CARE HOMES FOR OLDER PEOPLE
Derbyshire Haven Care Home 2 Brendon Road Wollaton Nottingham NG8 1HW Lead Inspector
Elaine Cray Unannounced Inspection 23rd February 2006 9:20
23/02/06 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.V281835.R01.S.doc Version 5.1 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.V281835.R01.S.doc Version 5.1 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.V281835.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th September 2005 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 DS0000002195.V281835.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 23rd February 2006 over a period of 3 hours. The deputy manager was present throughout the visit. Two staff were on duty and care practices and interactions between staff and residents were observed. Four residents were spoken with and two care plans and a variety of records were inspected. What the service does well:
Derbyshire Haven offers a homely and well maintained environment. The manager and staff encourage residents to be as independent as possible and to be part of the day to day running of the home. Residents are treated with a high level of dignity and respect and the deputy manager has an excellent understanding of the individual needs, preferences and personalities of each resident. There is a warm rapport between staff and residents. Residents presented as well groomed, relaxed and happy in the home. Care plans are detailed and form a good basis for an assessment of need and to provide the day to day support to enable residents to maintain their independence and be provided with appropriate care and support. Health care needs are well met and the staff at the home liaise well with health care and medical agencies. The management and staff form present as a cohesive team, with good communication between themselves, with the residents and with other professionals. Record keeping was accurate, up to date and organised. Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 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 DS0000002195.V281835.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 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 the following standard(s): 2, 3 and 5 Prospective service users, relatives and representatives are able to visit the home to look around and meet the manager, residents and staff to discuss the prospective service user’s needs and to find out about the running of the home. EVIDENCE: Service users spoken with said that they or their relative had visited the home prior to moving in and that they were very pleased with the helpful and supportive way in which the admission to the home was carried out. The deputy manager, some service users and care plans confirmed that the needs of each service user and the services available are discussed and assessed before moving into the home. Copies of the Terms and Conditions were available on the residents’ files. Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 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 the following standard(s): 7, 8 and 10 Residents’ health care and medical needs were identified, promoted and well met. There is a warm and interactive rapport in the home and residents rights to privacy and choice are treated with respect and dignity. EVIDENCE: Two care plans were viewed on this inspection. Medical histories, health assessments and how and who were involved in meeting these needs were recorded in each plan. Several residents commented that the manager and staff are very good at monitoring their health needs, calling the doctor when necessary and showing sensitivity and kindness when they are feeling under the weather. There was a warm and respectful rapport between the staff and residents. Staff were observed to provide a sensitive level of care in terms of ensuring the privacy and dignity of residents is respected. Residents said that staff were very polite and kind, knocking on bedroom doors and speaking to people with respect. Residents said that staff help with personal care and take their wishes around privacy into account.
Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 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): These standards were not inspected on this visit. EVIDENCE: Not Applicable Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 Page 11 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, 17 and 18 The staff have a clear awareness of the need to provide a safe environment for residents and to promote and protect the legal rights of the residents. Residents feel they can talk to the manager and staff about any concerns they may have. EVIDENCE: The deputy manager and staff presented a good understanding of the vulnerability of older people living at the home, the need for consistent observation and care and providing a safe environment. Risk assessments were detailed and included in the care plan. All the residents spoken with were happy with the care provided in the home and were confident that should they have any concerns then the manager and staff would be available to sort out any difficulties. All residents are on the electoral register and have postal votes arranged. Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 Page 12 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, 20, 25 and 26 The home presents as well maintained, homely, well decorated, comfortable and exceptionally clean. EVIDENCE: The lounge and the dining room were viewed and presented as clean, well decorated and very homely, with comfortable furnishings, lots of pictures, ornaments, plants and flowers. Standards of cleanliness were exceptional throughout the home. Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 Page 13 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 staffing arrangements in the home presented as well managed and staff have received a variety of training. EVIDENCE: On the day of this inspection, the home was adequately staffed. The manager and many of the staff have worked at the home for an extensive period of time and provide a good level of experience. All the residents spoken with on this visit gave positive comments 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 demonstrated that staff were knowledgeable about the needs of the residents, were aware of the policies and procedures of the home and the inspector observed appropriate care practices throughout the inspection. Two staff files were checked and these demonstrated that the manager maintains a thorough recruitment and selection process including obtaining all the required background checks and ensuring staff are inducted at the beginning of their employment. Staff training, including refresher courses, in Moving and Handling, Health and Safety and First Aid had been provided in the past year.
Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 Page 14 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): 33, 37 and 38 The management of the home was well organised, with clear lines of accountability, roles and responsibilities. Records were, on the whole, well maintained, accurate and up to date. EVIDENCE: Record keeping in the home was detailed, accurate and up to date. Care plans were detailed and practical for the day to day care for each resident and other required records were available in the home. The manager has introduced questionnaires for residents and visitors in order to monitor the quality of care provided in the home. The deputy manager was present throughout this inspection and provided a thorough knowledge of the management and administration systems and the running of the home, in the absence of the registered manager. The health and safety procedures are well managed in the home. Fire safety checks had been regularly completed.
Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 Page 15 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 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X X X 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X 3 3 Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 Page 16 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. Refer to Standard Good Practice Recommendations Derbyshire Haven Care Home DS0000002195.V281835.R01.S.doc Version 5.1 Page 17 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
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