Inspection on 15/01/08 for Dercliffe Care Home

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dercliffe Care Home 09/12/08

Dercliffe Care Home 22/08/07

Dercliffe Care Home 06/06/06

Dercliffe Care Home 31/01/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Dercliffe Care Home Juno Street Nelson Lancashire BB9 8RH Lead Inspector Mrs Julie Playfer Unannounced Inspection 09:30 15 January 2008 th 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 Dercliffe Care Home DS0000065155.V355281.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. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dercliffe Care Home Address Juno Street Nelson Lancashire BB9 8RH 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) 01282 603605 Dercliffe Care Home Ltd Mrs Dawn Quinn Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 32 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 22nd August 2007 Date of last inspection Brief Description of the Service: Dercliffe is registered with the Commission for Social Care Inspection to accommodate 32 older people aged over 65 years. The home, a former vicarage, is a detached property set within its own grounds in a residential area. The home offers 24 single and 4 shared bedrooms, all have ensuite toilets and hand wash basins. Various aids and adaptations including a passenger lift are provided to assist with self-help and mobility. There are 4 lounge/dining rooms, 2 additional sitting areas and a conservatory. The residents have access to a garden to the rear of the property and a paved forecourt at the front of the home, where some car parking is available. Dercliffe is situated close to local facilities, including shops, post office and a public house. A bus service is available approximately 5 minutes walk from the home. At the time of the inspection the scale of charges ranged from £342.50 to £386.00 per week. Privately funded residents paid £366.00 per week. Additional charges were made for hairdressing, chiropody and optical services. The registered manager made information available to prospective residents by means of a statement of purpose and service users guide. The service users guide was usually given to relatives and/or prospective residents on viewing the home or at the point of assessment. In addition, all residents accommodated in the home had been issued with a personal copy of the service users guide. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. A key unannounced inspection, which included a visit to the home, was conducted at Dercliffe Care Home on 15th January 2008. The previous key unannounced inspection took place on 22nd August 2007. There has been one random unannounced inspection since August 2007, which was carried out by the Pharmacy Inspector. The report relating to this inspection can be obtained from the Commission on request. At the time of the inspection, there were 31 people accommodated in the home. The inspection comprised of spending time with the residents, looking round the home, looking at the residents’ care records and other documents and discussion with the staff and the registered manager. As part of the inspection process the inspector used “case tracking” as a means of gathering information. This process allows the inspector to focus on a small group of people living in the home to determine an assessment of the quality of services provided. A Pharmacy Inspector also carried out a detailed inspection of the management of medication within the home. The Inspector’s findings are included in the report. Following the previous key inspection, the responsible individual and registered manager submitted a detailed improvement plan and has kept the lead inspector informed of developments in the home. This information was considered as part of the inspection process. Prior to the visit, satisfaction questionnaires were sent to the home, 8 questionnaires were received back from the people living in the home, 9 questionnaires were received from relatives and 16 from the staff. What the service does well: Current and prospective residents were provided with appropriate written information. This ensured the residents were aware of the services and facilities available in the home. The residents were able to exercise choice and control over their lives. The daily routines were flexible and designed to meet the wishes and preferences of the residents. As such the residents could decide when they wished to get up and go to bed. The residents spoken to felt that the staff respected their rights to privacy and personal care was delivered appropriately. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. The relatives who Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 6 completed a questionnaire were satisfied with the quality of care provided, one person wrote, “the home provides individual care and attention to all residents and listens to requests”. The residents were aware of the complaints procedure and knew who to talk to in the event of a concern. Residents’ meetings were held on a regular basis, which gave the residents the opportunity to discuss all aspects of life in the home. The residents were provided with clean and comfortable bedrooms. The residents could personalise their rooms, with their own belongings. The sitting and dining areas were decorated in a homely fashion, with a variety of armchairs, footstools, side tables, ornaments and pictures. A good percentage of staff had achieved NVQ level 2 or above. This qualification provided the staff with the necessary knowledge to carry out their role effectively. What has improved since the last inspection? What they could do better: The residents must be consulted, wherever practicable, during the development and review of their care plans, to ensure staff are aware of their wishes and they have input into the delivery of their care. Further to this, the care plans must include details about the residents’ healthcare needs along with guidance for staff. This is to ensure the staff have sufficient information about how best to meet, monitor and respond to these needs. Care plans must also be up to date for residents that look after their medicines to help ensure they receive the right amount of support to do so safely. All staff that administer medicines by specialised techniques such as injecting insulin should receive training from a suitably qualified healthcare professional and be assessed as competent to ensure residents receive their medicines correctly. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 7 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. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 8 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 Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home had their needs assessed and they were provided with appropriate written information to enable them to make an informed choice about where to live. EVIDENCE: Written information was available for the people who live in the home in the form of a statement of purpose and service users guide. The statement of purpose was available for reference in the hallway and the service users guide was displayed in each of the bedrooms. An information card was also available for prospective residents, which provided an overview of the services and facilities available and included some photographs of the interior and exterior of the home. All the residents who completed a questionnaire indicated that they had received enough information about the home, before they made the decision to move in. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 10 All residents were issued with a statement of terms and conditions of residence or contract. The contracts had been updated to include the current level of fees. The ‘case tracking’ process demonstrated that the residents had their needs assessed prior to admission to the home by a social worker and/or the registered manager. Copies of the preadmission assessments were seen on the residents’ files. The assessment format addressed the person’s religious and cultural needs. However, some of the assessments seen were brief and provided only limited information for staff about the prospective resident’s overall needs. The registered manager confirmed that residents were informed the residents in writing that, having regard to the assessment, their needs could be met within the home. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans did not provide the sufficient information about how best to meet the residents’ healthcare needs. Arrangements for the administration of medicines help ensure they are given to residents correctly. EVIDENCE: From the case files seen, it was evident that all residents, apart from one person who was newly admitted to the home, had a plan of care based on their assessment of needs. However, there was limited evidence seen to indicate the residents had been involved in the development and review of their care plans. None of the residents spoken to could recall discussing their care needs with the staff. One person’s plan was not fully developed and did not cover social and cultural needs. Other aspects of the plan were brief and did not provide staff with detailed information about how best to meet the person’s needs. The plans were supported by records of personal care, which provided information on changing needs and recurring difficulties. All records seen described the residents’ needs in respectful terms. However, it was noted that Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 12 not all records had been maintained on a frequent basis. This meant there were periods of time where there was little or no information about the residents’ condition or the personal care provided. Risk assessments in respect to moving and handling, falls, pressure sores and nutrition had been incorporated into the care plan documentation. However, risk management strategies had not always been recorded. This meant the staff had limited information about how best to manage the identified risks in a consistent and safe manner. This was particularly the case in relation to risk assessment pertaining to pressure sores. Healthcare needs were not always fully addressed in the care plan and there was little guidance for staff within the care plans on how best to monitor and meet the residents’ healthcare needs. As referred to below in the Pharmacy Inspector’s report, the staff had failed to make a consistent record of one resident’s daily blood sugar readings and a detailed care plan had not been drawn up to manage and monitor the person’s diabetic condition. The manager was aware of the resident’s needs and when alerted made immediate arrangements for the Doctor to visit. A copy of the person’s updated care plan was received by the Commission a few days after the inspection. There was evidence to indicate the residents had accessed NHS services and had received specialist support as necessary. Residents also accessed opticians, chiropodists and dentists. The manager and staff had a good relationship with the District Nurses, who visited the home on a regular basis. The residents spoken to felt the staff respected their rights to privacy and dignity. Residents were able to use the bathing facilities on their own should they wish to do so and this was particularly appreciated by one resident spoken to. The bedroom doors were fitted with suitable locks and keys had been distributed as appropriate. This enabled the residents to lock their bedroom door. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. All the residents who completed a questionnaire indicated that the staff listened to and acted on what they said. The Pharmacy Inspector carried out an inspection of the management of medication in the home and made the following findings: As part of this inspection the pharmacist inspector looked at the handling of medicines because previous inspections had identified weaknesses that were putting residents at risk of not having their medicines administered as prescribed. We looked at the recording of medicines and we found continued improvements. Records of medicines receipt, administration and disposal were detailed and usually accurate, which helps prevent mistakes when administering medicines. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 13 We looked at how residents were supported when they looked after their own medicines. Assessments and care plans had been completed but some of the information was not up to date, the records said that some medicines were being self-administered but we found that these had been discontinued sometime ago. Having accurate up to date information is important to ensure residents receive the right amount of support. We checked medicines records against current stock and found that medicines were usually given ‘as prescribed’. Previous inspections had found this not to be so. Senior staff now carried out regular audits in which some mistakes had been found. We gave further advice on how to improve the content and recording of these audits. Having good audits helps ensure staff are competent and checks whether medicines are being administered as prescribed. Care plans for medicines prescribed as ‘when required’ continued to have little information and in some cases it was not up to date. This is important to support their safe use and continues to be strongly recommended to ensure residents only get medicines when they need them. We looked at how a diabetic resident was looked after. Staff were administering insulin but no evidence of staff training was seen. The manager said staff had handled this type of insulin before and they were confident using it. However this is considered a ‘specialised technique’ that care staff must be trained to do on an individual resident basis. Staff were supposed to check this residents’ blood sugars on a daily basis but records showed it had not been carried out for seven consecutive days. The care plan to support the management of this resident’s diabetes was not detailed and lacked important information to help safely manage their health. Daily records showed raised blood sugars on several occasions but care staff did not contact a relevant healthcare professional for advice, raised blood sugars can be due to poor diabetic control and/or infections. Failure to respond to these high blood sugar readings placed the health and wellbeing of this resident at unnecessary risk. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents were able to choose their lifestyle and social activity and kept in contact with their friends and family. The residents liked the food. However, on the day of inspection not all residents were given sufficient assistance to eat their meal. EVIDENCE: The residents’ preferences in respect of social activities were recorded as part of the assessment process. One person’s file contained a personal profile, which provided useful information about the person’s past life experiences and current pastimes. The registered manager and staff reported that the residents were encouraged to pursue a range of activities, which included professional entertainment, film matinees, sing-a-longs, tabletop games and music and movement. Some residents spoken to said, “There was not a lot going on”. The residents had a choice of whether to participate in activities and one person said they preferred to rest. Information about forthcoming activities was displayed in the hallway. Residents were observed on the day of inspection to be watching television, chatting to staff and attending a church service. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 15 The residents were supported to follow their chosen religion and representatives from the local churches visited the home on a regular basis. An ecumenical service was held most Tuesday afternoons in the conservatory. Residents were asked if they wished to attend the service on the day of the inspection. The routines in the home were well established and residents had the choice in the times they got up and went to bed. One resident said, “I can do as I please”. A member of staff spoken to said breakfast was taken to the residents’ room if they wished to have a lie in. The staff were observed to seek the residents views throughout the inspection and the residents spoken to said they felt comfortable to comment on life in the home. There were no restrictions placed on visiting times and residents were able to receive their guests in the privacy of their own rooms, should they wish to do so. A relative spoken to on the day of inspection said she was satisfied with the care and support provided. The relatives who completed the questionnaires indicated they were satisfied with the quality of care provided, one person wrote, “It feels like a friendly, homely, warm place. Staff seem to genuinely care for the residents”. The residents said the meals were “good” and “very nice”. They also said there was plenty to eat and the food was a good quality. There was a choice of meal each mealtime and residents were asked prior to each meal what choice they wished to make. The meal served on the day inspection looked appetising and was well presented. However, it was noted that one person did not receive appropriate supervision and assistance to eat her lunchtime meal and as a result she had very little to eat. The weekly menus were displayed in the hallway and residents were aware of the forthcoming meal. Drinks and snacks were served at specific times throughout the day and at other times on request. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to express their views and had access to a clear complaints procedure. Policies and procedures were in place to respond effectively to any allegations or suspicions of abuse. EVIDENCE: The complaints procedure was included in the statement of purpose and service users guide. The procedure contained the necessary information should a resident wish to raise a concern. The procedure incorporated the relevant contact details for the Commission. The residents spoken to said they could speak to the manager, staff or the owner if they had a problem. All the residents who completed a questionnaire indicated that they were aware of how to make a complaint. The relatives who completed the questionnaires were also aware of the complaints procedure, one person commented, “I know I can go to one of the managers at any time and discuss any concerns”. The registered manager had not received any complaints since the last inspection. The policies and procedures for safeguarding vulnerable adults were available and provided guidance to staff should they suspect or witness any harmful practice. These issues were incorporated into the induction training and staff received specific tuition as part of their NVQ training. Staff spoken to were aware of whom to refer any incident to and the various agencies involved. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were provided with a clean, pleasant and comfortable environment. EVIDENCE: Dercliffe is a detached house set in its own grounds. The home is located close to local shops and other amenities. Accommodation is provided in 24 single bedrooms and 4 shared bedrooms. All the bedrooms have ensuite facilities. There are also for bathrooms for assisted bathing, including a “parker” bath, a shower and two conventional baths with chair lifts over. Communal space is provided in four lounge/dining rooms, two sitting areas and a conservatory. There are a sufficient number of toilets. The registered manager reported that new carpets had been ordered for three lounges, the conservatory, most corridors and 7 bedrooms. All the carpets were due to be fitted by the end of January 2008. Systems were in place to Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 18 report repairs and routine maintenance and records had been maintained of the work completed. It was evident on a partial tour of the building that the residents had personalised their rooms with their own belongings and decoration was good throughout. The residents spoken to said they liked their rooms. Residents were provided with aids and adaptations to assist their independence skills; these included grab rails, handrails and raised toilets. The passenger lift provided access to first floor accommodation. The provision of specialist equipment was determined by the needs of the residents. There was a call facility in every room, including the conservatory. The doors to residents’ bedrooms were fitted with suitable locks and keys had been distributed to the residents, as appropriate. A stand aid hoist was available to assist the residents’ mobility, where necessary. Radiators were fitted with guards or had a guaranteed low surface temperature. To prevent scalding the baths and showers had been fitted with preset valves to guarantee water was delivered close to 43°C. Preset valves had also been fitted to the hand washbasins. The home was clean and odour free at the time of the inspection. The residents spoken to said that a good level of hygiene was maintained at all times. There was a separate laundry room, which had sufficient and appropriate equipment to meet the laundry needs of the number of residents accommodated. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff received appropriate training and new staff were vetted before commencing employment in the home. EVIDENCE: The registered manager maintained a master staff rota. Changes to the master rota were recorded in a diary. The registered manager confirmed all staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. The number of staff on duty was sufficient for the number of residents living in the home. A recruitment and selection procedure was available and a checklist was used to track documentation required for the recruitment of new staff. The files of two new members of staff were inspected. It was evident both people had completed an application form, provided a full working history and had attended the home for an interview. Two written references and a CRB (Criminal Records Bureau) check had been received prior to the staff commencing work in the home. Arrangements were in place for all new employees to undertake an in house induction programme and complete a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. According to information supplied by the registered manager, 19 out 29 members of staff had achieved Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 20 NVQ level 2, this equated to 65 of the overall staff team. In addition, two members of staff were working towards NVQ level 3. All the staff who completed a questionnaire confirmed they received training relevant to their role and all staff interviewed during the inspection said they had access to good training opportunities. Staff training records indicated that staff had received health and safety training, including moving and handling, fire safety, food hygiene and first aid. Two members of staff had also completed a course entitled, “Safer Food, Better Business”. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of service was monitored and systems were in place to protect the health and safety of residents within the environment of the home. EVIDENCE: The registered manager had completed NVQ level 4 in Management and the Registered Manager’s Award. The manager has 26 years experience working in the home and has been registered with the Commission for over two years. Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the staff. One person who completed a questionnaire said “I can rely on them” and another person commented, “I’ve always been more than happy with Dercliffe and all the staff”. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 22 The registered manager had established a programme of staff supervision to ensure each member of staff received supervision six times a year. Records of supervision were seen during the inspection. The service was awarded an Investor’s in People Award in 2001 and this had been reaccredited in 2005. Satisfaction questionnaires had been distributed to the residents, their relatives and visiting professional staff in February 2007. The results of the surveys had been collated and action plan had developed in response to each comment. Residents meetings had been held and from the minutes seen, it was evident a varied range of topics was discussed. The registered manager had conducted six monthly audits of the various systems operational in the home and had devised an annual development plan detailing the planned developments to the service. The registered manager confirmed that the annual satisfaction survey was due to be carried out in February 2008. Appropriate arrangements were in place for handling money, which had been deposited with the home by or on behalf of a resident. A random check of monies was found to be correct. Records were also maintained in respect to the amount of fees charged and received. Not all records had been collated and maintained in accordance with the Care Homes Regulations 2001, for instance records relating to the care planning process. There was a set of health and safety policies and procedures available, which included the safe storage of hazardous substances. Staff had received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation seen during the previous inspection demonstrated that the gas and electrical safety systems were serviced at regular intervals. The electrical safety certificate was dated 2003 and was valid for 5 years. The fire log demonstrated that staff had received instructions about the fire system and fire alarms were tested weekly. Systems were in place to carry out regular health and safety checks around the building. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 23 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 3 3 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 3 Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 (1) Requirement The residents must be consulted, wherever practicable, during the development and review of their care plans, to ensure staff are aware of their wishes and they have input into the delivery of their care. The care plans must include details about the residents’ healthcare needs along with guidance for staff. This is to ensure the staff have sufficient information about how best to meet, monitor and respond to these needs. (Previous timescale not met 01/11/07). Timescale for action 28/02/08 2 OP8 15 (1) 15/02/08 3. OP9 18(1)(a) 15/02/08 All staff that administer medicines by specialised techniques such as injecting insulin should receive training from a suitably qualified healthcare professional and be assessed as competent to ensure residents receive their medicines correctly. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 25 4. OP9 13(2) For residents that look after their own medicines a written risk assessment must be carried out that is regularly reviewed. This is important to ensure residents receive the correct amount of support from care staff. (Previous timescale of 01/10/07 – not met). All records listed under the Care Homes Regulations 2001 including the care plans must be accurate and up to date at all times, to ensure the best interests of the residents are protected. (Previous timescale – 22/08/07 – not met). 15/02/08 5. OP37 17, 18 and 19 15/01/08 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 OP3 OP7 Good Practice Recommendations The information gathered as part of the assessment process should be more detailed. This is to ensure staff are fully aware of the resident’s needs. The records of care provided should be made on a more frequent basis to ensure staff are alerted to any recurring difficulties or changing needs. The risk assessments should include risk management strategies whenever a risk has been identified. This is to ensure that the staff are aware of how best to monitor, manage and reduce any identified risks. Medicines prescribed as when required or, as a variable dose should have clear written criteria for care staff to follow to ensure they are administered correctly. Patient information leaflets should be used for all Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 26 3 OP8 4 OP9 medicines kept in the home to ensure medicines are administered correctly. All handwritten medicines records should be an exact copy of the pharmacists dispensing label, which should be double-checked and countersigned, this should help prevent mistakes. The procedures for administering medicines should be improved to help staff give and record medicines correctly. 5. OP36 Staff should receive supervision at least six times a year to ensure their training needs and any deficiencies in their work performance are clearly identified. Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Dercliffe Care Home DS0000065155.V355281.R01.S.doc Version 5.2 Page 28 - 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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