Inspection on 18/08/05 for Deansfield

This inspection was carried out on 18th August 2005.

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 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

Deansfield 19/12/06

Deansfield 03/05/06

Deansfield 20/12/05

Deansfield 08/03/05

Deansfield 14/09/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Deansfield Kynnersley Telford Shropshire TF6 6DY Lead Inspector Terry Woods Unannounced 18 August 2005 09.30 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Deansfield Address Kynnersley Telford Shropshire TF6 6DY 01952 603267 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sheila Foster Mrs Daphne Coope Care Home 16 Category(ies) of 16 Old Age registration, with number of places Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: Deansfield is owned by Mrs S Foster, Mrs T B Foster and Mr D B Foster, and registered with the Commission for Social Care Inspection to provide care for 16 Older People. The Registered Manager is Mrs Daphne Coope. It is a residential home situated in a former Victorian Rectory and is set within two acres of attractive gardens in the rural village of Kynnersley, Nr Telford. The village is accessible by the local bus service or by car. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 18th August 2005 over two and a quarter hours and was carried out as a routine unannounced visit. A full tour of the premises took place and samples of five residents’ care records and all staff records were inspected. Seven of the residents were spoken to during the morning. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 6 The home has a satisfactory and functional admissions procedure providing an effective needs assessment and suitability evaluation for prospective residents. EVIDENCE: Care files for five residents were examined, two of which were the most recent admissions. Good evidence was seen of pre-admission assessments. No community care / single assessment documentation was seen however one file contained a hospital discharge sheet. The home’s assessment process forms a natural path to the care planning system Deansfield does not provide an intermediate care facility. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 There is a clear and consistent care planning system in place to adequately provide staff with the information they require to satisfactorily meet residents’ needs. EVIDENCE: The care planning system used at Deansfield is effective and contains the required components to identify individual care needs and set out the care to be provided. Three care plans were examined in detail and there is good evidence of daily reporting, general well being notes and regular monthly reviews carried out by the home. Case tracking identified two individuals with diabetes, the management of which was confirmed in conversation with each resident, dietary evidence, medication records and the observed visit of a supporting community nurse. Outstanding requirements with regard to medication storage and record keeping have been completed satisfactorily. Staff were observed showing respect and kindness towards residents. Residents themselves reported that the carers were pleasant and always provide what they wanted. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Deansfield provides a good homely lifestyle for the people in residence. Meals at Deansfield are of a good homely type offering a variety and catering for special dietary needs. EVIDENCE: A group of residents spoken with in the lounge prior to lunch reported initially that they were ‘bored’ and ‘sat around’ a lot. However they later reflected on some of the in house activities available but said they did not always want to join in. Reading newspapers or books that are made available was mentioned as well as watching television, videos and listening to music. Two residents spoke of their pleasure in going for short walks when the weather is fine. Residents reported that their visitors are made welcome and could ‘entertain’ them either in the lounge or in their own rooms. A visitors record book is available for completion in the entrance hall. Residents reported that they are very satisfied with the meals offered at Deansfield. They added that it is ‘home cooking’ and that there is ‘always plenty to eat’. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has a satisfactory complaints system in place The arrangements for the protection of residents from abuse are satisfactory. EVIDENCE: The home has a readily accessible book kept in the entrance hall for the recording of complaints. The only entry was made in 2003 and concerned a minor issue. There have been no complaints directed to the Commission for Social Care Inspection within the previous 12 months. There is an adult protection policy and procedure in place, which as previously reported, staff feel that they are able to operate effectively should such an occasion arise. The owner advised that the home does not as a rule hold money or valuables for residents. This was confirmed in conversation with a group of residents in the lounge. Only one said that she kept money about her person to spend, whilst the others relied totally on their families to manage their finances. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 & 25 Deansfield provides a homely and comfortable environment for those in residence. The owner continually avoids meeting certain requirements made at each inspection which in some cases has the potential to place residents at risk, EVIDENCE: On the day Deansfield presented as a homely, comfortable and generally safe place for those in residence to live. The owner reported that all outstanding redecoration at the home has now been completed and observations confirmed that the walls and paintwork generally were in good decorative order. Residents spoke of the pleasure of being able to use the new lift rather than the stairs, which they said has been an asset to the home for the benefit of those less ambulant. A tour of the home was undertaken and all areas including residents’ rooms were seen to be clean and well furnished. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 12 It has been a requirement of the previous three inspections that bedroom doors must be fitted with locks suited to residents capabilities and accessible to staff in an emergency. A resident consultation exercise has been undertaken and a document shown at the previous inspection contained signed statements by Residents, all of whom declined the offer to have a key to their room. The statements, which should now include a further three newly admitted residents, were no longer available and said to have been misplaced. The Inspector was, as during the previous inspection, informed that the home is still awaiting delivery of locks with longer shafts to enable fitting to the thicker ‘fire doors’. A further previous requirement made for the owner to install radiator covers for the protection of residents has not been completed and four radiators (two in individual residents’ rooms) remain unguarded. There are no health and safety risk assessments completed other than those concerning moving and handling. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 There is a stable staff group working positively and enthusiastically to provide the residents with a quality of life that meets their individual requirements and aspirations It is not clear whether the current staffing arrangements which includes support by the owner are adequate in an emergency situation EVIDENCE: Generally, the Home has a minimum of two Care Staff on duty at any one time, which includes the manager. The duty rota and observations on the day confirmed this. Care Staff on duty considered that these levels were adequate to meet the current needs of the residents. A Domestic Assistant, two Cooks and two Handymen support the Care Staff. The owner, Mrs Foster, who lives in a flat on the second floor reported that she is always available on call. This includes supporting the lone working waking night staff member. It is noted however that Mrs Foster is now seventy five years of age and as observations suggest not in good health. The manager reported that she remains available to advise staff over the telephone at most times whilst off duty. Three members of the care staff have completed the NVQ level 2 programme and one has completed NVQ level three. All the staff’s individual training records were inspected and confirmed that everyone had completed induction training and essential statutory courses including fire safety, moving and handling, food hygiene and the safe handling of medicines. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 14 The home’s recruitment procedure is robust and includes an application form, interview process, two references and a CRB check prior to starting work. Staff files are kept to the standard required. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 37 & 38 The systems in place to ensure that residents’ health, safety and welfare are promoted and protected including environmental issues are not adequate. EVIDENCE: Records are generally well kept although staff training documents are no longer up to date. A requirement made at the previous inspection concerning the weekly monitoring and recording of bath water temperatures is not being completed and has the potential to place residents at risk. Quality monitoring documents were available to be given out to residents and sent to families however there was no evidence presented of any being completed. The owner and the manager suggested that their system was too complicated for residents to understand and complete. They will be reviewing this to make it more user friendly. There were no family visitors on the day to contribute to the inspection. Staff files contained evidence of recorded formal supervision being carried out regularly. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 16 The manager confirmed that the home does not manage any residents financial affairs. This was confirmed in conversation with a group of residents. Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 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 3 x x x x 2 2 x 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 Standard No 16 17 18 Score 3 x 3 x x x x x 3 3 2 Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24.5 Regulation 12.4.a Requirement The home is required to fit all bedroom doors with locks suited to residents capabilities and accessible to staff in an emergency The home is required to ensure that all radiators are guarded or have guaranteed low temperature surfaces The home is required to carry out risk assessments to allareas with regard to the health and safety of the residents The home is required to carry out weekly recorded monitoring checks concerning the regulated delivery of hot water to all baths Timescale for action 19.10.05 2. 25.5 13.4.a.c 19.10.05 3. 38.6 13.4.a.c 19.10.05 4. 38.3 13.4.a.c Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Deansfield E56 E01 S20544 Deansfield UAI V245147 180805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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