Inspection on 25/07/07 for Denecroft Care Home

This inspection was carried out on 25th July 2007.

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 27/06/06

Denecroft Care Home 24/11/05

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 Key Unannounced Inspection 09:45 25th to 31st July 2007 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.V344211.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. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 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 Mrs Catherine Yvonne Routledge Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Denecroft is a care home that provides personal care for up 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 are 11 single and 2 double bedrooms. Both double rooms are currently used for single occupancy. No bedrooms have en-suite facilities. Two bathrooms and four separate toilets are provided. There is easy access by public transport. Local amenities and shops are available in Throckley and Newburn. A guide to the home’s services and inspection reports are readily available at the home. The current weekly fee is £373 for residents funded by the Local Authority or who are privately funded. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out by: • Looking at information received since the last inspection on 27th June 2006. • Getting the provider’s view of the service and how well they care for people. • An inspector visiting the home on 25th and 27th July 2007. • Talking to the provider, manager and other staff about the service. • Looking at records about the people who live at the home and how well their needs are met. • Looking at a range of other records that must be kept. • Checking that staff have the knowledge, skills and training to meet the needs of the people they care for. • Looking at the resources that the home has to operate the service. • Getting the views of people who use the service, and their relatives by talking to them and from surveys they completed. What the service does well: People living at the home feel they are offered personalised care and have their privacy and dignity respected. They said, “The staff here have made a real family home for which I am truly grateful”, “I am very well looked after”, and “I like the small, intimate nature of the home and have settled well”. Relatives were also complimentary about the care provided and praised the staff. Residents have their individual health, personal and social care needs thoroughly assessed. Each person has well recorded care plans that show what he or she can do independently and how staff will give assistance. A good level of support is given to access medical professionals and meet residents’ health care needs. There are safe medication practices and trained staff administers medication. A variety of social activities and outings are provided that residents have been consulted about. Residents are supported to maintain contact with their family and friends, and the local community. Each person is encouraged to live their preferred lifestyle and make choices and decisions. Residents are offered a good diet and said they enjoy the food. There is a clear complaints policy that residents and visitors understand and would use if they were unhappy about the service. Procedures are in place to prevent abuse and staff receive training on protecting vulnerable people. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 6 Residents live in clean and comfortable accommodation that is maintained to a good standard. Staffing levels are appropriate to meet the needs of the number of people living at the home. New staff are properly recruited and vetted to make sure residents are not put at risk. Staff receive suitable training on meeting the needs of older people and a wider range of courses is being offered. An experienced manager who is working towards a management qualification runs the home. Residents have their personal finances safeguarded. There are safe working practices to promote residents’ health, safety and welfare. 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. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 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.V344211.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are considering moving into the home have their care needs properly assessed before admission is agreed. EVIDENCE: The care records of the last two people admitted to the home were examined. Care Manager assessments are obtained from Social Services where the Local Authority is funding the person’s placement. The home’s manager and/or senior worker visit the person in their home or hospital and carry out an assessment of his or her care needs. The assessment also verifies that the person and/or their relatives have visited the home prior to admission. Daily notes recorded on the day of admission showed details of the person’s usual routines and preferences. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 9 The majority of residents who completed surveys said they received enough information before moving in so they could decide if it was the right place for them. A new resident told the inspector that she has settled well at the home and her needs are being met. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have good standard care plans that show how their individual care needs will be met. Residents have access to a full range of medical services and are well supported in meeting their health care needs. Residents are protected by the home’s medication policy and practices. Staff uphold resident rights to privacy and dignity and treat them with respect. EVIDENCE: Residents have a range of ongoing assessments completed that are updated monthly. Information from assessments is used to record individual care plans. The manager has been providing in-house care plan training for staff. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 11 The sample of care plans examined were well recorded and addressed identified health, personal and social care needs. Interventions were personalised to the individual and demonstrated their independent abilities. ‘Acute’ care plans are put in place where the person has short–term needs, for example if they are poorly. The plans are evaluated at least monthly to show how they are working. Entries to day and night reports were recorded to a variable standard. The inspector discussed with the manager how these could be improved to reflect better links to care plans. Residents use two local GP practices. The District Nursing Service visits as needed. There are arrangements for an optician, dentist and podiatrist to attend residents at the home. Vision and hearing tests are organised. A phlebotomist provides input to residents who take anticoagulant medication. A psychogeriatrician is currently monitoring one resident with mental health frailty. All contact with health care professionals is recorded. Each resident who spoke to the inspector or completed a survey said they always receive the medical support they need. One lady said her health needs were very well attended to. Other comments included, “Very prompt when needed”, and, “If I am not well the manager sends for the doctor”. Information about each person’s medical history and current health conditions is obtained before admission and recorded. Appropriate aids and equipment are used to assist independence and as preventative measures, for example pressure-relief cushions and mattresses, and moving and handling aids. Residents have their moving and handling, nutrition, and continence needs assessed. Good examples were seen of care plans addressing these needs and other specific medical conditions. The manager has reviewed and improved records that show how residents with continence needs are assisted with toileting. Risks associated with individual’s vulnerability are assessed and action to be taken to minimise or manage risks is planned. Examples seen included managing risks of falling, skin conditions and behaviour that could affect the resident’s welfare. Residents are asked if they wish to take responsibility for their prescribed medication. No residents currently self-administer medication. All staff who administer medication have completed relevant training, and some were in the process of updating training. There is a photograph of each resident at the front of their medication charts for identification purposes. The home uses a monitored dosage system and receives pre-printed charts from the pharmacist. Handwritten directions for medication were thoroughly recorded. Medication charts were satisfactorily Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 12 recorded. There were no gaps to signatures to verify medication given, and codes were entered to confirm any reason why medication was not given, for example ‘refused’. No residents currently take Controlled Drugs. The home has procedures in place for ensuring privacy and dignity and confidentiality. The manager said that staff aim to offer personalised care and respect individuals rights. Examples were given relating to residents refusing medical tests and treatment. Privacy and dignity issues are built into resident care plans. All personal care and any medical examination/treatment are carried out in the resident’s bedroom. No bedrooms are currently shared as the two double rooms are used for single occupancy. Residents told the inspector that staff are friendly and respectful. Each person is asked the name he/she wishes to be addressed by and this is recorded. Residents are informed that the home employs an all female staff team. Residents have use of a cordless telephone or can make/receive calls in private in the office. Mail is given unopened to residents and staff will support with reading and dealing with correspondence if this is needed. Denecroft Care Home DS0000065918.V344211.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): 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of daily activities and monthly outings are offered to help residents meet their social needs. Residents are well supported to maintain contact with relatives and friends and make use of the local community. Residents are actively encouraged to make choices and decisions and keep control over their lives. Residents enjoy the food and menus are being changed to offer more choice of meals. EVIDENCE: Residents who spoke with the inspector confirmed there are flexible routines and they are offered plenty of choice. They said they choose how to spend their days and some described following their own interests. Each resident has a social assessment that provides details of his/her background, lifestyle, Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 14 routines and interests. The information is used to draw up individual social care plans. Residents are consulted about social activities, outings and events at Resident Meetings. There is a three-week activities programme that is displayed on a notice board in the dining room. The manager said the programme is flexible and residents sometimes choose a different activity on the day. A social diary is recorded of activities that have taken place and the residents who participated. Entries showed activities such as reminiscence, sing-a-long, bingo, armchair exercises, cards, dominoes, baking, quiz, and arts and crafts. Staff need to make sure that they keep the diary up to date. Outings are organised to take place monthly. Residents usually opt to go out for pub lunches, however the next trip is to South Shields and other places of interest are being explored. One resident said they had enjoyed a day out for pub lunch very much. Residents who completed surveys gave variable responses to being asked whether there are usually activities arranged by the home that they could take part in. Two said there ‘always’ are, two said ‘usually’, one said ‘sometimes, and one resident said there ‘never’ are. One person commented, “Not active enough”. Another resident said that they call the numbers when bingo is played. The home has an open visiting policy and visitors are welcomed. Residents choose whom they wish to see and to receive visitors in their bedroom or communal areas. Telephone contact is encouraged where relatives and friends are unable to visit regularly. The manager said that there is generally good support from relatives. They are invited to attend individual’s care reviews and advocate on the resident’s behalf if necessary. Staff and relatives support residents to make use of local and wider community facilities. Visitors who completed surveys said the home always or usually helps their relative/friend to keep in touch with them. Each said they are kept up to date with important issues affecting their relative/friend. One person commented that they are very satisfied and another said staff contact them immediately to inform them of any matters. The home has policies on residents maintaining autonomy and being offered choices. Personal choices are built into individual’s care plans. Some residents continue to take responsibility for managing their own finances. Residents choose how to personalise their bedroom. They are informed of the furnishings provided and agree the extent of possessions to bring in before they are admitted. Care plans are discussed with residents and relatives at care reviews. The manager reported progress is being made in involving residents in their care planning to make sure individual preferences are established. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 15 Visitors who completed surveys said the service supports people to live the life they choose and meets the different needs of people. One person commented, “My mother and I are very, very happy and satisfied with the care”. The home has a 4-week cycle of menus with set meals, though alternatives are always available. In recent weeks the cooks have been introducing more choice of dishes to residents. This is with a view to revising menus in the near future and including second choice of meals. The manager is planning to introduce preference sheets and look at information on the dietary requirements of older people. Resident nutritional needs are assessed and weights are monitored. Independent eating is encouraged with aids, if required, and staff support. Seasonal events and special occasions are catered for. On the day of the inspection residents had been going on an outing but the transport was cancelled. A fish and chip lunch was purchased from a local chip shop, followed by homemade rice pudding. Residents who talked with the inspector said the food at the home is very good and plentiful. One lady commented that there is good home cooking and extra portions are offered. Each resident who completed a survey said they like the meals. One person commented, “Always satisfactory”, and another said, “The meals are always nice”. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 16 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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear complaints procedure that residents and relatives understand and are confident to use. The home has appropriate procedures to protect residents from harm and trains staff to prevent abuse. EVIDENCE: The complaints procedure is provided to residents and is displayed in the home. Residents who spoke to the inspector and completed surveys said they would know who to speak to if they are unhappy and how to make a complaint. Each visitor who completed a survey also indicated they know how to complain. The Commission has not received any concerns or complaints about the home since the last inspection. No complaints have been made directly to the home during this time. The manager is aware of her responsibility to take prompt action in response to any complaints received. The home has a range of policies and procedures on recognising the signs of, and preventing abuse, protecting vulnerable adults (POVA), and ‘whistle Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 17 blowing’ (informing on bad practice). The manager and seven staff have completed safeguarding training. The remaining staff have been provided with in-house training whilst awaiting places on external courses. Residents told the inspector that staff treat them well and they feel safe living at the home. In the period since the last inspection the registered persons notified the Commission that a care worker was dismissed for neglecting residents and putting them at potential risk. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 18 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): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable building that is maintained to a good standard. EVIDENCE: The inspector looked around the building. All areas seen were suitably furnished, decorated and equipped. In the past year the kitchen has been refitted, and some bedrooms have had new carpets and been redecorated. New carpets are being ordered for the lounge, dining room and corridors. CCTV has been installed to doorways for security. The gardens are well maintained and consideration is being given to providing a patio area. Audits of the building are carried out and records are kept of day-to-day repairs and maintenance. Servicing agreements are in place for facilities and equipment. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 19 The provider is currently looking into the possibility of extending the building to accommodate people with dementia. The home has policies and procedures on hygiene and control of infection. Six staff to date have completed infection control training and further staff will be trained in the near future. The manager will be designating a member of staff to be a link person and attend meetings with the local Health Protection Agency. There are suitable hand-washing facilities throughout the building with liquid soap and paper hand towels. Supplies of disposable aprons and gloves are provided for staff use. The home has arrangements to dispose of clinical waste. All parts of the building seen were clean. Residents who talked to the inspector and completed surveys said the home is always fresh and clean. One lady praised the domestic staff and said her room is kept “spotless”. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are provided to meet residents’ needs. Good progress is being made in care staff gaining nationally recognised care qualifications. This enables residents to be cared for by skilled and competent workers. There is a thorough recruitment process to make sure residents are protected from unsuitable people being employed. Staff receive a good level of training on meeting the diverse needs of older people. EVIDENCE: Care staff employed at the home are over 18 years of age and staff left in charge are over 21. At the time of the inspection there was 13 residents. The rotas showed that there were three carers on duty in the morning (Monday to Friday), and two carers in the afternoons, evenings, and at night. Following discussion with the provider and manager, arrangements have been made to also have three carers in the morning at weekends. The home now has two Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 21 designated senior carers and a ‘bank’ carer to cover absences. Suitable weekly domestic and catering hours are provided. Residents who completed surveys said they receive the care and support they need. All said staff listen and act on what they say and that staff are “always” or “usually” available when they need them. Comments included, “I was very worried when I knew I had to give up my home and come into care. But I need not have worried. The staff here have made a real family home for which I am truly grateful”, “I find the staff very helpful, very polite and very nice indeed”, and, “The staff are always there to listen to you”. Visitors said the home meets the needs of their relative/friend, gives the support/care they expected and that staff have the right skills and experience. Comments included, “I am very satisfied at the level of care my mam gets”, “The care home has always given support and care as far as I am aware”. One person indicated they did not know about staff qualifications but said, “They certainly have the ability of dealing with the residents with kindness and understanding. I do believe they do their jobs well and have enough experience behind them to look after people properly”. The home has made progress with the number of care staff who have achieved National Vocational Qualifications (NVQ) Level 2 or equivalent, as recommended at the last inspection. Ten staff have NVQ Level 2 in care. Six staff are currently studying for qualifications, three staff at Level 3 and three at Level 2. All staff are recruited subject to Criminal Records Bureau (CRB) checks being carried out. One new staff member has been employed in the past year. Her recruitment file was examined and this was satisfactory. Information included application form, suitable references, interview assessment, and health questionnaire and statement. The manager has followed up on the previous requirement for all staff files to have photographs and statements of medical fitness. The home has links with training providers. Records of training and certificates are kept for each staff member. The manager is introducing a new induction training programme. In the past year staff have received training in the following areas: safeguarding adults, moving and handling, health and safety, food hygiene, infection control, and medication. In-house training had taken place on care plans, and protecting vulnerable adults. The manager said that staff were starting to do some distance learning courses on understanding dementia, report writing and the Mental Capacity Act. She is also sourcing training on continence promotion, and death and dying. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced and effective manager manages the home in the best interests of the residents. A variety of methods are used to check the quality of the service and improve standards. Residents have their personal finances properly safeguarded. There are good health and safety systems and practices to promote resident welfare. EVIDENCE: Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 23 Since the last inspection, Mrs Yvonne Routledge has been approved as the home’s Registered Manager. She is experienced in working with older people and has achieved NVQ Level 3. She is in the process of studying for the Registered Manager Award qualification and expects to complete this by the end of 2007. Mrs Routledge receives good support from the Registered Provider Mr Humphreys who is at the home most days. She is also supported in the management of the home by two senior carers. Residents commented positively about the level of contact they have with the manager and provider. The home’s quality assurance system has been further developed. A policy is in place that shows measurable methods that are used to check the quality of the service. Surveys have been introduced for residents, relatives and staff to ask their opinions on the quality of the service. A summary of the findings will be discussed at the next Residents Meeting and included in the home’s Service User Guide. Mrs Routledge said she acts on ideas for improvement. An example of this is that staff now wear name badges, as suggested by a resident. The manager and senior carers carry out a range of audits. These include checks of the environment, and auditing medication records, personal finances and care records. Residents and relatives are consulted about the standards of the service at meetings and individual care reviews. Residents told the inspector they are happy with the service provided at the home. Many commented on the personalised care and support. A lady who had recently moved in said she likes the small, intimate nature of the home. Visitors who completed surveys were asked what they feel the home does well. They said, “They seem to always have time for individual clients”, and “Tends to my mothers every needs. Excellent!” Relatives were also asked how they think the home can improve; no comments were received. Residents can hold cash in the home’s safe for personal spending. Personal finances records were examined. Individual sheets are recorded for each person’s account. Transactions are suitably recorded and two signatures verify each entry. Receipts are obtained for purchases and an internal receipt book is also used. Checks of balances and cash are carried out. Staff undertake health and safety training and courses in safe working practices (fire safety, moving and handling, first aid, food hygiene, and infection control). The home has a health and safety policy and associated procedures. Risks assessments are documented for safe working practices and potential risks in the environment. The manager was updating the assessment for smoking in line with the new smoke-free legislation. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 24 The fire logbook was examined. Entries showed that all fire safety checks, tests and instructions to staff are conducted at the required frequency. The Fire Brigade had approved the home’s fire risk assessment in January 2007. Accident reporting was appropriately recorded and demonstrated any first aid/treatment provided and follow up checks to any injuries. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 25 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 3 X 3 X 3 X X 3 Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 26 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. 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. 1. 2. Refer to Standard OP7 OP12 Good Practice Recommendations Day and night reports should be developed and show better links to care plans. The social diary should be kept up to date to show all activities that have been provided. Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. Extracts may not be used or reproduced without the express permission of CSCI Denecroft Care Home DS0000065918.V344211.R01.S.doc Version 5.2 Page 28 - 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!