Inspection on 09/05/07 for Delaheys Nursing Home

This inspection was carried out on 9th May 2007.

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

Delaheys Nursing Home 10/06/09

Delaheys Nursing Home 05/01/06

Delaheys Nursing Home 14/09/05

Delaheys Nursing Home 01/03/05

Delaheys Nursing Home 19/11/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Delaheys Nursing Home 215 Clifton Drive South Lytham St Annes Lancashire FY8 1ES Lead Inspector Mrs Christine Marshall Unannounced Inspection 9th May 2007 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 Delaheys Nursing Home DS0000006036.V330462.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. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delaheys Nursing Home Address 215 Clifton Drive South Lytham St Annes Lancashire FY8 1ES 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) 01253 714946 01253 782097 delaheysuk@btconnect.com www.delaheys.co.uk Mr Alan Wilson Mrs Carolyn Wilson N/A Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 28 service users to include: up to 28 service users in the category of OP (Older People) and up to one service user in the category of PD (Physical Disability) The home may from time to time admit one service user between the age of 55 and 65 years in the category of (PD) Physical Disability within the registered maximum of 28 service users in the category of OP (Older People) 5th January 2006 2. Date of last inspection Brief Description of the Service: Delaheys is a Care Home with Nursing that is registered to offer care and nursing for 28 people over the age of 65 years. The home has a special condition of registration that allows them, from time to time, to accommodate a person between the age of 55 and 65 years with a physical disability. The home is a detached property with ground, first and second floor levels. There is a passenger lift in place. Gardens are to all sides of the home and a large conservatory is at the front. Accommodation is in single and double rooms, some with en-suite facilities. The home is furnished to a high standard. At the time of this visit the fees for care were from £508 to £650 with some extra costs for hairdressing, newspapers and chiropody. The registered providers are Mr and Mrs Wilson and Mrs Wilson manages the day-to-day care of the home. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Delaheys included a site visit to the home that was done between late morning and mid-afternoon; the visit was unannounced, which means that the owners, staff and residents did not know it was taking place until the inspector arrived. Time was spent sitting and talking with people who use the service, alongside their relatives, and observing the day-to-day routines of the home and care staff, as they provided support. The people who live at the home said that they preferred to be called residents. A tour of the home included looking at bedrooms, lounges and dining areas, kitchen and laundry rooms. This was to assess whether the home provided a comfortable, homely environment for the enjoyment of everyone, and to ensure the residents’ safety. Comment cards were sent to the home for residents and relatives to fill in; and those that were returned showed an excellent level of satisfaction with the care at the home. Some of the views expressed were – “I can’t speak highly enough of Delaheys.” “The cleanliness is absolutely wonderful.” “We are made to feel like the Matron’s extended family. Thank you Delaheys.” Relatives’ comments included – “I have always been more than happy with my mother’s care. The staff are excellent.” “All homes should be like Delaheys.” The manager completed a pre-inspection questionnaire and forwarded it to the commission. This document contained a good level of information about the home and helped in the planning of the visit. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 6 Residents were spoken with and commented that – “It’s lovely here.” “I have been here six years and I wouldn’t want to be anywhere else.” “I have a lovely room and I am very happy.” A visiting relative said that they were happy with everything at the home and had no complaints to make. Discussions took place with the manager Mrs Wilson and administration records were looked at. Care staff were also spoken with and said that they were happy and supported in their work. Everyone at the home was friendly, welcoming and co-operative throughout the visit. What the service does well: In line with established policies and procedures, Delaheys made sure that there was equal care given to all residents, considering their individual choices and preferences, and giving equal support to all, irrespective of their race, gender, disability, sexuality, age, religion or beliefs. There was equal consideration given to all employees and there were opportunities for male, female and overseas staff, between the ages of 18 and 65 years to work at the home; training and development programmes are offered to all members of staff. The home had made sure that residents have equal access all parts of the home through a passenger lift and wheelchair ramps. Residents at Delaheys are provided with a very good standard of accommodation. Several bedrooms were viewed and each was decorated and furnished to a very good standard, personalised and very well equipped. All the residents who were spoken to said they were very happy with the standard of care and accommodation provided at Delaheys. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 7 Residents were very complimentary about the manager and care staff and said that they were approachable and very helpful. They also said that they had full choices as to what they did with their day. 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. The summary of this inspection report can be made available in other formats on request. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 8 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 Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 9 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): Standard 3 (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is gathered about prospective residents, so that their needs can be met and so that they are given a good quality of life. EVIDENCE: The pre-admission assessments were looked at for the most recently welcomed residents and these were completed very well; they were comprehensive and included all aspects of physical, social and psychological care, making sure that any strengths and needs were identified, and that the home could provide the care that was needed. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 10 These assessments were done by the manager Mrs Wilson, and agreed by the resident and/or their family. Three residents were asked if they had been visited before going into Delaheys and confirmed that they had been assessed before entering the home. Generally all residents were assessed by the same tool, thus promoting equality of assessment and care provision. These assessments were good. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents health and social care needs were met and they were supported and treated with dignity and respect at this home. EVIDENCE: Care plans are written records that describe the care that is given to each resident. Three of these were looked at and found to be very informative and individual. All aspects of care had been considered, including a good social history. Residents saidy that they knew about their care plans. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 12 Residents said that they had the GP of their choice and equally that they had regular visits by the chiropodist, dentist, optician and also hearing aid services. The medication policies and procedures made sure that the residents were safe. Trained nurses give out the medicines, and to promote equality and choice, any resident who wishes to take responsibility for taking their own medicine is able to do so after a risk assessment, and signing a disclaimer for this. The medication system was looked at and found to be satisfactory, with all records accurate. The residents were seen to be treated equally with respect, privacy and dignity, and there were good personal interactions with the nurses and carers. Residents’ comments included “I am very well looked after.” “I couldn’t even think of being anywhere else.” “The Matron (Mrs Wilson) is wonderful; can’t do enough for me.” Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit by being supported, so as to promote the quality of their daily lives. They are given full choices of daily living and provided with a wellbalanced and nourishing menu. EVIDENCE: Residents said that they were offered good choices and supported in their preferred daily routines. They said that they could go to their room or to bed whenever they wished and that they made their own choices about what time they got up in the morning: They also said that they are given options of joining in with any activities that were provided, or to have quiet time in the lounges or their rooms. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 14 There are some planned activities and residents are given the choice of these. Mostly, the people said that they preferred a quiet life. Residents all agreed that they had a good choice of food. On the day of the visit, the midday meal looked very appetising. There is equality of choice for every resident and any preferences that are requested are catered for, for example vegetarian and diabetic food. The evening meal also offers full choices, with afternoon tea and suppers available. The residents said that the food was “good”, “very nice” and “nicely presented.” The dining room was very light and well furnished and the mealtime was relaxed and unhurried, with the carers helping discretely when needed. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 15 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): Standards 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to voice their opinions and know who to speak to if they have any concerns. Adult protection and quality checks are in place, which means that residents live in a safe environment where their satisfaction is assured. EVIDENCE: There is a written complaints procedure for the residents and their relatives and this is included in the home’s information pack; a copy is in every resident’s bedroom. The residents who were spoken to said that they had no complaints at all. There have been no complaints at the home or to the Commission for Social Care Inspection. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 16 Residents also said that they could get in touch with their relatives, solicitors or anyone else that they might need for help, if they wished: There are advocacy information leaflets and advice available, which is for anyone who is without relatives and needs someone to speak on their behalf. There are very robust policies in place for the protection of vulnerable people and the care staff are given training on abuse awareness. The complaint and abuse policies are commended for their approach to voicing concerns and for protection issues. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 17 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): Standards 19,20,21,22,23,24,25 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are provided with very clean, homely and pleasantly furnished surroundings and bedrooms are personalised and very comfortable; this means that people feel at home with their photographs and belongings around them. EVIDENCE: There are sixteen single and six double rooms, and each bedroom is personalised with pictures, photographs and small items of furniture. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 18 Twelve single rooms and two double have en-suite facilities and there are adequate toilets and bathrooms throughout the home. All lounges, dining areas and bedrooms are very comfortable and furnished to a high standard: There is an ongoing refurbishment programme in place. Residents said that they were happy with their bedrooms and the lounges and conservatory. There are aids and adaptations such as grab rails in toilets and special lifting and bathing hoists for the residents who need help with their mobility. There are also assisted baths for residents that cannot get in and out of the bath without help. Laundry systems make sure that there are no problems with cross-infection and the laundry area is kept very clean and tidy. The cleanliness of the home is commendable. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live at the home have their care needs are met through good levels of staff, who have the appropriate qualifications and experience necessary to give a good care service. EVIDENCE: The list of staff on duty showed that there are good levels of nurses, carers and domestic staff on duty at the home. The carers were very friendly and helpful and showed that there is a very good mix of people in place. National Vocational Qualifications (NVQ) training programs are in place for the carers, and 100 of staff have achieved this. This is commendable. The recruitment policies and procedures are very robust and make sure that the residents are in safe hands. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 20 The staff training and personal files were looked at and each was meticulously kept with all the required information about the training programmes that had been undertaken and Criminal Records Bureau (CRB) checks. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 21 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): Standards 31,33,35,36 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager makes sure that the best interests of the residents are protected through clear leadership, staff supervision and robust health and safety checks. EVIDENCE: Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 22 Mr and Mrs Wilson are the owners of the home and Mrs Wilson manages the day-to-day running of the home. She is a Registered Nurse who holds the Registered Managers Award. Equality of care is evident throughout in the policies and procedures for all aspects of care at the home. Regular resident quality surveys are undertaken and staff have regular meetings. Nurses and carers are encouraged to be involved in the planning and giving of care. Residents said that they get surveys to fill in and that the manager spends time regularly with them. Policies are in place for the protection of residents from any financial abuse. Those residents who spoke to the inspector said that they either looked after their own money or their relatives did it for them. Confidentiality is maintained through records being stored in locked filing cabinets, with staff looking at them only when they need to find out about any particular person’s care needs. There are planned supervision programmes in place and staff files confirmed this. Care staff also told the inspector that they had regular supervision sessions, making sure that they are giving a high level of care to their residents. The pre-inspection questionnaire gave good information about the Health & Safety policies and procedures, records and equipment servicing certificates. Information was also provided about extensive contingency plans that are in place for the health and safety of the service users, staff and the environment. This is commendable. Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 23 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 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 4 17 X 18 4 4 4 4 4 4 4 4 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 4 X 4 Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 Delaheys Nursing Home DS0000006036.V330462.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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. 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