CARE HOMES FOR OLDER PEOPLE
Deansfield Kynnersley Telford Shropshire TF6 6DY Lead Inspector
Mike Moloney Unannounced Inspection 20th December 2005 10:30 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 Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 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.V274359.R01.S.doc Version 5.1 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 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th August 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 DS0000020544.V274359.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on the 20th December 2005 over one and a quarter hours and was carried out as a routine unannounced visit. A partial tour of the premises took place and a number of risk assessments relating to the residents were looked at as were a range of other records relating to safety. A number of the residents were spoken to during the visit with some being more able to express themselves than others. 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 DS0000020544.V274359.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: All of the key standards in this section were assessed at the last inspection on 18th August 2005 and were found to have been met. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: All of the key standards in this section were assessed at the last inspection on 18th August 2005 and were found to have been met. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: All of the key standards in this section were assessed at the last inspection on 18th August 2005 and were found to have been met. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: All of the key standards in this section were assessed at the last inspection on 18th August 2005 and were found to have been met. The manager did, however, confirm that no new complaints had been received since the last inspection. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 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 the following standard(s): 24, 25 and 26 Service users are protected from being burned by hot surfaces and they are provided with an appropriate laundry service. The type of door locks used on the bedroom doors make this home unsuitable for those wishing to lock their bedroom door whilst in the room as if a key is to be issued to a service user then the inner key hole must be made unusable to ensure that a key is not left in the lock. It was not possible to ascertain whether or not service users wanted or were capable of being safely given a bedroom key. EVIDENCE: Two requirements outstanding from previous inspections had been wholly or partially addressed. The home had been required to fit radiator guards to reduce the chance of a service user being burned on the hot surfaces. Work on these was seen to be well advanced with all but one having been fitted. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 Page 12 The other requirement related to the fitting of door locks to the residents rooms. New locks have been fitted to the majority of the rooms but, unfortunately, an inappropriate type have been installed. No records were available to show whether or not service users wished to or were assessed as being capable of using a key to their bedroom. During the visit the laundry facilities were seen to meet the national Minimum Standards with the bedding and the clothes of all of service users seen looking clean and fresh. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: All of the key standards in this section were assessed at the last inspection on 18th August 2005 and were found to have been met. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Although the manager does not possess all of the qualifications required by the National Minimum Standards it is still considered that the outcome for standard 31 is met. However, it could only be of benefit to the service users if she were to compete her management training. The quality assurance processes adopted by the home are appropriate to the size of the establishment and the safety procedures that are in place promote the health, safety and welfare of the staff and service users. EVIDENCE: The manager has achieved NVQ4 in care and is supported in the day to day management of the home by the joint proprietors as well as their accountants. Within her duties she routinely obtains the views of the service users and their relatives and would address any complaints should the needs arise. The proprietors are regularly on the premises to assist her with this task as well.
Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 Page 15 The proprietor stated that the home does not manage the cash for any of the service users. The home’s fire log was seen to have been regularly completed providing evidence of such things as fire alarm checks. A hot water temperature check record was seen to have been maintained with assurances from the manager that the staff had been instructed to check the temperature as each bath is filled. The manager also reported that the kitchen had recently been inspected by an Environmental Health Officer who had not needed to make any requirements or recommendations. A range of risk assessments were seen to have been developed since the requirement to do so was made at the last inspection. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 Page 16 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x 2 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 Page 17 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 OP24 Regulation 12.4.a Requirement If a bedroom door key is to be issued to a service user then the inner key hole must be made unusable to ensure that a key is not left in the lock. Records must be available to show whether or not service users wished to or were assessed as capable of being given a key to their bedroom. Timescale for action 20/12/05 2 OP24 12.4.a 20/12/05 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 OP31 Good Practice Recommendations That the manager completes her management training. Deansfield DS0000020544.V274359.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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