Inspection on 31/01/06 for Dercliffe Care Home

This inspection was carried out on 31st January 2006.

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

Dercliffe Care Home 09/12/08

Dercliffe Care Home 15/01/08

Dercliffe Care Home 22/08/07

Dercliffe Care Home 06/06/06

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 31st January 2006 09:30 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.V272164.R01.S.doc Version 5.0 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.V272164.R01.S.doc Version 5.0 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 Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The responsible individual must submit an application for a registered manager within 3 months of registration. The home is registered for a maximum of 32 service users in the category of OP (Older People). 27th September 2005 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. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place at Dercliffe over seven hours on 31st January 2006. The previous inspection was carried out on 27th September 2005. No additional visits have been made to the home since the last inspection. The purpose of the inspection was to assess important areas of life in the home and check the progress made to meet previous requirements and good practice recommendations. Since the last visit the home had changed ownership and the former deputy manager had taken over the role of manager. On the day of inspection there were 31 residents accommodated in the home. Information was obtained from care records, staff records and policies and procedures. The inspector also spoke to the residents, the senior person on duty, the staff, and some visitors. A partial tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? A new care plan format had been introduced, which covered the residents’ health, personal and social care needs. Emphasis had been placed on the residents’ emotional needs and the maintenance of significant relationships. The records of personal care, which supported the care plans had been Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 6 maintained a more frequent basis and included details about the type and level of care provided. The staff rota had been revised and included details of which, staff were on duty at any time on a particular day. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Useful information was available about the home and this assisted prospective residents to make a choice. The home’s admission procedures, including pre admission assessments helped to determine whether or not prospective residents’ needs could be met. EVIDENCE: Written information was available for residents in the form of a statement of purpose and service users guide. Both documents met regulatory requirements and were presented in a readily accessible format. The registered person had also devised a summarised version of the service users guide in the form of a brochure, which was given to prospective residents and their families prior to admission. All residents were issued with a statement of terms and conditions of residence, which included details about fees, insurance and the complaints procedure. Residents’ files contained copies of assessments completed by health and social care professionals. From the documentation seen, it was also usual Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 9 practice for the manager to visit and assess prospective residents before offering them a place at the home. Following the assessment prospective residents received a letter confirming that their needs could be met at the home. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The new care planning system addressed the needs of the residents and provided clear guidance to staff on how these needs were to be met. However, the system must be extended to every resident to ensure all needs are met. Improvements must be made the management of medication to minimise the risk of errors and safeguard the residents. EVIDENCE: Since the last inspection a new care plan format had been implemented, which covered all aspects of the health, personal and social care needs of the residents. The plans were detailed and provided staff with clear guidance on how to meet needs. A pressure sore risk assessment had also been introduced, which identified those residents who were at risk of developing pressure sores. It was noted that emphasis had been placed on the residents’ emotional needs and the maintenance of significant relationships. However, it was evident that not all residents had a new style care plan and one resident’s plan had not been reviewed since September 2005. There was evidence the care plans had been discussed with the residents and their representatives and wherever possible residents had signed the plan and monthly review to indicate their agreement. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 11 The care plans were supported with records of personal care. Since the last inspection the records had been maintained on a more frequent basis and included details of daily care as well as any recurring difficulties. The home operated a monitored dosage system for the administration of medication, which was dispensed into blister packs. Policies and procedures were available to cover all aspects of managing medication in the home. Appropriate records were in place to record the receipt and administration of medication. However, there were omissions noted on the medication administration record, there were some creams and loose tablets without prescription labels and there were no specific instructions about where to apply creams on the body. It was also noted that some prescribed cream, which was stored with current medication was not entered on the medication administration record, a number of watches were stored in the medication cupboard and the stock of medication was not appropriately rotated. The overall storage of medication was cramped and not efficiently organised. Residents spoken to felt their right to privacy was respected by the care staff and personal care was carried out with respect to their dignity. All residents were referred to by their preferred mode of address, which was documented on the care plan. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents were able to exercise choice and control over their lives and maintained good contact with their family and friends. Consultation with residents would be improved by meeting more frequently with them. EVIDENCE: The residents said the daily routine was flexible and they were able to get up and go to bed at a time of their choosing. One resident said “I always go to bed when I like” and another person said, “I like to go to my room in an evening and watch television”. Residents had a range of opportunities to pursue activities both inside and outside the home. Activities inside the home included professional entertainment, hairdressing, music and movement, tabletop games, aromatherapy and quizzes. Residents were also involved in activities outside the home, which included going to the local club, walks around the surrounding area and visiting family and friends. There had been one residents’ meeting held since the last inspection and consultation with the residents was therefore largely dependent on informal conversation. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 13 There were no restrictions placed on visiting and the residents were able to entertain their guests in private. The visitors spoken to on the day of inspection, said they were satisfied with the overall level of care. Specific comments regarding some systems and routines in the home were discussed with the senior person on duty and later with the manager. Residents were encouraged to exercise choice and control over their lives. As such residents were supported to manage their own finances. Residents were also able to bring in personal belongings and arrange their rooms how they wished. The menu was on display in the home and the choice of meals was discussed with the residents. The residents were satisfied with the quantity and variety of meals and described the food as “very good” and “very tasty”. Drinks and snacks were available at set times throughout the day and evening and at all other times on request. A detailed record of meals served to residents was maintained. The inspector observed the meals served to residents on the day of inspection and noted that the food was plentiful, nicely presented and nutritionally balanced. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 Systems were in place to ensure any complaints would be taken seriously and acted upon. Established policies and procedures at the home ensured residents were protected from abuse or harm. EVIDENCE: The complaints procedure was incorporated in the service users guide, which was available in all bedrooms. The procedure contained the necessary information should a resident wish to raise a concern with the home or direct to the Commission. However, the details given about the local authority ombudsman were no longer applicable. There had been no complaints made about the home. When spoken to the residents were aware of the procedure and were confident they would be listened to if they had any complaints. There was a whistle blowing procedure and an appropriate procedure for staff to follow should they suspect or witness an incident of abuse. The staff on duty confirmed these issues were discussed with new staff during the Induction period. A copy of “No Secrets in Lancashire” was also available. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Residents were happy with their accommodation at the home and lived in a safe, clean and well-maintained 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 of the bedrooms have ensuite facilities. The home also provides four bathrooms for assisted bathing, including a “parker” bath, a shower, and two conventional baths with chairlifts over. Communal space is provided in four lounge/dining rooms, two sitting areas and a conservatory. It was evident from a tour of the home that residents had personalised their rooms with their own belongings and decoration was good throughout. The residents said their rooms were comfortable and warm. Residents had been provided with aids and adaptations to assist their independence skills, these included grab rails, handrails and raised toilets. The Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 16 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. The doors to residents’ bedrooms had been fitted with suitable locks and keys had been distributed to residents, as appropriate. Radiators had been fitted with guards. To prevent scalding the baths and showers had been preset valves to guarantee water was delivered close to 43 degrees Celsius. Preset valves had not been fitted to hand wash basins. The home was clean and odour free at the time of the inspection. A resident said, “The home is always kept very clean”. The systems for maintaining hygiene included procedures for infection control. Plastic aprons and gloves were available to staff when undertaking care duties. 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.V272164.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Arrangements were in place to ensure staff were employed in suitable numbers and received appropriate training in line with the needs of the residents. EVIDENCE: Since the last inspection a staff rota had been maintained which indicated which staff were on duty at any time on a particular day. 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. All new employees undertook an in house induction programme and competed a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. At the time of inspection the equivalent of 38 of the care staff were trained to NVQ level 2 or above and a further 2 members of staff were waiting for accreditation NVQ 2 or 3. Staff also attended both internal and external training courses and had at least three paid days training a year. A recruitment and selection procedure for the employment of new staff was not available for inspection. There had been no staff recruitment since the last inspection. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 36 The staff and residents enjoyed positive relationships, which promoted an open and friendly atmosphere. Quality monitoring systems must be improved in order to monitor outcomes for residents. EVIDENCE: Since the last inspection, the home had changed ownership. Whilst the previous registered provider no longer acted as a manager, she had continued to remain involved with the home. The former deputy manager, has applied to Commission to be the registered manager, but the process of registration had not been completed at the time of the visit. 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, who they described as “very good” and “friendly”. The staff received supervision at least six times a year. Topics discussed during supervision were Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 19 recorded on a suitable format, which included a section on policies and procedures. The home achieved an Investor’s in People Award in November 2001 and this was reaccredited in April 2005. Satisfaction questionnaires had been distributed to residents and their relatives in May 2005. However, whilst comments made about the service were positive, the results of the surveys had not been collated, published and fed back to all interested parties. A survey had not been carried out of stakeholders in the community and visiting professional staff. Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 20 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 3 3 X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X 3 X X Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP8 Regulation 15 15 Requirement A care plan based on the assessment of needs must be generated for every resident. All residents must have an up to date care plan, which details their healthcare needs and includes guidance for staff on how to meet these needs. The medication administration record must be signed immediately after the administration of medication to avoid omissions in the record. All prescribed medication must be clearly marked with a prescription label. The medication administration record must include instructions about where to apply prescribed cream on a person’s body. All current prescribed medication must be entered on the medication administration record, all medication, which has been discontinued must be returned to the pharmacy. The manager must be registered with CSCI. Timescale for action 31/03/06 31/03/06 3 OP9 13 (2) 31/01/06 4 5 OP9 OP9 13(2) 13 (2) 31/01/06 31/01/06 6 OP9 13 (2) 31/01/06 7 OP31 8, 9 15/03/06 Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 22 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 3 4 5 6 7 Refer to Standard OP9 OP9 OP12 OP16 OP25 OP28 OP29 Good Practice Recommendations The storage and organisation of medicines should be improved. The stock of medication should be rotated in date order. Apart from medication and items associated with medication no other item should be stored in the medicines cupboard. Residents meetings should be held on a more frequent basis. Details relating to the local government ombudsman should be removed from the complaints procedure in the service users guide. Preset valves of the type unaffected by changes in water pressure and which have fail safe devices should be fitted to hand wash basins to provide water at 43° C. 50 of the care staff should be qualified to NVQ level 2. A written recruitment and selection procedure should be devised, which takes into account the amendments to the Care Homes Regulations 2001 and the introduction of POVA. The registered person should ensure the results of satisfaction surveys are collated and published and made available to all interested parties. A satisfaction survey should be carried out of all stakeholders in the community and visiting professional staff. The results of the surveys should be collated and published. 8 9 OP33 OP33 Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Dercliffe Care Home DS0000065155.V272164.R01.S.doc Version 5.0 Page 24 - 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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