Inspection on 28/06/05 for Underhall Resource Centre

This inspection was carried out on 28th June 2005.

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

Underhall Resource Centre 24/04/07

Underhall Resource Centre 06/04/06

Underhall Resource Centre 28/11/05

Underhall Resource Centre 19/01/05

Underhall Resource Centre 10/06/04

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 Underhall Resource Centre Chesterfield Road Two Dales Matlock DE4 2SD Lead Inspector Andrew Bailey Unannounced 28 June 2005 10.00am 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. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Underhall Resource Centre Address Chesterfield Road Two Dales Matlock Derbyshire DE4 2SD 01629 778511 01629 778519 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) Derbyshire County Council Vivienne Joy Bateman CRH - PC Care Home Only 8 Category(ies) of 8 places - OP Old Age only registration, with number of places Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Manager requirement Date of last inspection 19 & 23 January 2005 Brief Description of the Service: Underhall Resource Centre is a purpose built modern building situated in Two Dales, near to Matlock. The registration permits the admission of up to eight older people with personal care needs. The centre admits service users for short-term care, usually for one to two weeks duration (for respite care). The registered unit is part of a larger complex, which includes day care and sheltered housing (40 on-site flats). Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately 4 hours. A tour of the building took place. Discussion took place with five of the seven service users undertaking short-term care at the time of this visit. There were no relatives available to speak with during the inspection. A number of records were examined, including care plans (as part of the case tracking process, which is used to facilitate assessment of the home from the service users perspective). An assessment was also made of progress by the registered persons to address requirements made at previous inspections of this service. What the service does well: What has improved since the last inspection? Following service users suggestions, including feedback from the annual satisfaction survey, the range of social and leisure activities have been reviewed. The heating system has been repaired, with the installation of new boilers. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 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. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 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 Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 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 (standard 6 is not applicable to this service) Pre-admission systems are in place to ensure that service users are admitted on the basis of a full assessment of their needs. EVIDENCE: The Personal Service Plan files of the seven service users were examined at this inspection. The inspected files contained evidence of Community Care Assessments, with associated care plans that had been formulated prior to admission. The Personal Service Plan is developed by the staff, based on the Community Care Assessment/Care Plan and on the assessments undertaken upon admission of the service user to the unit. Service users spoken with confirmed that they had been involved in the assessment processes. The procedures in place indicate that there is a robust pre-admission system that involves the participation of the individual service user. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 The documentary standards of care plan entries are satisfactory. There are systems in place to promote the safe administration of medicines, but the assessment procedures in respect of self-administration of medicines need developing. Service users feel that staff maintain their privacy and dignity. EVIDENCE: There was written evidence (signatures) in the Personal Service Plans examined to support that service users had been involved in the formulation of the care plans. Service users spoken with also reported that they had been consulted about care issues. This demonstrates a partnership in care between staff and service users. There had been auditing of the medication system as part of wider Health & Safety auditing undertaken by the management. This provides reassurance that there is quality monitoring of the medication practices. All staff administering medication had received appropriate training. This indicates that competent staff are administering the medications. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 10 Service users are admitted for short-term care and therefore bring in their own medications. Some service users self-administer some or all of their medications. Whilst there are self-administration assessment/declaration forms completed in these instances, there must be a more detailed record made of the assessment process undertaken and record made on the assessment form of which medications are appropriate for self-administration. This is because there was evidence at this inspection that where some service users were self-administering medications, the completed medication assessment/declaration forms were not specific about which medication this applied to. Staff must also ensure that they are personally satisfied that individual service users have the capacity to self-administer medication, rather than there being reliance on the third party opinions e.g. from relatives. This is because staff can be held personally accountable for the assessments and there could be personal safety issues for some service users. Notwithstanding this, where appropriate, to aid the process staff may wish to consult with other professionals when undertaking competency assessments, for example discussion with the GP or community nurse. The current system has potential safety implications, and also legal implications in the event of any untoward incidents occurring concerning the self-administration of medicines. Service users spoken with confirmed the staff to be respectful of privacy and dignity in their daily interactions with the service users. For example, service users stated that staff members knock on the bedroom door before entering. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The social & leisure programme is well organised, providing stimulating and interesting opportunities for the service users. The meals are reported by service users to be of a good standard, with a choice available. EVIDENCE: Service users spoken with were very complimentary about the catering service at the centre. The daily menu is displayed so that the service users are aware of the choices available. Breakfast and tea is served in the unit dining room, whilst the midday meal is served in the main dining room in the resource centre. A good range of activities are organised by the resource centre staff, and short-term residents are invited to participate in the programme. Details of events are notified in the newsletter and displayed prominently in the unit so that service users are able to choose in advance which activities they wish to be involved in. The deputy manager on duty during the inspection stated that the programme had been improved since the last inspection, with a greater range of trips and entertainers organised. The service users spoken with were very appreciative of the social and leisure programme. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 12 Service users reported that the visiting arrangements were satisfactory and that they were able to exercise choice in how they spent their time in the unit. They also commented that the staff were very supportive and available to assist them when needed. A useful leaflet is given to service users before admission, which identifies what to bring in and what the visiting arrangements are. A member of staff commented that a relative had reported that it was not always easy to contact the unit by telephone in the evening and at weekends. Whilst a cordless phone was utilised in the unit when two staff were on duty, the signal was not optimum strength in all parts of the building. This indicated that the arrangements should be reviewed. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 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) 17 & 18 There is a complaints recording and investigation procedure in place and this is made known to the service users. The adult protection systems and the training of staff safeguard service users from abuse and neglect. EVIDENCE: The complaints procedure is displayed in the unit. There is a copy in the main day care unit and in the short-term residential area, making it readily available for service users and relatives to refer to. The complaints log was examined at this inspection and it was noted that there had been no recent significant concerns documented. There are also commendation forms in use, so that areas praise can be acknowledged, including individual efforts of staff. Staff have received training in adult protection issues and this provides reassurance that the service users are safeguarded as far as possible from unnecessary risk of abuse and neglect. Local adult protection reporting forms were readily available to the managers, so that prompt reporting could be effected should the need arise. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 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, 21, 24, 25 & 26 Service users are accommodated in a safe environment, which is kept in good order structurally and decoratively, with good standards of hygiene and cleanliness maintained. EVIDENCE: The premises are in good repair overall. Only minor maintenance issues were evident on the day of inspection e.g. broken kitchen tiles. There were arrangements in hand to have these repaired on the next weekend, when the disruption to the kitchen routines would be minimised. Whilst the short-term care facilities are self-contained, most of the service users choose to also use the main resource facilities when these were in use. The self-contained facilities include a dining room/lounge, which lead out to a garden area with seating and tables. The organised programme of in-house events is mainly centred around the main resource day-care unit (residents welcome to attend). Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 15 A service user spoken with commented that there was no shower provision within the unit. The remaining service users spoken with also then agreed that the lack of a shower was one of the few negative aspects of the unit. An assisted bath is available, but the lack of a shower can be a drawback to those service users who have a preference for a shower. There was use of plug boards in most of the bedrooms inspected during this visit. This demonstrates that the fitting of more electrical points would be worthwhile, not only to meet the National Minimum Standard, but as a means of reducing any health & safety concerns about possible trip hazards with the use of plug boards. The radiators in the bedrooms have covers, which protect service users from heat injury. However, there is no means of adjusting the temperature in individual bedrooms and this does not promote individual service user comfort or meet the National Minimum Standard, which states that heating may be controlled in the service user’s own room. There were available records to demonstrate that water temperatures had been monitored, to ensure that the risk of scalding is minimised. All service users spoken with expressed satisfaction with the cleanliness of the premises, indicating that hygiene standards are well maintained. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 16 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 & 30 A well-trained team of staff cares for service users. There is an established training programme to equip staff with the knowledge and skills to undertake their roles. The staffing levels are in accordance with the needs of the service users accommodated in the centre. EVIDENCE: Service users spoken with considered that there were sufficient staff to meet their needs. The deputy manager confirmed the levels of staff that are utilised on a day-to-day basis. Staff are rostered flexibly to meet the peaks of activity. The main challenge is for the managerial staff who also carry out care tasks, in that there is limited protected time available for them to perform the managerial role. This is particularly relevant in the case of the registered manager, who has limited supernumerary time for undertaking managerial duties. Examination of the rotas established that the manager frequently works between 28 and 30 hours/week, but most of these hours are primarily ‘on the floor’ hours. The training files examined indicated that there is a commitment to staff training at the unit. Overall, the records demonstrated that on-going training was up to date, but some staff were overdue for some of the safe working practice update training (see next section of the report). Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 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, 33 & 38 There is effective management of this facility and management is accessible and responsive to service users needs. Overall, the systems in place promote the protection of service users from health and safety perspectives, although staff updates are now due for some of the safe working practices training. EVIDENCE: There is evidence that the centre is run in an open and transparent manner, with records examined at this inspection that demonstrated the involvement and consultation with staff and service users. The records included the results of staff and service user surveys. It was apparent that the results had been acted upon. For example, one of the findings from the last service user survey was that service users considered that the trips out from the unit could be improved. This area of the activities programme has subsequently been reviewed and the feedback from the service users spoken with at this inspection was very positive in this respect. Service users also commented that all the staff (including management) are readily available to speak to. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 18 In general, the training for safe working practices was satisfactory. However, there are a number of staff who now require updates for food hygiene training (last undertaken in 2000 for two of the staff records sampled). Moving and Handling updates were to be arranged within the next few months (annual updates) and many of the staff had recently received fire safety training (June 2005). There was no dedicated training to cover the subject of infection control, although the theme forms a part of some of the other mandatory training e.g. food hygiene training. A positive development since the last inspection had been the fitting of new gas boilers (a previous requirement had been made for remedial action to the heating system). The deputy manager reported that work to meet the requirements of the last electrical installation inspection had been scheduled within the annual maintenance plan (not available at this inspection) and there was a requirement from the last inspection with reference to this work. Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 2 2 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 3 x x x x 2 Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 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 9 Regulation 13 (2) Requirement There must be a safe, riskassessed and fully documented system for service users wishing to retain responsibility for their own medication Additional electric sockets must be provided in bedrooms so that plugboards are not needed For the comfort of service users the heating must be adjustable in each service users bedroom All staff must receive regular safe working practices updates (e.g. food hygiene) The remedial work to address the electrical hardwiring survey must be completed (previous requirement to draw up a plan to address the matter - timescale of 30 July 2005) Timescale for action 31 July 2005 2. 3. 4. 5. 24 25 38 38 23 (2) 23 (2) 13 (3) 23 (2) 31 December 2005 31 December 2005 31 October 2005 31 October 2005 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 13 Good Practice Recommendations The contact arrangements for outside callers at weekends C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 21 Underhall Resource Centre 2. 3. 4. 21 27 & 31 38 and evenings should be reviewed due to the reported difficulties with the cordless telephone signal in some parts of the building Provsion of a shower should be made, in addition to the current bathing facility The registered manager should have more protected time for undertaking the managerial role There should be training specifically dedicated to the subject of infection control, including MRSA prevention and containment measures Underhall Resource Centre C52-C02 S35715 Underhall Resource Centre V234085 280605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection South Point 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. 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