Inspection on 07/06/05 for Ivonbrook Care Home

This inspection was carried out on 7th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Ivonbrook Care Home 25/11/08

Ivonbrook Care Home 13/09/07

Ivonbrook Care Home 13/09/06

Ivonbrook Care Home 24/10/05

Ivonbrook Care Home 03/08/04

Ivonbrook Care Home 28/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE IVONBROOK EVERSLEIGH RISE DARLEY BRIDGE MATLOCK, DERBYSHIRE DE4 2JW Lead Inspector Marie Bonynge Unannounced Inspection Tuesday 7th June 2005 at 10:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ivonbrook Nursing and Residential Home Address Eversleigh Rise Darley Bridge Matlock Derbyshire DE4 2JW 01629 735306 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) David Treasure Vacancy Care Home with Nursing 40 Category(ies) of OP registration, with number of places IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 3rd and 9th August 2004 Brief Description of the Service: Ivonbrook is a well established purpose built care home situated in its own grounds at Darley Bridge. It is registered to provide personal care and personal care with nursing and accommodation for up to 40 residents. Single accommodation is provided, some of which have en-suite facilities. The home has 2 large lounges and 2 separate dining rooms. Kitchen and laundry facilites are central. Car parking space is provided. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in June 2005. The main focus of this inspection was to monitor the progress from previous inspections and follow up compliance with the requirements and recommendations made. Many of these had been met and progress had been made regarding those not yet fully complied with. Some timescales have been extended and these requirements will continue to be monitored on future inspections. Inspection methods used included discussions with residents, members of staff and management and relatives / visitors to the home. Records examined included care plans, health records, staffing rotas and training records. A short tour of the building was made. What the service does well: What has improved since the last inspection? Improvements have been made regarding medication systems and their recording. A programme of installing locks to bedroom doors has commenced and some redecoration has taken place, one of the lounge carpets has also been replaced. Progress has been made in the care planning documentation, it is clearer and contains more information than on the previous inspection. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 6 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. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 and 5 The care needs of residents appeared to be generally met, although without full assessment information for every resident prior to their admission to the home there was the potential for gaps to occur. EVIDENCE: Three residents care plans were examined, discussions were held with the residents, their key workers and relatives where possible. Assessment information had been obtained for all 3 residents, however this was variable in its content and a nursing assessment had not been obtained for 1 resident. The acting manager advised that information was not always forthcoming from the hospital. The homes’ own assessment tool had not been fully completed for 1 of the residents. Discussions with care staff indicated that they were aware of the care needs of the person they were key worker for and they did refer to the care plans regularly. A requirement has been carried forward in respect of this. Discussions with relatives indicated that they were satisfied with the care that their relative was receiving. Positive comments were made including ‘there is attention to detail’ and ‘nothing is too much trouble’. There was a range of IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 9 skills and experience in the staff group to meet with the care needs of those residents accommodated. Residents were given the opportunity to look around the home prior to making a decision to stay and some residents had been to the home for a period of respite care. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Residents reported that they felt they were treated with respect and that their privacy was respected. Verbal communication systems enabled care staff to keep up to date with the general care needs of service users. However, residents’ health and personal care needs cannot be consistently met without comprehensive and detailed care plans that are regularly reviewed. EVIDENCE: Some improvements had been made to the care plans. One care plan included detailed information regarding the needs of the resident and how the identified needs could be met. However, one care plan had not been updated since the admission of the person in January 2005. It did not reflect this person’s circumstances and was not detailed in terms of the care to be provided. The risk assessments had been reviewed and did identify the action that needed to be taken to reduce the identified risk, for example falls. However the risk assessments had not been reviewed on a monthly basis as required at the last inspection. One requirement has therefore been met. The monitoring of residents weight was being recorded but not on a regular basis and the frequency did not reflect the nutritional risk assessment. Discussion took place with the acting manager and the proprietor regarding the completion of the care plans and an extended timescale was agreed for all the care plans to be IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 11 completed. Communication systems were in place such as handover for each shift and a communications book. Staff spoken with were able to give an account of the needs of residents and the reason for their admission. Medication systems were generally in good order and most of the requirements made at the last inspection had been complied with. One requirement has been carried forward. Residents and relatives spoke highly of the way in which care staff approached them and carried out the care. It was reported privacy was afforded to residents during personal care giving and when visitors came to the home. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 14 Service users experiences of the lifestyle of the home generally matched with their expectations affording them choices and a degree of flexibility. EVIDENCE: Residents and relatives reported that a range of leisure activities was provided including dominoes, music and movement and a programme of trips out. The range of activities had not been fully developed for those residents with dementia or other cognitive impairments although this was recommended at the last inspection. The daily routines of residents had been recorded and residents reported that the day was flexible regarding going to bed and getting up in the morning, being suited to individual preferences. Discussions with relatives indicated that residents were able to have visitors at any reasonable time and were supported to maintain links with family and friends. There were plenty of visitors on this inspection throughout the day. Bedrooms were generally personalised with photographs and ornaments and small pieces of furniture subject to agreement with the home. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Procedures and systems were in place to assist in safeguarding residents and to respond to complaints in a proactive manner. EVIDENCE: A complaints procedure was in place and a total of 7 complaints had been recorded. The outcome of these and the action taken had been recorded and showed that the complainant had been informed of the outcome. The proprietor has a ‘hands on’ approach and relatives and residents reported that they would approach him if there were a problem. Prompt action had been taken in responding to the complaints. The proprietor advised that all Criminal Record Bureau checks had been completed for all staff. This requirement has been complied with. Regulation 37 notices had been sent to the CSCI as required at the last inspection. Staff advised that they had attended training in the protection of vulnerable adults and were aware that abuse could take different forms and were aware of the action to be taken in reporting any suspicions of abuse. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23, 24 and 26 The home was generally clean, well maintained and decorated providing a comfortable and homely environment for residents. EVIDENCE: The home was generally well maintained and well decorated in a comfortable and homely manner. The home was purpose built and is situated near the village of Darley Bridge. Attractive and well maintained gardens are provided to enable residents to sit outside and benefit from surroundings. Several lounges are provided with separate dining space. Lighting and furnishings were domestic in character. There had been no changes to the bedrooms since the last inspection. Residents spoken with said that they liked their individual accommodation and those rooms seen were comfortable and individualised. A programme of installing locks to bedroom doors had commenced with 10 having been completed. The remainder are expected to be completed in batches of 10 at a time and a final date for completion has been set by the Proprietor. Areas seen were clean, hygienic and free from offensive odours. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Although residents and relatives reported that the general care needs of residents appeared to be met, to ensure that the needs of residents are fully met, staffing levels must be maintained at all times. EVIDENCE: There were 30 residents accommodated on this visit with a range of dependency levels. There were 7 residents with high dependency needs, 15 medium dependency and 9 low dependency. 20 residents had nursing needs and 10 residents were accommodated for personal care only. A number of residents had some level of dementia or other cognitive impairments. The proprietor is reminded that the home’s category of registration is for the general care needs of older people (OP) only and residents with a primary diagnosis of dementia should not be ordinarily accommodated. One resident had been admitted previously via Care Programme Approach (CPA). A sample of staffing rotas was examined for the period covering 28th May 2005 to 19th June 2005. There were 2 trained nurses on the morning shift today and 1 for the afternoon with 4 care assistants on in the morning and 3 in the afternoon. This was not in accordance with the Residential Forum guidance for staffing, details of how to obtain the guidance were given to the acting manager and the proprietor. A requirement was made at the last inspection regarding achieving and maintaining staffing levels. This will continue to be monitored at subsequent inspections. The rotas examined indicated that there were not sufficient cleaning hours on some days and cover had not been IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 16 provided. The Proprietor has agreed to keep the occupancy level at 30 residents and consult with the CSCI before increasing the occupancy. One CRB check for a volunteer who had worked in the home for many years had not been completed. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36 and 37 Although staff reported that morale was good and they worked as a team, the appointment of a permanent manager is essential to ensure that the home runs in the best interests of residents. EVIDENCE: The Registered Manager has resigned since the last inspection in August 2004 but has remained as Acting Manager in the interim period. The Proprietor has made attempts to recruit a permanent manager but the post remains vacant. The Acting Manager has been given some supernumerary time, however this has not been sufficient to ensure that all of the requirements have been met from the last inspection such as the formal supervision of staff and the completion of care plans. This will continue to be monitored on future inspections. Formal recorded supervision of staff was still not taking place on a regular basis and remained an outstanding requirement from previous inspections. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 18 Staff reported that they would find formal supervision helpful. Records were generally well kept and maintained with the exception of those identified in the main body of the report including care plans and one CRB check. IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 1 x x x x 1 2 x IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 (1) (a) (b) Requirement The registered person must ensure that full assessment information is obtained for each service user prior to their admission to the home that fully covers standard 3.3. From inspection report 03.08.04. The registered person must continue to develop care planning documentation with completion by the agreed date. From inspection report 29.10.03. The registered person must ensure that the service user plan sets out in detail the action needed to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. From inspection report 03.08.04. The registered person must keep the service users plan under review in accordance with the recommended guidelines of at least once a month and updated to reflect changing needs and current objectives for health and peronal care and actioned. From inspection report 03.08.04. Timescale for action Previous timescale 30.10.04. New timescale 01.08.05 Previous timescale 30.12.03. New timescale 01.09.05 Previous timescale 30.11.04. New timescale 01.09.05 2. OP7 15 3. OP7 15 (1) 4. OP7 15 (2) (b) Previous timescale 30.10.04. new timescale 01.08.05 IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 21 5. OP8 12 (1) (a) The registered person must ensure that all risk assessments are updated on a regular basis and in accordance with changing need. 6. OP8 12 (1) (a) 7. OP9 13 (2) 17 (1) (a) Schedule 3 8. OP27 18 (1) (a) 9. OP27 18 (1) (a) 10. 11. 12. 13. OP27 OP27 OP29 OP31 18 (1) (a) 18 (1) (a) 13 9 14. OP31 18 (1) (a) Previous timescale 30.10.04. New timescale 01.08.05 Nutritional screening must be Previous undertaken on a periodic basis, timescale weight gain or loss must be 30.10.04. undertaken and recorded on a New regular basis. From inspection timescale report 03.08.04. 01.07.05 If the MAR chart is handwritten Previous or altered by a member of staff timescale this must be signed and dated by 30.09.04. them. This must then be New checked, signed and dated by a timescale second member of staff. From 01.08.05 inspection report 03.08.05. The Proprietor and Manager Previous must continue to ensure timescale sufficient suitably qualified, 30.09.04. competent and experienced staff New are available to meet the needs timescale of residents. From inspection 01.09.05 report 03.08.05. Minimum staffing levels must be Previous maintained for the 30 residents timescale accommodated and reviewed 30.09.04. should the situation change. New From inspection report 03.08.04. timescale 01.09.05. Cover for cleaning hours must be 01.09.05 provided. The registered person must 01.08.05 adhere to the Residential Forum Staffing guidelines. A completed CRB check must 01.09.05 obtained for the volunteer worker. The registered person must 01.09.05 recruit to the vacant managers post and continue to keep the CSCI informed of the interim arrangements. Supernumery time must be Previous made available to the Manager timescale to ensure that the home 30.08.04. Version 1.30 Page 22 IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc 15. OP36 18 (2) complies with requirements as identified in this report. From inspection report 03.08.04. A supervision policy and formal supervision must be in place. From inspection report 03.08.04. 16. 17. OP37 17 Records must be completed as identifed in the main body of the report. New timescale 01.08.05 Previous timescale 30.12.04. New timescale 01.09.05 01.09.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP4 Good Practice Recommendations The home should consider the provision of a loop system for the benefit of residents with hearing loss and obtain an assessment in the first instance. From inspection report 29.10.03. The registered person should continue to develop the range of activities for service users with dementia or other cognitive impairments. Staff meetings should continue to be held on a regular basis. From inspection report 03.08.04. 2. 3. 4. OP12 OP31 IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 IVONBROOK C52 CO2 S2061 Ivonbrook V232259 070605 Stage 4.doc Version 1.30 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. 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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