Inspection on 22/08/07 for Dercliffe Care Home

This inspection was carried out on 22nd August 2007.

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 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 15/01/08

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 09:45 22 August 2007 nd 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.V339650.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.V339650.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.V339650.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. 6th June 2006 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 the paved 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 £345.00 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.V339650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Dercliffe Care Home on 22nd August 2007. 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 person. As part of the inspection process the inspector used “case tracking” as a means of gathering information. This process allows to the inspector to focus on a small group of people living at the home. Prior to the inspection the registered person completed a detailed questionnaire about all aspects of the care home, which provided useful information and evidence for the inspection. Satisfaction questionnaires were sent to the home for the residents and their relatives. Two questionnaires were returned from relatives/visitors to the home and six questionnaires were received from the people who live in the home. Two days following the inspection, a Pharmacist Inspector carried out a detailed inspection of the management of medication within the home. The Inspector’s findings are included in the report. What the service does well: The admission procedure involved an assessment of people’s needs. This enabled the registered manager and the prospective residents to determine whether or not their needs could be met within the home. Prospective residents were encouraged and supported to visit the home prior to admission. This provided the opportunity to meet other residents, have a look round the home and sample the meals. The daily routines were flexible and designed to meet the wishes of the residents, many of the residents chose to have a lie in and breakfast was served throughout the morning to suit their preferences. The residents spoken to felt they were well cared for and the staff respected their rights to privacy and dignity. Varied and well-presented meals were served. All residents spoken to described the meals as “very good” and “lovely”. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 6 The residents had access to a clear complaints procedure, which contained clear information about how to make a complaint or raise a concern. The residents were provided with clean, nicely decorated bedrooms that were well maintained. The residents could personalise their rooms with their own ornaments and small items of furniture. The sitting and dining areas were decorated in a homely and comfortable fashion, with a variety of armchairs, footstools, side tables, ornaments and pictures. The overall atmosphere was warm and friendly and the staff and residents enjoyed a good relationship. What has improved since the last inspection? What they could do better: The care plans must set out all the residents’ health and welfare needs, so that staff have clear information to ensure all needs are met. Medicines must be administered to residents as prescribed and at the right time in relation to food intake, the paperwork to support this needs improvement for this to happen. Receiving medicines at the wrong dose, wrong time or not all can seriously affect the health and well being of residents. The training and competence of care staff in handling and recording medicines must be improved to ensure residents receive their medicines correctly. Checks (audits) on medicines must be carried out to show that they are being given to residents as prescribed and to prevent mistakes from happening again. Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 7 Arrangements for residents that look after their own medicines must be improved to ensure they receive any support they might need. When recruiting new staff the registered manager must be able to demonstrate that all appropriate records and checks have been obtained in line with legal requirements. This is to ensure the residents are protected and the new staff are fully vetted before working in the home. 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.V339650.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.V339650.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, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home had their needs properly 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. Since the last inspection, both documents had been updated to include the registered provider’s contact details. An information card had also been produced, which provided an overview of the services and facilities available and included some photographs of the interior and exterior of the home. Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 10 All residents were issued with a statement of terms and conditions of residence or contract. However, it was noted that two of the contracts seen did not contain any information about the level of fees and one person’s contract was with the previous registered provider. The ‘case tracking’ process demonstrated 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 and included details about the resident wished to practice their religion. The registered manager had also informed the residents in writing that, having regard to the assessment, their needs could be met within the home. Prospective residents were actively encouraged to spend some time in the home prior to making the decision to move in. This gave them the opportunity to meet the other residents and staff and experience life in the home. Dercliffe Care Home DS0000065155.V339650.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 poor. This judgement has been made using available evidence including a visit to this service. The care plans did not always provide sufficient information to staff to ensure all the residents’ needs were met. Medicines were not always given to the residents correctly, which can seriously affect the health and well being of residents. EVIDENCE: From the case files seen, it was evident each resident had a plan of care, based on their assessment of needs. Since the last inspection, the care plans and risk assessment formats had been updated. The plans were supported by records of personal care, which provided information on changing needs and any recurring difficulties. All records seen described the residents’ needs in respectful terms. However, it was noted that not all records had been maintained on a frequent basis. For instance, for instance there had been no entry made in one person’s records for 11 days. It was also noted that not all the plans had been updated once a month. Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 12 The residents’ relatives were consulted and involved in the care of the residents. A visitor spoken to on the day of inspection, said the staff kept her informed about any important issues affecting her mother’s well being and she felt confident they would contact her in the event of a concern. This was also reflected in the questionnaire responses received from relatives/visitors, which indicated they were always kept up to date about the care of their relative. Risk assessments in respect to moving and handling, pressure sores and nutrition had been incorporated, where necessary, into the care plan documentation. Health care needs were not always addressed within the care plan and there was little guidance for staff within the care plan on how best to monitor and meet the residents’ healthcare needs. There was evidence to indicate the residents accessed NHS services and received specialist support as necessary. Since the last inspection, a set of “sit-on” scales had been purchased and a chart was maintained to monitor the residents’ weight. The residents spoken to felt the staff respected their rights to privacy and dignity and all made complimentary remarks about the staff, for instance one person said the staff were “very good, they are grand”. The residents, who completed the questionnaires prior to the inspection, also made positive comments about the staff, for instance one person commented, “They do as much as they can to help”. 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. The residents who were currently looking after their own medicines were not fully supported do so. Written risk assessments and supporting care plans had not been carried out, this is important to ensure residents receive any support they might need. Medicines were administered at or just after mealtimes and this was confirmed by care staff and residents. Part of the morning medicines round was observed, this took approximately three hours to complete, which is too long. The general organisation of the round was not good and the trolley used to transport medicines did not help the carers to give and record medicines efficiently. Several medicines were given at the wrong time in relation to food intake, which could affect the way they work and can increase the chances of side effects. The medication administration records were not always complete. Records of medicines received into the home and given to service users were not always accurate showing staff were not giving and recording medicines the right way. Examples of medicines not “adding up” correctly were found and the senior carer confirmed that the mistakes had occurred. Handwritten records, notably Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 13 for short courses of treatment such as antibiotics, were often incomplete or incorrect which had contributed to the mistakes. Records of medicines returned to the pharmacy for safe disposal were not always made, the most recent returns had not been recorded and the deputy manager confirmed this. Poor record keeping can lead to medicines not being safely disposed of. Not all medicines prescribed as “when required” or, as a “variable dose” had clear written instructions for care staff to follow to ensure they are given correctly. This is particularly important for residents that are suffering with pain or who are agitated and have difficulty communicating. Medicines were securely stored in a dedicated room but the trolley used to transport them to residents was not secure. The arrangements for the preparation, administration and recording of medicines were cramped, which may have contributed to mistakes happening. Regular checks (audits) on medicines records and stocks were not carried out, recent mistakes in recording and administering medicines have not been found, it is important to do this to ensure staff are handling medicines in the right way. The manager said, staff that handle medicines had received training but no formal assessment of competence had been carried out. Carers were not regularly supervised to ensure they were competent. Poor record keeping and mistakes when giving medicines show some care staff were not competent when giving medicines. Dercliffe Care Home DS0000065155.V339650.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 good. This judgement has been made using available evidence including a visit to this service. Residents were able to choose their lifestyle and social activity and kept in contact with their friends and family. The residents received a healthy and varied diet according to the assessed requirement and choice. EVIDENCE: The residents’ preferences in respect of social activities were recorded as part of the assessment process. The residents were encouraged by the registered manager and the staff to pursue a range of activities. A record of activities had been maintained and was seen during the inspection. Activities included professional entertainment, film matinees, sing-a-longs, tabletop games, aromatherapy and music to movement. Several of the residents also said they enjoyed trips out of the home with their families. The residents had varied views about the frequency of the activities provided, of the 6 residents who returned a questionnaire 2 people said activities were “usually” arranged, 2 people indicated that activities were “sometimes” arranged and 2 people said appropriate activities were “always” arranged. The residents had a choice of whether to participate in activities and one person commented in a questionnaire, “There are activities, but I prefer not to be included”. Information about forthcoming activities was displayed in the hallway. Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 15 Residents were observed on the day of inspection, to be watching television, chatting to staff and looking at books and magazines. There was also music and movement arranged for the afternoon of the visit. The routines in the home were well established and residents had a choice in the times they went to bed and got up in the morning. One resident said “I can get up when I want to” and another person said “I like to get up about 8, but some days it is 8.30”. Breakfast was served throughout the morning to suit the wishes of the residents. The staff were observed to seek the residents’ views throughout the inspection and the residents spoken to said that they felt comfortable to comment on life in the home. The residents were supported to follow their chosen form of religious worship and representatives from the local churches visited the home on a regular basis. Two residents spoken to said they particularly enjoyed the ecumenical service held once a month in the conservatory. There were no restrictions placed on visiting times and residents were able to receive their guests in privacy of their bedrooms, should they wish to do so. The relatives who returned a questionnaire and the relatives spoken to on the day of inspection said they felt welcome in the home and all were satisfied with the level of care provided. One person commented, that there is a “family atmosphere and the residents are clean, warm and well fed”. The residents described the meals as “lovely” and “very good”. They also said there was always plenty to eat and the food was a good quality. There was a choice of food each mealtime and residents were asked prior to the meal what choice they wished to make. The meal looked appetising and was well presented. The residents spoken to said they enjoyed their meal. Drinks and snacks were served throughout the day and at other times on request. Residents were observed asking for drinks during the inspection and were promptly served by staff. The menu was displayed in the hallway and residents were aware of the forthcoming meal. Dercliffe Care Home DS0000065155.V339650.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 incorporated 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 had been updated since the last inspection to include the new local address for Commission. The residents spoken to said they could speak to any of the manager, staff or the owner if they had a problem. The manager had received 3 complaints since the last inspection, two of which had been of a serious nature. The complaints had been investigated in line with the appropriate procedures. A record had been maintained of the investigations and the subsequent outcomes. 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.V339650.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. Whilst several areas of carpet looked worn, the registered manager reported that plans were in place to replace some of the carpets in the near future. The registered manager also said that ten new lounge chairs and fifteen sets of Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 18 bedroom furniture were on order. Systems were in place to report repairs and routine maintenance and records had been maintained of the work completed. It was evident on a partial tour of the home 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. One person said, “I really like my room, it’s very nice”. Since the last inspection, the hall and stairway had been redecorated and the front garden had been landscaped. Residents had been 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. A call point in the conservatory had recently been installed. The doors to residents’ bedrooms had been fitted with suitable locks and keys had been distributed to the residents, as appropriate. Since the last inspection, a stand aid hoist had been purchased to assist the residents’ mobility, where necessary. Radiators had been fitted with guards. To prevent scalding the baths and showers had been fitted with preset valves to guarantee water was delivered close to 43°C. At the time of the inspection, work was in progress to fit preset valves 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.V339650.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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst staff received appropriate training, some documentation was not available to demonstrate all staff were fully vetted prior to commencing employment in the home. EVIDENCE: The registered manager maintained a staff rota. However, the rota did not clearly indicate which member of staff had worked on which days, for instance how staff sickness or annual leave had been covered. 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. Since the last key inspection, a recruitment and selection procedure for new staff had been implemented. The file of one member of staff, who had recently commenced working in the home, was inspected. It was evident the person had completed an application form, provided a full working history and had attended the home for an interview. A POVA check had also been received. However, there was only one reference seen for this person. A record had been made when the second reference had been received, but it could not be located for inspection purposes. Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 20 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 NVQ level 2, this equated to 65 of the overall staff team. In addition, a further nine members of staff were working towards this qualification. 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.V339650.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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst, the residents benefited from the ethos and management approach in the home, some aspects of the administrative systems required improvement, to ensure the residents’ best interests are protected. EVIDENCE: Since the last inspection, the registered manager confirmed she had completed NVQ level 4 in Management and the Registered Manager’s Award. The manager had been working at the home for over 25 years and has been registered for 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 said the “Staff are very nice, they look after me and I have Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 22 no complaints whatsoever””. A programme of staff supervision was in place however, from the records viewed during the inspection it was evident staff had not received six supervisions in the last year. The service was awarded an Investor’s in People Award in 2001 and this had been reaccredited in 2005. The registered manager had continued to develop the quality assurance processes in the home. 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. 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 management of medication and 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 was seen during the inspection which, confirmed 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. Appropriate arrangements were in place for recording accidents and incidents in the home. However, it was noted the details of one accident recorded in a resident’s care records had not been recorded in the accident records. Dercliffe Care Home DS0000065155.V339650.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 2 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 2 2 Dercliffe Care Home DS0000065155.V339650.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 OP8 Regulation 15 (1) Requirement Timescale for action 01/11/07 2. OP9 13 (2) 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. An accurate record of all 01/10/07 medicines received into the home, administered to residents and disposed of must be made to help ensure residents receive them as prescribed. Care staff must have appropriate medicines handling training and be assessed as competent to help ensure medicines are given to residents correctly. Systems must be put in place that ensures the quality of medicines handling is maintained. A regular medicines audit can achieve this. For residents that look after their own medicines a written risk assessment must be carried out that is regularly reviewed. This is DS0000065155.V339650.R01.S.doc 3 OP9 18(1)(a) 01/11/07 4 OP9 24(1) 01/10/07 5 OP9 13(2) 01/10/07 Dercliffe Care Home Version 5.2 Page 25 important to ensure residents receive the correct amount of support from care staff. 6 OP9 13(2) Medicines must be given to residents as prescribed and at the right time in relation to food intake. Receiving medicines at the wrong dose, wrong time or not all can seriously affect the health and well being of residents. 01/10/07 7 OP29 19 (1) The registered person must 22/08/07 ensure all documentary evidence is available to fully demonstrate the home is meeting the requirements of the regulations in relation to the recruitment and selection of new staff. (Previous timescale of 20/03/07 – not met). All records listed under the Care 22/08/07 Homes Regulations 2001 must be accurate and up to date at all times, to ensure the best interests of the residents are protected. A record must be made of all 22/08/07 accidents, which includes all relevant details as set out in the Regulations. This is to ensure the staff are aware of any accident to a resident and their condition can be monitored. 8 OP37 17, 18 and 19 9 OP38 17 (2) Schedule 4 (12) Dercliffe Care Home DS0000065155.V339650.R01.S.doc Version 5.2 Page 26 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 OP2 Good Practice Recommendations The contracts should be with current registered provider and include details about the actual level of fees charged. This is to ensure the residents are aware of the full terms and conditions of residence. 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. 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 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. The staff rota should indicate, which member of staff worked a particular day, as well as details about how staff sickness and annual leave has been covered. This will demonstrate that appropriate staffing levels have been provided at all times. 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. 2 3 OP7 OP9 4 OP27 5 OP36 Dercliffe Care Home DS0000065155.V339650.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.V339650.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. 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