Inspection on 24/11/05 for Denecroft Care Home

This inspection was carried out on 24th November 2005.

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 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

Denecroft Care Home 25/07/07

Denecroft Care Home 27/06/06

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

CARE HOMES FOR OLDER PEOPLE Denecroft Care Home 200 Newburn Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9AH Lead Inspector Elaine Malloy Unannounced Inspection 24th November 2005 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 Denecroft Care Home DS0000065918.V265441.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. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Denecroft Care Home Address 200 Newburn Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9AH 0191 2676422 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) Mr Sunny Okukpolor Humphreys Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12.4.05 Brief Description of the Service: Denecroft is a care home that provides personal care to 15 older people. The home is located within a residential area of Throckley in Newcastle upon Tyne. It was built in 1911 and the property was converted to a care home and has been extended. The home is over two floors with a passenger lift. There is easy access by public transport. Local amenities and shops are available in Throckley and Newburn. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3 hours. The owner, manager, staff, residents and a visitor were spoken to. Each of the areas that the home was asked to improve at the last inspection was checked. The building and a range of records were inspected. The Inspector had also visited the home twice since the last inspection. This was to check the progress of improvements needed, and meet the new owner of the home. What the service does well: What has improved since the last inspection? Action had been taken action on each of the previously required improvements: Up to date information on the home’s services and facilities is now available. Residents’ contracts with the home were being renewed because of the change of ownership. Repairs and health and safety issues in the home have been followed up. A programme is organised to make improvements in the building. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 6 More staff have completed and are starting to study for care qualifications. All staff have criminal records checks carried out. Staff have been provided with fire safety and moving and handling training. New policies and procedures were being introduced. 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. Denecroft Care Home DS0000065918.V265441.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 Denecroft Care Home DS0000065918.V265441.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): 1, 2 and 3. Information on the services and facilities that the home provides is in place. Residents’ contracts with the home are being updated because of the change of owner. Potential residents have their care needs assessed before admission is agreed. EVIDENCE: The outstanding Requirement to update the home’s Statement of Purpose had been actioned. The outstanding Recommendation for residents who are privately funded to have appropriate contracts was being addressed. New contracts were being drawn up to reflect the home’s recent change of ownership. Records for the last resident admitted to the home were examined. These showed that the resident’s care needs had been assessed before admission. The Care Manager’s assessment and care plan had also been obtained. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 9 Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 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): 8, 9, and 10. Arrangements are in place to meet residents’ health care needs. The medication system needs to be made safer by staff always signing records for medication given. Residents confirmed that they are treated with respect, and staff maintain their privacy and dignity. EVIDENCE: Details of visits from health care professionals are recorded in individual resident’s files. The home uses two General Practitioner surgeries. The District Nurse was currently visiting twice weekly. Residents have been given influenza vaccinations. Residents receive chiropody, and visits from an optician and dentist. A minority of carers have completed medication training. The Acting Manager, Mrs Blackburn has organised further staff to attend this training course in the near future. The home uses a ‘monitored dosage system’ for medication. Medication charts were examined. Pre-printed directions for the application of prescribed creams/ointments were not clear. Mrs Blackburn agreed to make Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 11 handwritten additions and follow this up with the supplying pharmacist. Staff were not always signing the records to confirm they had given medication. Residents told the Inspector that staff are respectful. They said that personal care is carried out in private and in a dignified manner. Residents said they were happy, well looked after and that staff treat them well. One lady said that moving into the home was the best thing she had ever done. No bedrooms are shared at present. How residents want to be addressed is checked and recorded in their care file. Residents are informed that the home currently employs only female staff. A pay telephone is available in the hall or residents can make/receive calls in the privacy of the office. Mail is given to residents unopened, or kept for relatives if preferred. Systems are in place to make sure that residents wear their own clothes. Clothing is labelled and there are individual laundry baskets. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 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): 13 and 14. Contact with family, friends and the local community is maintained. Residents are given choices and encouraged to make decisions in daily living. EVIDENCE: The home has a visiting policy. Residents can receive visitors at any reasonable time, in the privacy of their own bedrooms or in communal areas. Residents make use of facilities in the community such as local shops and The Grange community centre. There are links with a local church. Consideration is being given to providing work placements for pupil(s) from a local school. A visiting relative told the Inspector she was very happy with the care given to her mother. Residents spoken with said they are offered choices and encouraged to make decisions. The extent of personal possessions brought into the home is agreed before admission. Residents with capacity continue to handle their own financial affairs. There is currently no Appointeeship responsibility within the home for any resident’s finances. In practice relatives assist and the services of solicitors can be retained. A new policy on access to personal records had recently been introduced. Denecroft Care Home DS0000065918.V265441.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. Procedures are in place for making complaints and protecting residents from abuse. EVIDENCE: The home has procedures for dealing with complaints and protecting vulnerable adults. No complaints or allegations of abuse had been received in the period since the last inspection. Denecroft Care Home DS0000065918.V265441.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, 24 and 26. The home was clean and comfortable. Recorded evidence is now kept of all works carried out in the building, and there are plans to make improvements. EVIDENCE: Outstanding Requirements to devise a programme of maintenance, renewal and redecoration, and remedy health and safety issues in the building had been actioned. Records were being kept of repairs etc carried out in the building. The new owner had conducted an audit of the home and forward planned a prioritised programme of works. Servicing agreements were also being organised. The previous Recommendation to clean stained carpets in resident bedrooms had been addressed. The outstanding Recommendation to ask all residents whether they wish to have keys to their bedroom had been followed up. All areas of the home seen were clean. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 15 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. There is suitable care staffing levels for the number of residents. The home is now on target to meet the numbers of staff required to have care qualifications. All staff have criminal records checks carried out. Staff have had fire safety and moving and handling training. EVIDENCE: At the time of the inspection there was 13 residents. 2 carers were on duty across the waking day and at night. Minimum staffing levels for 13 residents are 3 carers in the mornings and 2 carers at all other times. This was brought to the attention of the Acting Manager and the new owner. Following the inspection staffing was increased accordingly. The outstanding Recommendation for a minimum of 50 of carers to achieve NVQ Level 2 by 2005 was being addressed. There is a total of 17 care staff. 6 have completed NVQ qualifications, and a further 3 were starting courses this month. A Warning Letter was issued to the Registered Person following the last inspection about applying for Criminal Records Bureau checks for all staff. Arrangements are now in place for these checks to be carried out. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 16 The outstanding Requirement to confirm dates for staff to attend fire safety and moving and handling training had been actioned. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 17 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): 33 and 35. A new range of policies and procedures is being introduced. Personal finance recording needs to be made safer by being checked and signed by two staff. EVIDENCE: The outstanding Recommendation for a full range of policies and procedures to be located/available had been addressed. The new owner is introducing new policies and procedures. Resident personal finance records were examined. Cash is held for safekeeping for 5 residents. Each resident has an individual book with records of transactions. Entries were suitably recorded, but not all had two signatures. Receipts are kept for purchases. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 18 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X X X Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 19 NO 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 Regulation 13(2) Requirement There must be no gaps to signatures/codes in medication administration records. Timescale for action 24/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP35 Good Practice Recommendations There should be two staff signatures to transactions in residents personal finance records. Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Denecroft Care Home DS0000065918.V265441.R01.S.doc Version 5.0 Page 21 - 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. 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