Inspection on 03/05/06 for Deansfield

This inspection was carried out on 3rd May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Deansfield 19/12/06

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 Rosalind Dennis Unannounced Inspection 3rd May 2006 10:00 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.V293704.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.V293704.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 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 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.V293704.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection to Deansfield lasted for approximately 4/2 hours and all key standards were assessed during this time. The inspection involved speaking with eight residents, observation of a random selection of resident’s bedrooms, looking at care records and observation of documents. The manager and owner were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: A requirement for the home to ensure that appropriate locks are fitted to the bedroom doors of residents remains as an outstanding requirement. However the manager and owner confirm that they are in the process of seeking alternative and suitable locks for those residents that wish to lock their bedroom door. The home did not meet the required standard regarding recruitment on this occasion, as an individual recruited from abroad had been appointed without a CRB disclosure being obtained. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 6 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.V293704.R01.S.doc Version 5.1 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.V293704.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Standard 6 is not applicable to this home. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The home has an admission procedure that is effective in ensuring that individuals moving into Deansfield know that the home will meet their needs. EVIDENCE: Care files for two residents were examined, one of these related to an individual that had recently been admitted for respite care. Both files showed that the home conducts thorough pre-admission assessments of prospective residents. The detail contained within the assessment shows that the resident and their significant other had been fully involved in the admission process. Discussions with an individual that had recently been admitted to the home confirmed their satisfaction of the admission process. Contained within care files are comprehensive “life histories” for each resident, drawn up from information given by the resident, their family and friends which provides staff with a history of the individual, enabling care to be given in a personalised way. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 9 Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and consistent care planning system in place that provides staff with the information they require to meet resident’s needs. The system for the administration of medication is satisfactory and ensures medication needs are met. EVIDENCE: Observation of two care files shows that individual choices and preferences form the basis of the care plans, such as preferred routines on waking/retiring to bed, daily routines and personal hygiene needs. A full range of individual risk assessments such as moving and handling, pressure sore and nutritional risk were also available, providing staff with all the information they require to meet residents needs safely. The format of the care plans and risk assessments demonstrate that staff have developed good relationships with residents and are aware of individual needs. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 11 Eight residents that were spoken with commented positively about the care they receive and confirmed that staff treated them well and with respect. Observation of the medication room confirmed that medication is stored appropriately and examination of medication administration charts identified that these are completed correctly. Certificates are available which show that staff involved in medication administration are appropriately trained in the Safe Handling of Medicines. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Staff at Deansfield assist residents to exercise choice as far as possible and according to capabilities. The home provides meals that offer variety and cater for different nutritional needs. EVIDENCE: The home does not have a structured activities timetable, instead activities are organised on a daily basis and according to individual needs, this can involve a game of cards, watching television, walks around the village, knitting. Discussions with residents during the inspection indicated that they were happy with the current level and type of activities provided and all spoke of how they enjoy the countryside views and watching the wildlife in the garden. Residents reported that their visitors are made welcome at any time of day and can entertain them either in the lounge or in their own rooms, the manager confirmed that the home operates an “open-visiting” policy. Residents confirmed that staff acknowledge and respect their preferred daily routines and any choices made. Residents were most complimentary about the choice and standard of meals served. The home records the dietary intake of all residents which is good Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 13 practice and the manager discussed that by recording this information staff can be alerted quickly if a resident is not eating well. Records were seen that demonstrate food is served at the correct temperature. The main home kitchen was not seen on this occasion. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints system in place and the arrangements for the protection of residents from abuse is satisfactory. EVIDENCE: Residents stated that they would feel comfortable raising any concerns or complaints with the manager, care staff or the provider. The manager confirmed that the home has not received any recent complaints or concerns. A copy of the local area adult protection procedure was observed to be readily available within the home and discussion with the manager confirmed her awareness of procedures to follow should an occasion arise. Dates for staff to attend adult protection/abuse awareness training are planned for next month. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26. Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Deansfield provides individuals with an attractive, clean and homely place to live. EVIDENCE: The areas of the home that were observed on this occasion included lounges, the dining room and a random selection of resident’s bedrooms; these were observed to be clean, well furnished and the décor satisfactory. Residents spoke of their satisfaction with their bedrooms and with the cleanliness of the home. It has been a requirement of previous inspections that bedroom doors must be fitted with locks suited to residents capabilities and accessible to staff in emergencies. The last inspection noted that locks had been fitted but were of an inappropriate type. The manager and owner report that at present only one resident has requested a key to their room and a discussion took place Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 16 regarding the appropriate lock type; the provider appears keen to achieve the requirement. The home has now fitted mixer valves to most hot water outlets that are accessible by residents and records show water temperatures for these outlets are maintained close to 43°C; prior to fitting the new valves temperatures of 50°C were recorded. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home employs appropriately skilled staff to meet the needs of residents, however it remains unclear whether the current staffing arrangements would be adequate in an emergency situation. EVIDENCE: Staffing levels remain at a minimum of two care staff on duty during the day and this figure usually includes the manager. There is only one member of staff on duty at night and this has been expressed as a concern at previous inspections. Discussions with the owner and manager confirmed that if additional support is required, the owner and a member of staff who lives on the premises are available to assist. The manager also lives nearby and provides “on-call” cover. A member of care staff who works a variety of shifts including nights considered the levels adequate and eight residents who were spoken with during the inspection felt the levels sufficient to meet their current needs. Although staffing levels appear sufficient to meet resident’s needs, as identified at previous inspections it remains unclear whether the staffing arrangements at night would be sufficient in an emergency situation, therefore further discussion with CSCI needs to take place. It was also discussed and Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 18 acknowledged by the owner that the dependency levels of residents be kept under review and staffing levels increased accordingly. Observation of staff files demonstrates that the home provides induction training to new staff, training in safe working practice topics and medication administration. As documented earlier in the report staff are due to attend adult protection training. One member of staff recently recruited by the home was observed to have all the required pre-employment checks present on file. Another individual that had been recruited from outside the UK via an employment agency had all documentation present on file apart from evidence of a CRB Disclosure. This deficit was discussed with the owner and manager and it appears there had been some confusion with the need for this individual to go through the CRB process. Clarification was provided that all prospective employees must go through the CRB process, including individuals recruited from abroad and this has led to the home not achieving this standard on this occasion. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the skills and knowledge to lead the staff team and manage the home. A well-maintained environment promotes the health, safety and welfare of residents. EVIDENCE: Since the last inspection the manager has commenced studying for the Registered Managers Award, which should further enhance already acquired skills and experience. Residents that were spoken with during the inspection were complementary regarding the service provided, level of care and the management arrangements. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 20 The home has commenced a quality assurance system based on seeking the views of residents and their representatives. A sample of questionnaires completed by residents and relating to the quality and provision of food show that residents are very satisfied with this area. The manager confirmed that other services provided by the home are to be audited. The home does not to have any involvement with resident’s financial affairs as residents and/or their representatives maintain responsibility for their own financial affairs. The areas of the home observed during the inspection appeared to be wellmaintained and safe. The manager was advised to seek advice from the local fire officer as a discussion with the manager had indicated that a number of residents prefer to have their bedroom doors open at night. No door wedges were observed in use during the inspection. All records pertaining to the maintenance and servicing of equipment were up to date and well organised. Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A 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 3 X X X X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 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.V293704.R01.S.doc Version 5.1 Page 22 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. Timescale for action 01/08/06 (Compliance not fully achieved by 20/12/05 as the home is reviewing the type of locks that are in use). 2 OP29 19 Schedule 4. The registered person must obtain CRB disclosures for all staff, including those individuals recruited from outside of the UK. 01/07/06 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 (Identified on 3/5/06 as in progress). That the manager completes her management training Deansfield DS0000020544.V293704.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 DS0000020544.V293704.R01.S.doc Version 5.1 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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