Inspection on 12/09/05 for Derbyshire Haven Care Home

This inspection was carried out on 12th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Derbyshire Haven Care Home 19/07/07

Derbyshire Haven Care Home 19/07/06

Derbyshire Haven Care Home 23/02/06

Derbyshire Haven Care Home 09/03/05

Derbyshire Haven Care Home 26/08/04

Derbyshire Haven Care Home 20/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Derbyshire Haven Care Home 2 Brendon Road Wollaton Nottingham NG8 1HW Lead Inspector Linda Hirst Unannounced 12 September 2005 @ 10:30 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 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. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Derbyshire Haven Care Home Address 2 Brendon Road, Wollaton, Nottingham, NG8 1HW 0115 9282110 0115 9133595 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) The Trustees of the Lucy Derbyshire Annuity Fund Barbara Mary Hadfield Care home only (PC) 11 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12/9/05 Brief Description of the Service: Derbyshire Haven is an eleven bedded purpose built home for older people situated near to Wollaton Park. The home is owned by the Lucy Derbyshire Annuity fund. The manager assesses the service users and they can reside at the home for as long as their needs can be met by the staff and facilities. The home is near a local church; park and bus ride to the city centre. The individual accommodation for the service user comprises of a bed/sitting room and shower/toilet. The home has two floors the second accessed by a lift. The staff team comprises of a manager, two deputies, care assistants and two cooks. The care assistants also undertake domestic duties. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting two residents and tracking the care they receive through checking their records and discussion with them. The medication records were inspected during this visit, staff files and training records were examined quality assurance audits and residents’ finances were also looked at to make sure that the arrangements are safe and protect residents. Staff were spoken with and lunch was observed. What the service does well: Residents are assessed before they come to the home to make sure that their needs can be met and to avoid unnecessary moves. The care plans are well written and offer clear guidance to staff about how to meet the needs of the people living at the home. Residents’ health care needs are assessed and met by a range of health service professionals and medication is given as prescribed by the Doctor. The staff treat residents with dignity and respect and value their independence and privacy. There are a range of activities provided at the home and the residents can choose whether to join in or not. The routines at the home are flexible and residents said they get a lot of freedom to choose their own lifestyle. The food is said to be tasty and plentiful. Residents know how to complain and feel confident to do so, they feel safe and protected at the home. The accommodation is clean and well maintained. The bedrooms are well equipped and personalised with the residents’ own furniture. The staffing levels are good and staff were highly praised as “good, patient and kind,” by the residents. They are well trained and competent in their role. Residents’ financial interests are protected by proper recording procedures. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 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. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 6 The manager assesses all potential residents before admission to make sure that the staff at the home can meet their needs, thus avoiding unnecessary moves. EVIDENCE: The most recently admitted resident was selected for “case tracking” to check she had been properly assessed before admission. There was a pre admission form and risk assessment on the file indicating in good detail the needs of this resident. The manager had clearly assessed her needs to ensure that the staff could meet them before agreeing to admission. One of the residents confirmed that the manager had been out to assess her in Hospital before she was admitted, and this is clearly done routinely. Intermediate care is not provided at the home and this standard is not applicable. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 The care plans are well written and offer clear guidance to staff about how to meet the needs of residents. Health needs are properly assessed and provided for by the staff and a range of health professionals. Medication storage and administration is safe and well managed. Residents are treated with dignity and respect and their independence is encouraged and promoted. EVIDENCE: The care plans for the case tracked residents were inspected to check that they detailed the residents’ needs and the action needed to address them. The care plans are of good quality, with evidence of residents or their relatives being involved in the development and reviews. They are reviewed monthly or more frequently if needed, and they cover residents’ needs, preferences and wishes in good detail. The care plans make reference to issues of dignity, independence, respect and privacy. One of the residents who was “case tracked” had a hoist, electric wheelchair, airwave mattress and a pressure relieving cushion in her room. There are appropriate risk assessments in place in respect of falls, skin care, mobility and nutrition. There is evidence of monitoring of accidents, falls, weights and diet. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 10 Residents said they have good access to health care and Doctors are called as needed. The arrangements for medication were inspected. The monitored dosage system is used to administer medication and to avoid errors in giving out tablets. The storage arrangements for the medication were safe and secure. Controlled drugs are properly recorded and the countdowns tally with the tablets remaining providing evidence that the medication has been given as prescribed. The medication administration records are very well recorded with no omissions showing clearly what medication the residents have had and when. Residents said that the staff assist with personal care in a way that protects their privacy and dignity and said that the staff are friendly and respectful in their manner. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 A range of activities are provided at the home and residents can choose whether to be involved or not. Residents have flexibility in terms of their lifestyle and can receive visitors at any time. Rising and retiring times are flexible. The residents praised the food, saying it was tasty and plentiful. EVIDENCE: Activities are provided regularly in the home and the arrangements are listed in the lounge to make sure that the residents are aware of what is being provided. Residents confirmed that the staff play cards and dominoes with them and an entertainer comes in once a month. One of the residents said she chooses not to take part in activities, preferring her own company and watching sport on TV. The residents confirmed that their family and friends can visit when they choose and they are always made welcome. Residents generally see their visitors in their own bedrooms to ensure privacy. One of the residents said she waits for staff to come and assist her to rise, but prefers that this is after 09.00, which is respected. She has bed rest in the afternoon on the advice of the District Nurse and sits up watching television in her room after tea until she wants to go to sleep. She said she has regular bed Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 12 baths and is encouraged to wash herself at the sink when she can to maintain her independence. Lunch was observed and consisted of chicken portions, croquette potatoes and green beans followed by coconut tart and custard. All of the residents were having the same meal and no alternatives had been prepared. Special diets are catered for including Diabetic diets and soft diets. The residents praised the food and said they enjoy their meals, they get plenty to eat and said it tastes “lovely.” The dining room is a comfortable environment for residents to eat in and the atmosphere was calm, with residents sitting chatting together. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 19 Residents know they can complain and any concerns are properly recorded, investigated and acted upon. The staff and manager are aware of issues of abuse and respond appropriately to protect the residents from harm. EVIDENCE: There is a complaints book in place but none have been received since the last inspection. The complaints procedure is displayed at the entrance of the home and good records of complaints are maintained. Neither of the residents interviewed had made a complaint but they knew how to do this and would feel confident that their concerns would be acted upon. There have been no allegations of abuse since the last inspection. There is a copy of the Adult Protection Procedure Manual at the home and the home’s policy and procedure is explicit and evidence would suggest these are followed. There have been no significant staff disciplinary issues, no incidents of restraint and no untoward incidents. Staff are aware of their obligations to report and the manager and staff make sure that the residents are protected from harm and abuse. The residents said they have never seen staff respond in an inappropriate way and they said they feel safe at the home as the manager is “very reassuring.” Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23, 24, 26 The residents’ bedrooms are comfortable, spacious and highly personalised. The home is clean and fresh and the residents confirmed that this is always the case. EVIDENCE: Residents were interviewed in their bedrooms which are larger than average and the two seen both had en suite facilities. One resident had furnished the bedroom fully with items from her own home. The room was comfortable and homely and she said she was very satisfied with it. Residents said that the home is kept “beautifully clean,” and they said the laundry is well organised. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29, 30 The staffing levels are appropriate and meet the needs of the residents. The staff provide good care to the residents and are well trained and competent. The checks on staff need to be more thorough to ensure that residents are properly protected from abuse. EVIDENCE: There were three staff on duty during this visit which is above the minimum required and appropriate for the needs of the residents. The residents who were interviewed said that the staff are “good,” “kind, patient and caring” and said that there are enough staff to meet the needs of residents and to make sure that alarms are answered promptly. Staff files were inspected to make sure they contain evidence of appropriate checks on staff. The files did contain most of the required documents but some which prove identity were missing on staff who have worked at the home for a long time. All staff files must contain the documents specified in Schedule 4 of the Regulations to make sure that residents are protected from harm. The staff training record was inspected to make sure that the staff are competent and trained for the work they do. All of the staff are up to date with the mandatory courses necessary to protect the Health and Safety of residents. Individual and central records are maintained and these are well organised and clearly evidence good access to training. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 38 Residents’ views are sought but the frequency of this should increase to ensure that the service is properly audited at least annually. Residents’ finances are well recorded and their interests are safeguarded by the procedures used. Health and Safety checks are undertaken as required to make sure that the residents and staff are properly protected. EVIDENCE: Quality assurance arrangements were examined to check that residents are properly consulted about the quality of care provided. The monthly visits by the trustees canvas residents’ opinions and an independent residents’ advocate has just been identified. Questionnaires were seen and contained comments such as “an exceptionally well run home,” “homely, cosy atmosphere,” “staff are friendly and helpful.” It is however recommended that these be undertaken and responses collated annually. If the residents need help to complete the forms the use of the independent advocate is recommended to ensure a fair reflection of views. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 17 The arrangements for supporting residents with their finances were inspected to check that their interests are safeguarded. The manager is not the appointee for any of the residents and only small amounts of cash (for hairdressing/chiropody) are held on behalf of the people living at the home. The records and the balances held on the premises were examined and they all tally. The records of expenditure are clear and well maintained ensuring that residents’ financial interests are properly safeguarded. Health and safety tests and checks were examined to make sure that these were conducted at the proper intervals. Accident records are well recorded and there is evidence that falls involving injuries to the head and face are referred to the GP for advice. There was evidence of safety checks on the gas and electric appliances and fire safety testing was undertaken at the required intervals to check all equipment is working. There was evidence that the home has followed recommendations made by the Environmental Health Officer and that the accommodation is safe and well maintained. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 3 x x 3 Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 19 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29 Regulation 17(2) Schedule 4 Requirement Staff files must contain all of the documentation and information specified in Schedule 4 of the Regulations. Timescale for action 12/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 33 Good Practice Recommendations Resident satisfaction questionnaires should be undertaken a minimum of annually. If help is needed with this process it is preferable that this be done by a person independent of the home. Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Derbyshire Haven Care Home C53 C03 S2195 derbyshire Haven v247357 120905 stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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