Inspection on 21/07/05 for Derbyshire House Care Home

This inspection was carried out on 21st July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 House Care Home 11/03/09

Derbyshire House Care Home 24/08/06

Derbyshire House Care Home 13/10/05

Derbyshire House Care Home 10/01/05

Derbyshire House Care Home 08/07/04

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 House Care Home Station Road East Leake Nottinghamshire LE12 6LQ Lead Inspector Linda Hirst Unannounced 21 July 2005 10:00 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 House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Derbyshire House Care Home Address Station Road East Leake Nottinghamshire LE12 6LQ 01509 852531 01509 853945 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) W.J. Yapp Trust C/o Acton Simpson and Hampson Mrs Wendy Newell Care home 19 Category(ies) of OP Old age, x 19 registration, with number of places Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 10 January 2005 Brief Description of the Service: Derbyshire House is a well established care home providing personal care and accommodation for 19 older people. It is owned by the W. J. Yapp Trust, which is a charitable body, and has operated as a care home since 1965. The home is located in the village of East Leake, a short walk away from the village centre. The village itself offers shops, pubs, churches and health and leisure services. Derbyshire House is a detached house surrounded by large and well maintained gardens. Most of the accommodation is on the ground floor. It offers 19 single bedrooms, many of which have en-suite facilities. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit involved one inspector who was at the home for half a day (including lunchtime). 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 where possible, discussion with them. One of the people selected for case tracking was very unwell and not able to be interviewed but observations were done and records checked. The record of complaints, medication, staff training complaints and staff files were also inspected and staff were observed in their duties throughout the visit. What the service does well: What has improved since the last inspection? What they could do better: Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 6 The money held on behalf of residents must be stored individually to make checking the amounts against the records easier. This would better protect residents’ interests. 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 House Care Home C53 C03 S8660 Derbyshire House V239908 210705 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 House Care Home C53 C03 S8660 Derbyshire House V239908 210705 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 ensures that potential residents are properly assessed before admission to be sure their needs can be met at the home and to avoid any unnecessary moves. EVIDENCE: The person most recently admitted to the home was selected for “case tracking. ” There was evidence of a pre admission assessment undertaken by the home to make sure they can meet her needs and to avoid any unnecessary moves. The resident said she had transferred to Derbyshire House from another home where she was most unhappy. She said she has always lived locally and had received good reports about the home and decided she wanted to live here. Intermediate care is not provided at the home and this standard is not applicable. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 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 organised and give staff clear guidance about how to help the residents with their needs. These plans have been drawn up with the involvement of residents or their representatives. The residents’ health needs are properly assessed and provided for. Medication storage and administration is safe and record keeping is of a high standard evidencing that residents get their medication as prescribed by their GP. Staff treat the residents with dignity and respect and their privacy is maintained and valued. EVIDENCE: The care plans covered all of the main needs of the residents and there were signatures in place to evidence that residents or their relatives have been involved in developing their care plans. One of the residents said she had not seen her care plan, (she had signed various documents within the plan) but was “perfectly happy” with the way staff provide care to her. The care plans Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 10 are kept under review and the risk assessments highlight both strengths and needs. One of the “case tracked” residents is very unwell and is cared for in bed. She has an Alpha Xcell mattress to prevent pressure sores developing and her skin is intact as staff provide two hourly turns. The District Nurse comes on request. This resident has bed rails in place and the District Nurse has signed to authorise their use. Daily care charts are in place and these are properly completed giving good evidence of regular care being provided to keep the resident comfortable. The resident was seen in bed, where she was propped with pillows and looked very comfortable. Her skin and mouth were well hydrated and the evidence would suggest she is well cared for. Another resident said she receives regular visits from the District Nurse and if ahe wanted a GP to visit this would be arranged. Medication is properly received, stored, safely administered and returned for destruction by the Pharmacist. There are excellent records in place to evidence that residents receive their medication as prescribed. Residents confirm that staff give drinks to residents to enable them to take their tablets but one self medicates inhalers and nebulisers. Residents said that the staff help them in a discreet way and protect their dignity. Staff always knock on doors before they come in and residents feel their privacy is respected. From observations during the visit, staff ask residents if and how they want helping and do not make assumptions. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 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 Residents have happy and fulfilling lifestyles at the home and their choices are recorded and promoted by staff and the flexible routines at the home. The menu is healthy and varied and promotes the residents’ health and helps to maintain their appetite. Special needs are well catered for. EVIDENCE: One resident said she enjoys her lifestyle at the home, she chats or watches TV during the day unless there are activities arranged such as BINGO, films, cards or dominoes. She enjoys a nap after lunch and is visited in her room by another resident. Other friends visit regularly and are always made welcome. Some residents go out into the local community, but she said she was not able to go alone because of her restricted mobility. Residents’ routines and preferences are recorded in the care plans using the first person these are quite detailed to enable staff to have an idea of how to support people with their chosen lifestyles. Residents interviewed confirmed that they can choose what time to rise and retire, breakfast is served on a tray in people’s bedrooms to enable them to relax once awake. Lunch was observed and comprised ham, eggs, pineapple and sauté potatoes followed by strawberries and cream. The food was sampled and was tasty and Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 12 looked appetising promoting appetite. Two people have a soft diet at the moment and staff assist them to eat in their bedrooms, but other than this, most people have lunch in the dining room. The dining room is comfortable, and provides a pleasant environment for residents to eat in and the menu is displayed so that the residents know what is for each meal and can request any alternatives. Residents confirmed that the food is tasty, plentiful and varied and they get plenty to drink through the day and evening. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 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, 18 Residents know how to complain and feel confident to do so. The residents are properly protected from abuse by policies, procedures and the training and guidance staff receive. EVIDENCE: The complaints procedure is displayed in the hall so that residents and visitors are clear about the process to follow when raising issues of concern. The complaints record was inspected during this visit but none have been received at the home or via the Commission for Social Care Inspection. One resident interviewed said she has never made a complaint but she knew the process to follow and said she would be confident to raise any issue of concern. There is a copy of the Protection of Vulnerable Adults procedure manual at the home and staff know how to access this. There have been no allegations of abuse made in the past year and none of the staff have been referred to the Protection of Vulnerable Adults list for abusive behaviour. The residents interviewed had not seen staff respond to residents in an inappropriate way and they said they feel safe living at the home. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 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, 26 Residents’ bedrooms are furnished to their own tastes and are comfortable and well equipped. The home is clean and hygienic. EVIDENCE: One resident, although happy with her room wanted to have a bigger space to fit in more of her own furniture and the manager has promised to accommodate her wishes as soon as another room becomes available. The residents are able to fully furnish their own bedrooms with items from home if they so wish and many rooms are very personalised, some being like bed sitters. All parts of the home which were seen during this visit were clean and fresh smelling and the residents confirmed that the standards of cleanliness in the home are consistently high. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 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) 27, 29, 30 The staffing levels are appropriate to the dependency needs of the residents. The manager follows robust procedures to check that staff are suitable to work with vulnerable residents and that they are properly protected. Staff have good access to training and they put this into practice, ensuring the health and wellbeing of residents. EVIDENCE: There were three care assistants on duty during this visit in addition to the Deputy Manager and the manager. These staffing levels are appropriate to the needs of the residents and the layout of the building. Residents said that the staff are really good, “patient, kind and supportive and can’t do enough for you,” those spoken with feel there are enough staff to support residents. The staff files were checked and the necessary checks and documents are in place to enable the manager to be sure that staff are who they say and to protect residents from harm or abuse. The staff training record was inspected, there was evidence of all staff having undertaken a proper induction, eight staff have achieved NVQ 2, five are doing NVQ3 and two NVQ 4. Other training has included Moving and Handling, Cross Infection, Fire Safety and continence promotion. Training is planned on safe handling of medication and Basic First Aid. There is good evidence that staff Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 16 have access to plenty of training and observations would suggest they follow safe practice. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 17 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 Residents’ views are sought by the manager and any issues of concern are addressed and acted upon to improve the care provided. The records in respect of residents’ finances are well maintained but the actual sums must be held individually to protect residents’ interests fully. EVIDENCE: The quality assurance questionnaires completed by residents and their relatives were inspected with a good return rate of 12 out of 19 sent out. The responses were overwhelmingly positive and the home and care provided was highly praised by the residents. The only concern expressed related to an incident when the chickens entered the home. The manager develops action plans in response to any issues raised to make sure any concerns are addressed and acted upon. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 18 The manager is not the appointee for any of the residents. Small amounts of cash are kept on the premises on behalf of residents to pay for (E.g. hairdressing). The records were checked and these are well recorded but the money is not held individually, which would enable easy auditing. The money held on behalf of residents must be stored individually to enable checks to be undertaken and protect residents’ interests. Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 19 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 x x 3 STAFFING Standard No Score 27 3 28 x 29 3 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 3 x 1 x x x Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 20 NO 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 35 Regulation 13(6) Requirement Residents cash must be stored individually to enable proper auditing. Timescale for action 1/9/05 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 Good Practice Recommendations Derbyshire House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 21 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 House Care Home C53 C03 S8660 Derbyshire House V239908 210705 Stage 4.doc Version 1.40 Page 22 - 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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