Inspection on 21/06/07 for Derby House

This inspection was carried out on 21st June 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

Derby House 31/01/06

Derby House 01/06/05

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 Rob Padwick Key Unannounced Inspection 21st June 2007 2:15 Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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 Derby House DS0000018222.V329298.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 Adults 18-65. 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. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derby House Address 25 Derby Street Barnsley South Yorkshire S70 6ES 01226 203265 none none 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) Mrs Janet Barlow Mrs Janet Barlow Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Derby House is one of a group of services operated by Mrs. Janet Barlow and is a three-bedroom terraced property in a residential area of Barnsley. The home is registered for three people with mental health needs and is within walking distance of the town centre and on a bus route. Whilst Derby House is registered as a care home for a maximum of six people with mental health needs, elements of the service are designed to ensure that people in the home are supported to be independent. The standard fee charged by the home is £296.96 with additional charges made for hairdressing, taxi fares and holidays. Derby House provides information to residents about its facilities in its Statement of Purpose and Service User Guide. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A Pre Inspection Questionnaire asking for information about the service was sent to the manager and information from this was included as part of the inspection process. Questionnaires requesting the views of people living in the home, staff and professionals in the community who know the service well were also sent, however no identifiable responses were gained from these. The Commission had received no information about the service since the last inspection. The inspection visit for this service lasted for 2.75 hours and during this period, time was spent talking with people living in the home and observing their daily lives. Other time was spent looking at their care plans and other records and talking to staff. The inspection visit also included a tour of the building. What the service does well: The manager ensures she has clear information about the needs of prospective residents, in order to confirm that the service is able to meet their needs. The home’s policies and procedures ensure admission to the service is a part of a staged and gradual process, involving visits to the home to meet other people living in the home and the staff, progressing to day visits and overnight stays. People living in the home are encouraged and supported to live as independently as possible. Daily routines are flexible in order to enable people living at Derby House to follow their own routines. People living in the home confirmed that they were supported to take part in a range of activities on a daily basis including social groups, day centres and visits to places within the local community. Staff are well motivated and provided with training to ensure they can meet the needs of people living there. Relationships in the home were observed to be positive and professional. The home is clean, well maintained and provides a comfortable and relaxing environment, which is safe and homely. The registered manager communicates a clear sense of leadership and the record keeping in the home is of a good standard. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 6 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. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 5 People who use this service experience excellent outcomes in this area. People living in the home had been involved in decisions about moving in to the service and had received an assessment of their needs prior to admission, in order to ensure that the home was able to meet these satisfactorily. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home confirmed they had been involved in decisions about moving in and had visited as part of assessment process, to try out the service and ensure it was suitable to meet their needs. Admission to the home is a carefully considered process and good records concerning the ‘settling in’ periods of people living in the home were contained within the case files inspected, together with copies of contracts which detailed agreement to the service’s rules regarding smoking, alcohol and use of drugs. No one had been admitted to the service since the last inspection visit, but the case file of the individual who had most recently moved in contained information about their individual needs, which the manager had obtained before they were admitted, so she could make informed judgements about the suitability of the service. A copy of the contract between the individual and the home was contained within the case file that was inspected, which confirmed agreement to the service’s rules regarding smoking, alcohol and use of drugs. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service experience excellent outcomes in this area. People living in the home were being supported well by staff to make responsible decisions about their lives, in order that their individual needs and choices could be appropriately met. This judgement has been made using available evidence including a visit to this service. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 10 EVIDENCE: People living in the home confirmed they were able to make decisions about their lives and that staff supported and encouraged them to be as independent as possible. One of the case files of people living in the home was inspected which contained person centred plans of support as well as goals identified as part of a recent annual development plan, together with actions needed in achieving these. The support plans covered a range of aspects of health, social and emotional need and focussed on developing the strengths of the individual concerned. Discussion with people living in the home confirmed they participated in regular evaluations and reviews of their care plans, in order to ensure they continued to reflect their needs and wishes. Daily recordings in the case file indicated that the assessed needs of people living in the home were being appropriately monitored, with evidence of good liaison with members of the wider Community Multi Disciplinary Teams as required. People living in the home said that staff were helpful and observation throughout this inspection visit indicated that positive and friendly relationships existed between these two groups. Information about the management of identified risks to people living in the home was contained within the case files that were inspected, together with information for staff on what to look out for and do in these matters. A recommendation is made that these are directly linked to each of the elements contained within the individual support plans, in order to ensure that they provide clearer guidance on how the individual’s concerned can be best supported. Staff demonstrated good insight into the support required to assist people living in the home to make informed choices, which were consistent with their individual rights and responsibilities. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use this service experience good outcomes in this area. People living in the home were being encouraged to maintain and develop their social and independent living skills so that their lifestyle needs and wishes could be appropriately met. This judgement has been made using available evidence including a visit to this service. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 12 EVIDENCE: The group of people living at Derby House have a range of support needs and from discussion with them it was apparent that they were able take part in a variety of activities according to individual preference. The routines at the home were flexible and geared to enabling choice and maximising independence. People living in the home were observed freely coming and going during this inspection visit and case files inspected contained evidence of support with attending day centres, help with domestic tasks and carrying out personal interests. Staff were observed offering helpful support and advice to individuals and the interactions within the home were open and friendly. People living in the home confirmed they contributed to decisions about things like choices of food served, outings and other activities in the home. Generally, staff prepare meals served in the home and discussion with people living at Derby House confirmed these were of good quality. Inspection of the associated records for these indicated that the dietary provision was healthy and nutritious. The service has a visiting policy and procedure and people living in the home confirmed that they were able to have friends visit or stay with relatives. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service experience good outcomes in this area. Staff were supporting and encouraging people living in the home to ensure that their health and personal care needs were appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home were largely independent with regard to their personal care and discussion with them indicated that staff encouraged them to take an interest in this aspect of their lives, in order to promote their general sense of well being and personal dignity. The support plans inspected contained information about the wishes and preferences of the individual concerned, together with guidance for staff about particular issues to be aware of. The case file inspected documented issues and aspects of the health needs of the individual, together with evidence of liaison with medical professionals as required. People living in the home confirmed they were supported to attend medical check ups and other health related appointments as needed. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 14 The service had a medication policy and procedure to ensure that staff adhered to this aspect of practice safely. People living in the home confirmed they had been consulted about assistance with their medication needs. Risk assessments contained within the case file identified if the individual was able to administer their own medication together with evidence of support from staff to ensure they were complying with their responsibilities in this regard. Staff confirmed they had received training on the safe use and handling of medication and a random inspection of the home’s medication records confirmed that these were being satisfactorily maintained. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good outcomes in this area. The concerns of people living in the home were being taken seriously and staff had received training to ensure that people living in the home were protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service had satisfactory policies and procedures to ensure that the concerns of people living in the home were taken seriously and that they were safeguarded from abuse. The Commission for Social Care Inspection had received no complaints about the service since the last inspection visit and people living at Derby House said they felt staff listened to their views and they knew how to make a complaint, if they needed to. The home’s complaints log contained no entries since the last inspection and positive feedback received from professionals associated with the home were contained in the home’s quality assurance records. Information provided by the manager confirmed that staff in the home had received formal training about the protection of vulnerable adults and discussion with the staff member on duty indicated she was aware of the home’s policies and her responsibilities in these matters. People living in the home are encouraged to manage their own finances and discussion with them confirmed they were able to spend their weekly allowances how they chose. The records of money held on behalf of the people living in the home were randomly checked and found to satisfactory. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use this service experience good outcomes in this area. The home was being well maintained and was clean and comfortable, so that people living in the home had an environment that could safely meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a domestic property and inspection of the building confirmed it was clean and being well maintained. Records relating to the upkeep of the service indicated that action was being taken to ensure people living in the home had an environment that was homely and safe. The doors on the bedrooms were not fitted with locks, but discussion with people living in the home confirmed they had been provided with secure facilities for the storage of valuables and evidence in the case files indicated that they had been consulted about this. All of the people living in the home stated that they enjoyed living at Derby House. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People who use this service experience good outcomes in this area. Staff had received training to ensure they could support the needs of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home confirmed that staff supported them in meeting their needs. The staff member on duty displayed confidence in her interactions with those living in the home and it was evident that strong relationships existed between these two groups, with friendly advice and assurance being provided where this was needed. The file of the staff member contained evidence of an appropriate training and induction programme, in order to ensure staff were equipped with the necessary skills to do their jobs. Whilst the file contained details of an annual personal development appraisal having been carried out, some gaps were identified in the regularity of supervision taking place. A recommendation is made about this. Information provided by the manager indicated that 50 of the staff team had obtained an NVQ at level 2 or above. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 18 The home had a recruitment policy and procedure in place to ensure staff were safe to work with the people living in the home. No new staff had been employed in the home since the last inspection visit and examination of the file of the staff member on duty confirmed these had been appropriately followed. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use this service experience good outcomes in this area. The conduct and management of the service was good with appropriate record keeping and involvement with people living in the home, in order that their health, safety and welfare is promoted and protected. This judgement has been made using available evidence including a visit to this service. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager has many years experience within the caring profession and is currently undertaking her Registered Managers Award. A deputy manager has recently been appointed and discussion with him confirmed that he is a qualified registered mental health nurse and is enrolled on a diploma in management course. Both staff and people living in the home expressed confidence in the management’s leadership style and evidence of good communication was seen in the minutes of regular meetings held. This ensured that both staff and people living in the home could participate in decisions about the home. Evidence was seen of close management support systems and whilst not present all of the time, the managers visit the service on a very regular basis. People living at Derby House confirmed they could contact them at other times and that they were quick to respond to requests for support. Quality assurance systems had been developed to ensure the service was meeting its aims and objectives and feedback contained within the records for these from both professional staff and people living in the home was very positive in nature. All the home’s records inspected were well organised and carefully maintained and plans had been developed relating to the business, staff training and the upkeep of the home. Information provided by the manager indicated that regular checks were being carried out to ensure the health and safety of staff and people living in the home. A random check of the home’s records confirmed these were up to date with certificates relating to fire, gas and electricity satisfactorily in place. Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 4 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 22 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. 1. Refer to Standard YA9YA9 Good Practice Recommendations The registered manager should consider linking the risk assessments for the people living in the home directly to the elements contained within their care plans, in order to provide clearer guidance on how they can be best supported in these respects. The registered manager should ensure that staff receive regular formal supervision The registered owner/manager should attain the Managers Award. 2. 3. YA36YA36 YA37YA37 Derby House DS0000018222.V329298.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Derby House DS0000018222.V329298.R01.S.doc Version 5.2 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. 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!