of the manager of the home. The registered manager should make sure that there is consistency in the information recorded in the individual service users assessments of need. The registered manager should make sure that healthcare abbreviations and symbols are not included in the service users records. The registered person should make sure that the last wishes of the services users in the event of their deaths is recorded. This will help to develop any end of life plans for individual service users. The registered person should consider providing the senior care staff with uniforms so that they are more in keeping with the rest of the staff in the home and make them more easily identifiable to visitors and service users. DS0000033109.V343816.R01.S.doc Version 5.2 Page 30 5. OP27 De Lacy House 6. OP28 7. 8. OP31 OP33 9. OP34 The registered person should make sure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent to support the professional care that they provide in the home The registered person should make sure that the homes manager completed their application to the Commission as soon as her CRB is returned. The registered person must make sure that the homes quality assurance and monitoring system is re-established to allow other people to offer their views on how the services in the home are provided. The registered person should make sure that the accounts for the service users comfort fund is accurately recorded and kept up to date. De Lacy House DS0000033109.V343816.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 De Lacy House DS0000033109.V343816.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. 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