Inspection on 01/06/05 for Derby House

This inspection was carried out on 1st June 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Derby House 21/06/07

Derby House 31/01/06

Derby House 09/03/05

Derby House 15/10/04

Derby House 11/02/04

Derby House 08/01/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Derby House 25 Derby Street Barnsley South Yorkshire S70 6ES Lead Inspector Jayne Barnett-Middleton Unannounced 1 June 2005 09:30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Derby House Address 25 Derby Street Barnsley South Yorkshire S70 6ES 01226 203265 None None Mrs Janet Barlow 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) Mrs Janet Barlow PC Care home only 3 Category(ies) of MD Mental Disorder (3) registration, with number of places Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9 March 2005 Brief Description of the Service: Derby House is one of several domestic properties owned by Mrs Janet Barlow. The home is a three-bedroom terraced property in a residential area. It is close to Barnsley town centre and is on a bus route. The home is registered for three persons with mental health needs. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.30 a.m to 12.15 p.m. Three service users, the member of staff on duty and the registered manager/owner were spoken to. A sample of records were examined and an inspection of the property was carried out. Throughout the inspection positive and professional relationships were observed between the manager, staff and service users. The inspector wishes to thank the manager, staff and service users for their time and welcoming the inspector into their home. What the service does well: Service users were satisfied with the support that they received and described the manager and staff as “very good” and “supportive”. The home had a relaxing and friendly atmosphere. Care plans checked set out in excellent detail the action that was required by staff to ensure that all aspects of service users personal, social support and healthcare needs were met. Through discussions and observations it was evident that residents were encouraged and supported to make decisions relating to their own lives. Service users confirmed that they attended various activities on a daily basis that included social groups; day centres and visiting places within the local community. Service users were supported to maintain positive links with their family and friends. The staff employed had worked at the home for several years and had an excellent knowledge of service users life history, likes, dislikes and care needs, which enabled them to provide a personal level of care. Relationships between the staff, manager and service users were observed to be professional and caring. The manager and staff had an excellent knowledge of service users healthcare needs and were able to demonstrate the individual Support that they required. All areas throughout the home were very clean and it was evident that the manager and staff team were committed to encouraging service users to maintain a clean and hygienic environment. All staff had received training and the manager had good links with local colleges and training, which enabled her to keep up to date with training courses that were available for the staff team. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 6 The registered manager/owner had many years experience within the caring profession and it was evident that she was committed to supporting service users to live independently and enjoy a good quality of life. 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. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 and 4. Prospective service users and their relatives were provided with the information that they needed. A full needs assessment was carried out. Prospective service users were given the opportunity to visit the home for trail visits before making a decision to live there. EVIDENCE: A Statement of Purpose and Service Users Guide were available, these provided service users and their relatives with the information that they needed to make an informed choice about living at the home. The service users guide had been updated to include the most recent inspection report. A full needs assessment was carried out for all service user prior to their admission. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. There was an admission policy to ensure that prospective residents were able to visit the home before making a decision to move there. Introductory visits were offered which included day visits and overnight stays. A record of ‘settling in’ periods was maintained in service user files, which detailed service users progress and their compatibility with other service users living at the home. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9. Care plans were detailed and were reviewed on a regular basis to reflect the changing needs of service users. Service users were encouraged and supported to live as independently as possible. Service users were offered the opportunity to contribute to the quality of service that they received. EVIDENCE: Care plans checked set out in excellent detail the action that was required by staff to ensure that all aspects of service users personal, social support and healthcare needs were met. The Care plans had been completed with the involvement of the resident, which gave them the opportunity to agree with staff the help that they needed to live as independently as possible. Care evaluations were carried out on a monthly basis to ensure that the changing needs of service users could be monitored. Through discussions and observations it was evident that residents were encouraged and supported to make decisions relating to their own lives. One service user said “we are encouraged to live independently”. Service user meetings were held regularly, which enabled service users to contribute to the running and organisation of the home. Service users said that the meetings were “useful”. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 10 Resident files contained detailed risk assessments relating to all aspects of residents lives both inside and outside the home. They clearly identified the individual risks that were presented to service users on a daily basis and the action required to reduce the risk, which enabled service users to live an independent lifestyle. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 13,15 and 16. Service users were encouraged to maintain and develop social and independent living skills. Opportunities were provided for service users to engage in activities within the local community and to maintain positive relationships with their relatives and friends. Service users rights were encouraged and respected. EVIDENCE: All Service users participated in the day to day organisation of the home. Service users had formulated a rota for household chores with the assistance of staff, and service users said that this “still works well”. All areas within the home were very clean, tidy and it was evident that this arrangement worked very well. Service users maintained very good social skills and were comfortable in conversation and welcoming the inspector into their home. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 12 Service users confirmed that they attended various activities on a daily basis that included social groups, day centres and visiting places within the local community either with staff or independently. One service user had recently been encouraged to join a local lunch club which she was “enjoying and the food is beautiful”. Service users were supported to maintain positive links with their family and friends. One service user confirmed that they “Visited “ their family at weekends. One service user had several pen friends and said, “I write to my family regularly”. It was evident that the staff promoted independence, individual choice and freedom of movement. Staff were observed to be asking service users what their plans for the day were and encouraging them to spend their day constructively. The staff employed had worked at the home for several years and had an excellent knowledge of service users life history, likes, dislikes and care needs, which enabled them to provide a personal level of care. Relationships between the staff, manager and service users were observed to be professional and caring. Staff were observed to be respecting service users privacy and dignity. Privacy locks were fitted to bathroom doors but there were no locks to bedroom doors. The manager/owner confirmed that she was in the process of providing locks for service users who had chosen to have one fitted. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20. Service users received personal support, which promoted their privacy, dignity and independence. Service users physical and emotional needs were met. Service users were protected by the homes policies and procedures for dealing with medicines. EVIDENCE: The manager and staff had an excellent knowledge of service users healthcare needs and were able to demonstrate the individual Support that they required. One service user file (Care Plan) checked demonstrated that service users were visiting healthcare professionals at regular intervals, e.g. general practitioner, community psychiatric nurse, dentist and chiropodist. One service user who had recently suffered ill health had received excellent support to access the appropriate help. Staff were able to demonstrate the action that they had taken to access the help that the service user required, and were observed to be supporting the service user with their planned healthcare appointments. Daily records checked evidenced that detailed records of the service users physical and emotional health were being monitored to ensure that the appropriate care and support could be offered. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 14 There was a medication policy and procedure to ensure that staff adhered to safe practices. Staff had received medication training; all promoting that medication was appropriately administered to residents. Residents had been consulted about staff assisting them with medication, risk assessments had been carried out to identify if service users could administer their own medication. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The homes complaints procedure was clear and accessible. Service users were confident that their views would be listened to. There was an adult protection procedure and all staff had received adult protection training. EVIDENCE: The home had a complaints procedure. The registered manager/owner visited the home on a regular basis. Staff and service users described the manager/owner as “approachable” and were confident that she would listen to any concerns or comments that they may have. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. All staff had received adult protection training, which enabled them to identify and report any allegations or incidents of abuse to residents. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. The home was clean, comfortable and very well maintained. Service users were provided with an environment that met their individual needs and lifestyles EVIDENCE: The home was warm, well maintained and was furnished in a homely manner. All the bedrooms were clean and brightly decorated. Service users had been encouraged to personalise their bedroom with personal mementoes. All areas throughout the home were very clean and it was evident that the manager and staff team were committed to encouraging service users to maintain a clean and hygienic environment. There was a pleasant enclosed garden, which was well maintained. The home is situated to Barnsley town centre and there was good access to local transport and amenities. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34.35 and 36. A caring and committed staff team supported residents. All staff received training and support appropriate to their role. The home operated a thorough recruitment policy that promoted the protection of service users. EVIDENCE: Service users were satisfied with the support that they received and described the manager and staff as “very good” and “supportive”. The staff had been employed at the home for several years, which enabled them to have a good understanding of service users individuals needs. It was evident that staff and service users had developed positive and professional relationships, and that service users were confident in the staffs abilities to support them in their daily lives. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 18 All staff had received training that included adult protection, medication, food hygiene and first aid. The manager confirmed that both members of staff held an NVQ qualification, which developed their skills and competence. The manager had good links with local colleges and training agencies, which enabled her to keep up to date with training courses that were available for the staff team. Staff had recently completed health and safety and fire refresher training. The manager had planned for staff to attend a ‘Disability Rights’ training course. A thorough recruitment policy and procedure was in place that promoted the protection of service users. Two staff files checked contained a range of required information including two references, declaration of health and qualifications/training. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level. A thorough induction programme was in place for new employees. One to one support and supervision was offered to new staff until they had a good knowledge of service users individual needs and were confident to work unsupervised. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40 and 42. Service users and staff benefited from the leadership, experience and management style of the homeowner. Staff received excellent support and were appropriately supervised. Policies and procedures were in place that promoted and protected the health, safety and welfare of service users and staff. EVIDENCE: The registered manager/owner had many years experience within the caring profession which, enabled her to contribute to the care of service users and communicate a clear sense of leadership to staff. The manager had recently completed the NVQ assessor’s award to support the staff in achieving a NVQ qualification. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 20 Staff and service users described the manager/owner as “brilliant” and “approachable”. The manager had an excellent knowledge of service users individual needs. There was a relaxed and friendly atmosphere within the home and positive relationships were observed between the manager, staff and service users. The manager visited the home on a regular basis to support the staff and to keep up to date with service users progress. The records sampled were very well organised, up to date and securely stored in accordance with the data protection act. All documents checked were thorough and information was easy to track. The staff had received regular training to promote the health, safety and welfare of service users and their colleagues. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 x 3 x 3 2 x Standard No 31 32 33 34 35 36 Score x 3 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Derby House Score 3 4 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 4 x 3 x J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA16 Regulation 12,16 Requirement The registered person must provide locks on bedroom doors and service users must be offered a key(subject to their risk assesemnt). Timescale for action 1st August 2005. 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 YA37 Good Practice Recommendations The registered owner/manager should attain thier Managers Award by 2005. Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ground floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Derby House J51 S18222 Derby House V230358 01.06.05 UI Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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