Inspection on 06/10/05 for Dearne Valley Care Centre

This inspection was carried out on 6th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Dearne Valley Care Centre 29/06/06

Dearne Valley Care Centre 09/06/05

Dearne Valley Care Centre 15/12/04

Dearne Valley Care Centre 20/04/04

Dearne Valley Care Centre 07/10/03

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dearne Valley Nursing Home Furlong Road Bolton On Dearne Rotherham South Yorkshire S63 9PY Lead Inspector Jayne Barnett-Middleton Unannounced Inspection 6th October 2005 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 Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 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. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dearne Valley Nursing Home Address Furlong Road Bolton On Dearne Rotherham South Yorkshire S63 9PY 01709 893 435 01709 892 128 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) Guardian Care Homes (UK) Limited Vacant Care Home 34 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (14) of places Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The managers hours are full time supernumary to the care staff hours. The minimum staffing levels specified in the Residential Forum Care Staffing in Care Homes for Older People must be maintained at all times, in accordance with actual occupancy levels. The upper floor is to be used exclusively for service users in the category DE, the ground floor is to be used exclusively for service users in the category of OP. 9th June 2005 3. Date of last inspection Brief Description of the Service: Dearne Valley Care Centre is a purpose built care home in the village of Bolton on Dearne. The home provides personal care and accommodation for thirty-four older people, including care for twenty service users with Dementia. All bedrooms have en suite facilities. Ample car parking is provided at the front of the property and there is a small, enclosed garden to the rear of the property. The home stands back from the main road. The village has a range of amenities including a railway station. The A1 motorway is approximately ten minutes drive from the home. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.30 am to 3.00 pm. Most of the service users were seen during the inspection. Seven service users, eight staff, two visitors, one visiting professional and the manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. Throughout the inspection positive and professional relationships were observed between staff and service users. The inspector wishes to thank the manager, staff and service users for their time and cooperation throughout the inspection process. What the service does well: What has improved since the last inspection? All previous requirements had been met. The care plan format had been reviewed however some work was still required to ensure that they met the required standard. All areas throughout the home were clean and one bedroom carpet had been replaced, which promoted a hygienic environment. The manager was in the process of recruiting extra staff to ensure that staffing levels were above the required minimum. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 6 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. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 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 Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 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. Service users were not admitted to the home without their needs being assessed. Service users were given the opportunity to visit the home prior to their admission. EVIDENCE: A full needs assessment was carried out for all service users prior to their admission. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. Service users and two relatives said that they had been invited to visit the home prior to their admission, to assess the quality, facilities and suitability of the home. One visitor said that she had chosen Dearne Valley for her relative due to the home being “friendly” and “clean”. The home does not provide an intermediate care service. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 9 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): 7,8,9,10 and 11. Service users individual needs were assessed. Care plans were in need of some amendments to ensure that they met the required standard. Service users had good access to health care services, which met their assessed needs. The recording and storage of medication required reviewing to promote the safe administration of medication. Service users privacy and dignity was respected EVIDENCE: Three Care plans set out in detail the action that was required by staff to ensure that all aspects of service users care needs were met. The care plan format had recently been reviewed to ensure that all of the required information was available. The care plans checked did not demonstrate that they had been completed with the involvement of the service user, to enable them to agree that it was a true reflection of their care needs. Service users preferred funeral arrangements were not recorded, to ensure that their wishes following their death could be respected. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 10 Records of healthcare visits were maintained and these evidenced that other healthcare professionals, e.g. general practitioner, chiropodist and optician were visiting service users. Service users said that their healthcare needs were met and were able to describe the healthcare visits that they received. One visiting health care professional confirmed that the staff were “always helpful” and said that the staff would follow the advice that they gave to promote and maintain the residents health. Comprehensive risk assessments had been completed. They clearly identified the individual risks that were presented to service users on a daily basis and the action required to reduce the risk, which enabled service users to live as independently as possible. The moving and handling risk assessment in one care plan checked did not clearly identify the equipment and techniques required to safely care for the service user. The recording and storage of medication was checked on a sample basis. One medication administration record (MAR) checked stated that the prescribed medication should be administered twice per day, however medication had only been administered once per day and there was no clear record to demonstrate why the medication had not been administered. Two service users prescribed medications were checked and the amount in stock was more than the record stated had been administered. Gaps were noted on several medication administration records and it was difficult to determine if the prescribed medication had been administered. The manager agreed to audit the recording and storage of medication to promote the safe administration of medication. Service users were observed be receiving personal care in a manner that respected their privacy and dignity. One service user confirmed, “The staff always respect my privacy”. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 11 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. The daily routines within the home were flexible and promoted service user choice. Service users were encouraged to maintain contact with their family, friends and the local community as they wished. Service users were encouraged to make informed decisions with regards to their daily lives. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: There was a relaxed atmosphere within the home. Service users were observed to be following their preferred routines. Several service users were sitting in the lounges either reading or socialising with other service users whilst others had chosen to spend time in the privacy of their bedroom. Service users said that the routines within the home were flexible and confirmed, “The staff give me choices”. Service users said that their friends and relatives were welcome to visit them at any reasonable time. One relative confirmed that they visited the home regularly and that they were always made to feel welcome. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 12 Service users said that they were satisfied with the level of activities provided which included bingo and professional entertainment. An activities worker was due to commence employment at the home and service users were looking forward to the planned activities. A good choice of menu was offered and special dietary needs were catered for. The cook had a good knowledge of service users dietary requirements. Service users said that they enjoyed their meals and described the food as “very good” and “a good choice”. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 13 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. The complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure, however some staff had not received adult protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Service users stated that they were satisfied with the care provided. They confirmed that if they did have any problems about their care, they were confident that the staff was “approachable”, and would listen and resolve any concerns that they may have. A recent complaint had resulted in an adult protection investigation. The area manager confirmed that she had investigated and acted upon the issues that had been identified. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The majority of staff had received adult protection training to promote the protection of service users. However, one member of staff who had recently commenced employment at the home stated that they had not received training or instruction on the homes adult protection procedures. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 14 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): 19,20,23,24 and 26. The home was clean, comfortable and very well maintained. Service users were provided with an environment that was safe, accessible and homely. EVIDENCE: The home was very well maintained. Service users had access to two lounges, which were bright and pleasantly decorated. The furniture and fittings were of a good quality. The handyman who was employed at the home carried out a routine programme of maintenance to promote a safe environment. Several bedrooms were checked and all were very clean, attractively decorated and individually furnished. All bedrooms seen had been personalised by the service user with small items of furniture, photographs and mementoes, which encouraged service users to retain their own identity. Service users said that they were happy with their bedrooms “ I like it”. All areas within the home were very clean. One relative commented that the home was “always spotless”. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 15 The Staff had attended Infection Control training enabling them to promote a hygienic environment to control the risk of infection. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 16 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): 27,29 and 30. A training and development programme was in place. Staff received regular training, which enabled them to meet the needs of service users. The home operated a recruitment procedure, which needed some amendments to promote the protection of service users. EVIDENCE: All service users spoke positively about the staff team and described them as “very friendly” “helpful” and “they make sure that I am o.k.” Staff rotas checked, demonstrated that the agreed staffing levels were being met to meet the individual needs of service users. The area manager had recently reviewed the required hours specified by `The Residential Forum Care Staffing in Care Homes for Older People`. The manager stated that she was in the process of recruiting extra staff to ensure that staffing levels were above the required minimum. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Staff training records evidenced that staff had attended various training courses that included food hygiene, fire, moving and handling, infection control and first aid. One member of staff who had recently been employed at the home confirmed that they had received induction training to enable them to appropriately care for service users and that the staff team had been “Very helpful”. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 17 A recruitment policy and procedure was in place that promoted the protection of service users. Two files checked did not contain a full employment history of the employee. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 18 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. Service users and staff benefited from the ethos, leadership and management approach. Service users financial interests were safeguarded by the procedures at the home. The homes policies and procedures promoted the health, safety and welfare of service users and staff. EVIDENCE: There was a relaxed and friendly atmosphere within the home. Service users were comfortable to talk about the care that they received. All service users spoke positively about the staff team describing them as “good” and “they do well”. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 19 The manager had been employed at the home for almost two weeks. All service users, staff and relatives confirmed that she had taken the time to introduce herself and felt positive about her appointment. The manager confirmed that she had planned a staff meeting and that she aimed to hold regular service user meetings, to enable them to contribute to the development of the service. Service users were encouraged to manage their own finances, which enabled them to maintain their independence. Arrangements were in place for service users who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. The two records checked were very well maintained and safeguarded the financial interests of service users. Detailed Records of accidents and injuries were maintained to ensure that service users were provided with the appropriate observation and supervision required. A handyman was employed at the home and a routine programme of maintenance was in place. Areas throughout the home were well maintained which promoted a safe environment. The staff had received regular training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 20 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 2 8 3 9 2 10 3 11 2 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 2 3 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 X 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 Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 21 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 2 Standard OP7 OP11OP7 Regulation 12,15 13,15 Requirement Care plans must be completed with the involvement of the service user (where practical) Moving and handling assessments must clearly demonstrate the action required by staff to safely care for the service user. Service users preferences regarding funeral arrangements must be recorded on their care plan A review of the storage and administration of medication must be carried out. A record of current medication for each service user must be maintained. Records of medication administered to service users must be maintained. Records of medication in stock at the home must be maintained. All staff must receive adult protection training and guidance. Staffs’ personal files must contain a record of the employee’s full employment history. Any gaps in employment DS0000036246.V254379.R01.S.doc Timescale for action 01/11/05 01/11/05 3 OP7 12,13 01/11/05 4 5 6 7 8 9 OP9 OP9 OP9 OP9 OP18 OP29 13 13 13 13 13 19 16/09/05 16/09/05 16/09/05 16/09/05 31/10/05 30/11/05 Dearne Valley Nursing Home Version 5.0 Page 22 must be accounted for and recorded. 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 OP28 Good Practice Recommendations A minimum of 50 of care staff should attain NVQ Level 2 in care by 2005. Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Dearne Valley Nursing Home DS0000036246.V254379.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!