CARE HOMES FOR OLDER PEOPLE
DEFOE COURT Defoe Crescent Newton Aycliffe County Durham DL5 4JP Lead Inspector
Belinda Parker Unannounced 6 June 2005 9:00am
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Defoe Court Address Defoe Crescent, Newton Aycliffe, County Durham. DL5 4JP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01325 316 316 01325 316 633 Highfield Home Properties Ltd Mrs Lynn Clark Care Home 41 Category(ies) of TI Terminally Ill, 3 places, OP Old Age, 41, PD registration, with number Physical Disability, 4 of places DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Up to 4 persons above the age of 55 may be accommodated within the category of PD commensurate with the home`s Statement of Purpose. Date of last inspection 16th December 2004 Brief Description of the Service: Defoe Court is a registered care home with nursing. It is owned by Highfield Home Properties Ltd and located in a residential area of Newton Aycliffe, close to all local amenities. The home is situated in its own private grounds and provides personal care and accommodation for up to 41 older people. The home is purpose built for older people and is on two floors. Personal accommodation and communal areas are located on both floors. Service areas are located on the ground floor. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on 6/6/05 over a period of 5 hours. On the day of the inspection discussion took place with service users, staff and one relative. We toured the building and a number of records were examined. Since the last inspection seven of the eight requirements made have been addressed. What the service does well: What has improved since the last inspection?
Since the last inspection the manager was able to show that she has a clear plan for development of the home and evidence was available to show that there has been many improvements to the internal and external environment, which improves the overall standards of comfort for service users. A review of records has taken place and systems have been introduced to improve the quality and frequency of the information recorded to ensure the protection of service users. Staff morale has improved due to improved training opportunities, and being able to have time to sit and discuss their role and professional development with their line manager. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 6 A relative spoken to and staff said that over the past six months the overall service has improved. 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. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 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 standard(s) EVIDENCE: This standard section was not assessed at this inspection. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 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 standard(s) 7 and 9 Since the last inspection the system for evaluating care plans is more consistant and clear to ensure the needs of individual service users is being met. Limited progress has been made in ensuring the correct procedure is followed for receiving medication into the home, which potentially could put service users at risk. EVIDENCE: Since the last inspection the development of care plans has progressed. The manager has implemented a monthly programme for staff to ensure that all care plans are evaluated monthly and changing needs of individual service users is identified and actioned. Mar sheets examined showed that on occasion staff are still not signing for receipt of medication into the home (issue highlighted at the last inspection). The manager said discussion has taken place with staff to address this issue as this is important to ensure the protection of service users. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 14 The range of activities available are flexible and varied to meet the collective needs of the people who live in the home. The manager conducts the home in a way to enable service users to exercise their autonomy and choice, but this should be developed further to provide other forms of information i.e advocacy services. EVIDENCE: Since the last inspection the programme of activities has improved. The manager consults with the activities co-ordinator and service users as to the choice of activities to be made available. A weekly list is displayed in the home but this is flexible according to weather etc. A three monthly programme has been developed for major activities such as trips out, musical entertainment and other events in the home. Two service users spoken to said they were aware of the range of activities available but they preferred not to join in, another service user said he enjoys attending musical events n the home. Service users spoken to said they were able to make their own choices and decisions and staff listened to their views. The manager said she still has to obtain information on advocacy services (outstanding since the last inspection) to enable service users to make an informed choice as to whether they wish someone independent to speak on their behalf.
DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Improvements for the recording of the outcome of complaints since the last inspection ensures that there is now a clear and consistant complaints system in the place, with some evidence available to show that the service users views are listened to. EVIDENCE: Since the last inspection the process for recording the outcome of complaints made to the home has been improved ensuring the protection of service users. Since the last inspection their has been six complaints made to the home by relatives and a visitor. These complaints consisted of : 1 1 1 1 1 1 x x x x x x Housekeeping/ care issue – partially upheld visitor being kept waiting to speak to nurse in charge – not upheld Care Practice - upheld care Practice - upheld Housekeeping - upheld Staff attitude – partially upheld. Service users and a relative spoken to during the inspection said the manager and staff are approachable and they would not hesitate to speak to them if they were not satisfied with the service. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22 Recent investment has significantly improved the appearance of this home creating a comfortable and safe enviroment for those living there and visiting. EVIDENCE: Since the last inspection there has been improvements made to the overall environment e.g renewal of some furniture, carpet, redecoration and landscaping to the front elevation of the building to improve the standard of comfort for service users. Work is still ongoing to address all the remaining enviromental issues highlighted at the last inspection e.g redecoration and baths. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 and 29 Staff morale is good resulting in an ethusiastic workforce that works positively with service users to improve their quality of life. EVIDENCE: Since the last inspection discussion with staff and evidence available showed that training is provided relevant to the role and responsibility of staff to equip them with the skills and abilities to provide a good standard of service to the people who live in the home. The procedure for the recruitment of staff has improved. Personnel files examined included the required information to ensure the protection of service users. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35, 36, 37 and 38 The manager has a clear development plan for the home with some evidence that this plan is effectively communicated to service users, staff and relatives. Work is continuing to improve the standards of comfort, maintaining a safe environment for the people who live in the home. EVIDENCE: The manager had available for inspection a copy of the annual budget and monthly variances to show that the home was being run efficently and effectively. Since the last inspection the company has introduced a revised system for recording and accounting for money held by the home on behalf of service users. This system is potentially restrictive to service users in that individual service users money held on site is pooled and not on an individual basis.
DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 15 The manager has developed and implemented a system of formal supervision for staff, which covers all aspects of care practice, philosophy of care and career development needs. Staff spoken to said they thought this system was beneficial for their professional development to enable them to deliver a good standard of service to service users and other visitors to the home. All records examined during the inspection with the exception of specified MAR sheets were current and up to date, which ensured the protection of service users and other visitors to the home. DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 2 15 x
COMPLAINTS AND PROTECTION 2 x 2 3 x x x x STAFFING Standard No Score 27 x 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x 3 2 3 2 2 DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9, OP37, OP38 Regulation 13 (2) Requirement The registered manager must ensure staff responsible for receiving medication into the home adhere to the correct procedure i.e sign MAR sheets on receipt of medication (outstanding since the last inspection) Timescale for action immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19, 21 Good Practice Recommendations The registered provider should continue with the plan to redecorate and replace/repair specified baths where enamel is worn away (Outstanding since the last inspection). The registered manager should obtain and display information on advocacy services in the home. (Outstanding since the last inspection) The money held on behalf of individual service users in the home should not be pooled. 2. 3. OP14 OP35 DEFOE COURT B54 S39763 Defoe V231304 060605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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