Inspection on 19/12/06 for Deansfield

This inspection was carried out on 19th December 2006.

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 03/05/06

Deansfield 20/12/05

Deansfield 18/08/05

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 Pat Scott Key Unannounced Inspection 19th December 2006 11:00 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 Deansfield DS0000020544.V323653.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. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deansfield Address Kynnersley Telford Shropshire TF6 6DY 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) 01952 603267 None Mrs. Sheila Francis May Foster Mr. David Barry Foster, Mrs Thelma Buenafe Foster Mrs. Daphne Coope Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2006 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 15 Older People. The Registered Manager is Mrs Daphne Coope. It is a care home providing personal care 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. The home has a statement of purpose and service use guide. The inspection report is available in the entrance hall. The homes fees are 337.47 per week. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, staff records kept in the home, medication records, discussion with people who use the service, discussions with the staff team, discussion with the manager, tour of the premises, quality assurance process, Fire Authority reports, Environmental Health Office reports, observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? What they could do better: The provider should consult with the Fire and Rescue Service to determine the best system for maintaining security and safety at the front door/escape route. Please contact the provider for advice of actions taken in response to this Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 6 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. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Key Standard 3. National Minimum Standard 1 and 4 Prospective residents and their representatives may not have the information needed to choose a home which will meet their needs They have their needs assessed which determines the level of care they will receive after admission. EVIDENCE: Prospective service users are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and help them to feel comfortable in their surroundings, and enable them to ask any questions about life in the home. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 9 Admissions to the home only take place if the manager is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. The staff team are qualified and experienced to work with the needs of the service users. Documentation and training logs record that staff have recently been provided with training. e.g. infection control, manual handling and diabetes. The home provides a statement of purpose that is supported by a service user guide. These documents could not be located and it was thought that a service user had removed them. The manager reported that each service user is provided with a statement of terms and conditions prior to moving to the home. This sets out what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the service user. Terms and conditions are reviewed on a regular basis. These are being reviewed since the change in the Regulations September 2006. Admissions are not made to the home until a full needs assessment has been undertaken. Admission documentation seen was fully completed. For people whom are self funding and without a care management assessment the assessment is always undertaken by a skilled and experienced member of staff. Evidence confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the service user where the service user agreed. Where the assessment has been undertaken through care management arrangements the manager keeps a copy in the care plan file. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 7.8.9.10 The health and personal care, which a service user receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The service has a strong belief that it is essential to involve service users in the planning of care that affects their lifestyle and quality of life. Each service user has a plan that has been agreed with them. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes a risk assessment. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 11 The home ensures that each service user’s plan is reviewed regularly and involves the service user and where agreed their family. There is very good documentation to support this. The plan is updated and the necessary action taken to respond to any changes. All members of staff regard the plan as a working tool, they understand the plan and work to it. Service users receive clear feedback on all decisions and actions that affect the placement and their individual care. Service users have right of access to health and remedial services. The health care needs of those residents too frail to leave the home are managed by visits from local health care services. A district nurse was visiting the home during the inspection. Service users’ personal aids are well maintained and the home provides the necessary aids and equipment to support both staff and service users in daily living. Service users have individual health care plans that give a comprehensive overview of their general health and acts as an indicator to changing health needs. Service users have the choice to shower or bath when they wish, and are supported and facilitated to be independent in their personal hygiene. The home works to an efficient medication policy supported by procedures and practice guidance. There are no service users who have the capacity to keep and take their own medication. Medication charts were seen and fully completed. Particular attention is given to ensuring privacy and dignity when delivering personal care. Staff make every effort to enable service users to choose who delivers their care and respect their preferences. Deansfield is a small home and staff and service users were seen to be very comfortable in each others company. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 12.13.14.15 Service users are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Service user receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: The routines of the home are planned around the service users needs and wishes. The home encourages service users to take control of their life and be actively involved in the running of the home. Service users were confident to discuss their views and commented that they didn’t feel any improvements could be made. The home takes service user feedback seriously and makes changes where possible. Staff were seen to listen to service users as they went about their work. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 13 Sufficient staff resources are provided to allow time for activities and stimulation. The home is small which enables closer service user staff relationships where likes, dislikes and needs are shared. The home has developed a system for displaying information and bringing attention to community events and activities. When service users have particular interests every effort is made by staff to help the service user maintain their interest and keep up any community involvement. The design of the home provides seating areas within the communal areas of the home where service users can entertain their visitors, in addition to the privacy of their own room. Service users have the choice to bring a limited amount of small goods with them on admission to the home and are encouraged to keep personal items which are important to them in their own room. The home believes that service users should always be aware of any information held and written by the home, and have the right to read any documents they wish and staff promote this. This was seen clearly recorded in the care plans. Food and mealtimes are treated as an occasion and something to be looked forward to. An experienced cook is responsible for providing quality nutritional meals that meet the dietary needs of the service users. The cook talks on a daily basis with service users, listen to their choices and suggestions for the menu. The cook is familiar with the dietary requirements recorded in the service users care plan and provides a diet that meets their individual needs. E.g. there are currently 7 diabetics in the home. Tables are set attractively with the necessary cutlery and aids to help individuals during their meal. Birthdays and celebration are made special for individual service users. The home had recently enjoyed a Christmas party. Regular drinks are available and service users stated that staff will always make a cup of tea at any time when asked. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 16.18 Residents have access to a complaints procedure, are protected from abuse and have their legal rights protected. EVIDENCE: The service has a complaints procedure that is up to date, clearly written, easy to understand and on display. Service users stated they knew who to talk to if they were unhappy about anything. The complaint log recorded the last entry as 2003. None have been received since at the home or at the CSCI. Training of staff in the area of protection is regularly arranged by the home. 4 staff have recently completed this training with a further 5 attending in January 2007. Service users stated that they are very satisfied with the service provision, feel very safe and well supported by staff that have their protection and safety as a priority. Staff ensure that they can access places of worship or community facilities of their choice. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Key Standards 19.26 The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence but staff practice does not keep all designated escape routes accessible in the event of fire. EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the service users. Overall, it is a pleasant, safe place to live. Where rooms are shared it is only by agreement, and screening provided for privacy. Service users have the choice to bring small personal items of Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 16 furniture into the home. All the homes fixtures and fittings meet the needs of the service users and can be changed if their needs change. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. The home is well lit, clean and tidy and smells fresh. The manager has organised infection control training for staff. The front door is kept locked for security. The manager stated the key used to be hung on a hook by the door to let in visitors, for use in an emergency or in the event of fire. The manager stated that a service user has been removing the key so it was placed elsewhere. This does not allow for quick escape in an emergency and although there are other fire exits in the home, the main door is a designated escape route. This is particularly important as only one waking staff member is on at night. It took a few minutes to allow the inspector entry on arrival as staff were locating the key. This is not safe working practice. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 27.28.29.30 Staff in the home are trained and skilled to fulfil the aims of the home and meet the changing needs of residents. The service users, on balance, are safeguarded by the vetting process. EVIDENCE: Rotas show the staff on duty. The night shift is covered by one waking staff. The manager reported that a member of staff who lives on the top floor of the home is always available and she and the provider are very close by if they are needed. The rota does not state this arrangement. The manager should clearly record who is on the ‘sleeping duty’ for each night of the week rather than rely on the ‘loose arrangement which currently exists. Service users said that staff working with them are very kind, and are consistently able to meet their needs. The manager ensures that all staff employed receive relevant training. Topics such as adult protection, first aid and infection control have been covered this year. Induction was examined at the key inspection in May 2006 and found to be satisfactory. There have been no changes to this process. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 18 The service has a good recruitment procedure that clearly defines the process to be followed. This procedure has previously been followed in practice with one exception of a missed CRB check at the last inspection for an agency worker. This could not be verified at this fieldwork visit as the certificates could not be accessed by the manager, although she did report that this shortfall had been rectified. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 31.33.35.38 The management and administration of the home is based on openness and respect. Effective quality assurance systems developed by the provider enables service users to comment on the service they receive. EVIDENCE: The manager has completed the registered managers award and is awaiting the result. She works to continuously improve services and provide an increased quality of life for service users. There is a strong ethos of being open and transparent in all areas of running of the home. The manager is service user focused and leads and supports a long serving staff team who have been recruited and trained to a good standard. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 20 The home has a good record of meeting relevant health and safety requirements and legislation. Records are of a good standard and are routinely completed. Where issues have been identified, for example, in care plans, these have been acted upon successfully to ensure service user care is not compromised. Service users said they had confidence in the safe working practices of staff. Improvement required to staff practice regarding the front door fire escape has been reported on in the environment section. The manager has the skills and ability to provide a quality assurance and monitoring process which had been implemented earlier this year. Service users and their families take responsibility for managing their own money. Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 21 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 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 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 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 23(4)(b) Requirement The registered person shall ensure adequate means of escape through the front door fire exit. The registered person shall keep a record of the duty roster of persons working at the care home, and a record of whether the roster was actually worked. Timescale for action 19/01/07 2 OP27 17(2)sche dule 4(7) 19/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Deansfield DS0000020544.V323653.R01.S.doc Version 5.2 Page 24 - 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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