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Inspection on 19/07/06 for Derbyshire Haven Care Home

Also see our care home review for Derbyshire Haven Care Home for more information

This inspection was carried out on 19th July 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a small, quiet, homely environment where staff are committed to providing a good standard of care. It is well run with staff understanding the needs of residents and ensuring that they are protected from abuse. Staff are well trained and provided with support to carry out their role. Residents are able to spend the day as they choose and are provided with wholesome and nutritious meals in a pleasant dining room. Bedrooms are spacious and clean and are all personalised. Care plans provide staff with clear information on how to meet residents` needs and maintain their physical health.

What has improved since the last inspection?

There were no requirements set at the last inspection.

What the care home could do better:

The Registered Person must ensure appropriate recruitment checks are made for all staff employed by the home.

CARE HOMES FOR OLDER PEOPLE Derbyshire Haven Care Home 2 Brendon Road Wollaton Nottingham NG8 1HW Lead Inspector Susan Lewis Key Unannounced Inspection 19th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Derbyshire Haven Care Home DS0000002195.V301945.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. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derbyshire Haven Care Home Address 2 Brendon Road Wollaton Nottingham NG8 1HW 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) 0115 9282110 0115 9133595 The Trustees of the Lucy Derbyshire Annuity Fund Barbara Mary Hadfield Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: The fees for 2006/07 are £385 per week. 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 the staff and facilities can meet their needs. 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. There is a communal lounge and dining room with access to a small garden at the rear of the home. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection was unannounced and took place over 6 hours one Tuesday in July 2006, and was conducted by one inspector as part of the annual inspection process. A tour of the building took place and a selection of residents’ bedrooms was inspected. Residents’ records were inspected and residents and staff on duty were spoken with. What the service does well: 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 DS0000002195.V301945.R01.S.doc Version 5.2 Page 6 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 Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The quality in this outcome area is good. Residents are assessed and assured that their needs will be met before moving in to the home. EVIDENCE: This service does not offer intermediate care. Three care plans were viewed and all contained assessments, which had been carried out prior to the person being admitted to the home. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality in this outcome area is good. Residents’ health, personal and social care needs are set out in an individual plan of care. Residents’ health needs are fully met and they are protected by the home policy and procedures for dealing with medication. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Three care plans were viewed during this inspection. All plans viewed contained medical histories; health assessments and who was involved in meeting these needs were recorded in each plan. Residents were not always aware of their care plans but staff spoken with said that when they review plans residents were asked about their care and how they felt it had changed and this was included in the plan. It is recommended that evidence of this involvement be recorded. Medication was handled appropriately with residents signing to say they do not wish to self medicate. It is recommended that where Medication Administration sheets are hand written that they are signed and countersigned to ensure that they are correct. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 9 Residents spoken with during the course of the inspection were positive about the care and support they received saying ‘staff are very kind’ and ‘I get all the care I need’. ‘Staff call a doctor when I need to see one’. Staff were observed with residents and there was a positive relationship and a pleasant atmosphere. Residents were all clean and well groomed; residents said they wore their own clothes. Residents confirmed that staff were respectful when providing care and knocked on their bedroom door before entering. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality in this outcome area is good. Residents find the lifestyle experienced in the home matches their expectations and preferences, satisfying their social, cultural, religious and recreational interests and needs. Residents maintain contact with family and friends and can exercise choice over their lives. Residents receive wholesome appealing meals in pleasant surroundings at times convenient to them. EVIDENCE: On the day of the inspection most residents were sat in the lounge, some were taking part in game of ‘Who wants to be a millionaire’. Staff were sat with residents interacting and chatting. Residents who chose not to get up and dressed early were still either in bed or getting dressed. If required breakfast could be taken on a tray in the residents bedroom. Residents spoken with said that they could choose how they spent their day and what time they got up or went to bed. A visitor spoken with said that she was always made welcome and that she could see the person she visited in private. Residents confirmed that they had visitors whenever they wanted to. Residents bedroom are personalised and the manager and staff actively encourage residents to exercise personal autonomy and choice. Residents spoken with said that they were happy with the meals and that they were served at a time convenient to them. Residents said that they were able Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 11 to have drinks through out the day. Evidence was seen that homemade cakes were being prepared for teatime. The menu did not show choice at lunchtime, the manager said that residents were able to ask for an alternative to the main meal if they did not want it. Residents spoken with were not aware that they could ask for an alternative, however all said that the food was good. Meals are served in a pleasant dining room with staff available to provide support as necessary. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, and 18 The quality in this outcome area is good. Residents are confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: The Commission has not received any complaints since the last inspection and has no concern in this area. Residents spoken with all said that they had no complaints about the care that they receive and that if they did they would either speak to the manager or a member of staff, all felt confident it would be dealt with. Staff spoken with understood what action to take if a resident complained. The home has received no complaints from residents since the last inspection. Staff spoken with had a good understanding of what was abuse and what they must do if they witnessed it or suspected it. Residents spoken with all said that the staff were kind and caring and that they felt very safe. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality in this outcome area is good. Residents live in a safe, wellmaintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The home is well maintained internally, with the exception of the garden area. Some of the paving slabs have large clumps of weeds protruding creating a possible trip hazard for residents. It is recommended that the Registered Person have this area cleared. The home was spotlessly clean throughout the home, evidence was seen of a domestic cleaning residents bedrooms. The manager said that there was a cleaning rota that meant that residents had their bedrooms deep cleaned regularly. The laundry area meets standards, staff spoken with understood the importance of infection control. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality in this outcome area is adequate. Residents’ needs are met by the numbers and skills mix of staff. Residents are not supported and protected by recruitment policies and practices. Staff are trained to do their jobs. EVIDENCE: Staff rotas were seen that show that the home is adequately staffed at all times. Staff spoken with confirmed that staffing was adequate to meet the needs of residents. Rotas showed that there were sufficient staff also to meet that standards relating to hygiene and food. All the residents spoken with were positive about the staff and felt safe and well looked after, with staff encouraging them to be independent and providing support when needed and requested. Discussion with the manager and observation of the staff evidenced that staff understood the needs of the residents, were aware of the policies and procedures of the home. Three staff files were looked at and showed that appropriate recruitment practices are not taking place. The Registered Person must ensure that all recruitment checks are carried out in line with regulations. Staff training, including refresher courses, in Moving and Handling, Health and Safety and First Aid had been provided and is up to date. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The quality in this outcome area is good. Residents live in a well managed home, run in the best interests of residents, where their finances are safeguarded and their health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager is qualified and competent to run the care home. She is able to demonstrate she is familiar with the conditions associated with old age and there are clear lines of accountability with the external management. There is a quality questionnaire and it is used in the Service Users Guide, although the results do not appear to be actively used to inform the development plan of the home. Residents’ money is stored securely and records show what transactions have taken place. The home is well maintained with health and safety monitored and appropriate records maintained. Fire safety checks had been regularly completed. Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 16 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 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 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 17 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. 1 Standard OP29 Regulation 19(1-6) Sch 2 Requirement The Registered Person must carry out appropriate recruitment checks are carried out prior to the person starting work at the home. Timescale for action 01/09/06 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 OP9 Good Practice Recommendations Evidence of residents’ involvement in reviews is recorded. Where Medication Administration sheets are hand written that they are signed and countersigned to ensure that they are correct. The pathway in the garden is cleared of weeds. 3 OP19 Derbyshire Haven Care Home DS0000002195.V301945.R01.S.doc Version 5.2 Page 18 Commission for Social Care Inspection Nottingham Area Office 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 DS0000002195.V301945.R01.S.doc Version 5.2 Page 19 - 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. 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