Inspection on 28/11/05 for Underhall Resource Centre

This inspection was carried out on 28th November 2005.

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

Underhall Resource Centre 24/04/07

Underhall Resource Centre 06/04/06

Underhall Resource Centre 28/06/05

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 Derbyshire DE4 2SD Lead Inspector Angela Kennedy Unannounced Inspection 28th November 2005 10:00 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 Underhall Resource Centre DS0000035715.V268741.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. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 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 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) Derbyshire County Council Vivienne Joy Bateman Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Underhall Resource Centre is a purpose built modern building situated in Two Dales, near Matlock. The registration permits the admission of up to eight older people with personal care needs. The centre admits service users for shortterm 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 DS0000035715.V268741.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over three hours. Ivan Barker (inspector) was present to support the lead inspector who was currently on induction. The deputy unit manager assisted the inspectors for most of the inspection. The unit manager, who was not on duty at the time of inspection, came into the unit to prepare for the Christmas party the following week and participated in the last part of the inspection. A tour of the building took place. A number of records were examined, including risk assessments and records of service users monies held. An assessment was also made of the progress by the registered persons to address requirements made at previous inspections. Two service users were spoken with during the visit. What the service does well: What has improved since the last inspection? Compliments/complaints and suggestions have improved on completion of evidencing; following feedback from service users a no smoking policy within the centre is due to be implemented in December 05. A new bath has been fitted within the respite/short stay unit, and an improved telephone system is now in place. Some of the staff have received safe practice training updates and the remainder of staff are due to undertake this training in January/February 2006. The manager has undertaken risk assessment and training for the protection of vulnerable adults. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 6 A wide screen television and satellite ‘sky’ channels have been purchased for the respite unit. Part refurbishment of the respite unit has been undertaken including lights for the lounge area and a new carpet and curtains for one of the bedrooms. 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 DS0000035715.V268741.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 Underhall Resource Centre DS0000035715.V268741.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): EVIDENCE: Standards 1-5 were not assessed at this inspection; standard 6 is not applicable to this service. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 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 the following standard(s): 9 The assessment procedures in respect of self-administration have been further developed, however they still do not provide the required information to ensure service users are fully protected. EVIDENCE: There was written evidence within service users personal files examined, to support that since the last inspection (when a requirement had been made) a more detailed record has been produced with regard to service users who retain possession of, and self-administer some or all of their medication. This included a declaration stating who would be responsible (either staff or service user) for keeping and administering each specific medication, following the prescribed instructions written on the pharmacy label of each medication. Both the service user and staff signed this declaration. However included with this declaration there must be an assessment of the service users capacity to self administer medication, this is because staff can be held personally accountable for the assessments, and their could be personal safety issues for some service users. The current system has potential safety and legal implications in the Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 10 event of any untoward incidents occurring with service users who selfadminister their medication. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 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 the following standard(s): 13 Contact arrangements for the unit by telephone have improved to reduce the difficulties to outside callers contacting the unit. EVIDENCE: A recommendation from the last inspection was to review the contact arrangements for outside callers to the unit by telephone, as a cordless phone was utilised in the unit where the signal was not optimum strength in all parts of the building. However this has now been reviewed and is thought to be caused by the buildings construction, which in some areas has little or no signal. However an improved administration and telephone support system has now been put in place, which hopefully will rectify this situation. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 12 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 There is a robust complaints procedure in place, and this is made known to service users, and visitors of the centre. EVIDENCE: There is a clear, simple and accessible complaints procedure displayed both within the main day care area and within the respite area. This specifies how complaints can be made and that they will be responded to within 28 days, written information on how a complaint can be referred to the commission for social care inspection is included. This is readily available to both service users and their visitors. The complaints log was examined and noted that following several complaints from service users regarding other service users smoking within the designated smoking area of the day centre, questionnaires were sent out to all service users for their views on smoking within the centre. The information gathered from the questionnaires has generated an agreement of a no smoking policy within the centre. This will commence from 12 December 05.A designated smoking area outside of the centre has been agreed; this area does provide some overhead shelter from weather conditions and space for seating. This demonstrates that complaints are dealt with promptly and effectively. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 13 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): 19,21,24,25 Service users are accommodated within a safe environment, which is kept in good order decoratively. Sufficient toilets and washing facilities are available. EVIDENCE: . On the day of inspection all the service users seen were accessing the daycentre area, and many were busy assisting staff with preparations for their Christmas party, due to take place next week. It was observed that positive interaction was taking place between service users and staff. A new bath, which can accommodate service users who require assistance, has been fitted in the respite/short stay unit. A shower facility is available within the flats (adjacent to the unit), which service users in respite can access if they so wish, with staff support as required At the last inspection a recommendation was made to consider the provision of a shower in addition to the current bathing facilities, following comments made by service users spoken with, who had agreed that the lack of a shower was one of the few negative aspects of the centre. The manager of the unit is at present considering options available to provide a shower facility, one option being to adapt the staff bathroom into a shower room that could be used by Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 14 service users. This bathroom is situated along the corridor that leads to the service users bedrooms, however to access this shower room service users would have to pass two rooms that are used as offices by admin/community staff during the week. This was not considered appropriate and it was agreed that clarification from the registered provider was required regarding which area s of the building are registered as respite before further developments are made. Each bedroom seen had a double electric socket, however plug boards continue to be used within the bedrooms, to enable electrical appliances to be used. The fitting of more electrical points was a requirement at the last inspection, to meet the national minimum standard and reduce any health and safety concerns about the possible trips hazards with the use of plug boards. Although the timescale for action of this requirement has not yet expired, the manager did not think this work would be achieved within the present timescale. 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. A requirement was made at the last inspection to allow the heating within service users’ bedrooms to be adjustable; this is in order to meet the national minimum standard, which enables service users to control the temperature of their bedroom, according to personal preference. Although the timescale for action of this requirement has not yet expired, the manager did not think this work would be achieved within the present timescale. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 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 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): 29,30 A thorough and established recruitment practice is operated within the home, which promotes the protection of residents. Staff are trained appropriately to enable them to meet the service users needs. EVIDENCE: One service user spoken to said that he would give the respite centre a five star rating, as the care was very good. The staff files examined demonstrated that all the necessary requirements are in place prior to staff being employed, included in this were two written references and a full employment history, satisfactory police and the protection of vulnerable adult checks and terms and conditions of employment. Some of the staff have now received their safe working practice updates, e.g. food hygiene (a requirement from the last inspection), the remainder of staff were booked to undertake this training in January and February 2006. At present there is no dedicated training planned to cover the subject of infection control (a recommendation from the last inspection). Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 16 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): 31,35,36,38 The systems in place promote the protection of service users and their financial interests are safe guarded by a robust system. Formal supervision for staff is somewhat sporadic due to the managerial time available. EVIDENCE: A recommendation from the last inspection was that the registered manager should have more protected time for managerial work. The manager works 30 hours a week. Most of these hours are rostered shifts, although 6.5 hours a week and one flexi-shift of 8 hours every three weeks have now been allocated for managerial duties, however the manager stated that the managerial hours allocated were not sufficient to provide formal supervision to staff, informal supervision was however provided as and when required. Care staff must receive formal supervision, this is recommended at least six times a year. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 17 Service Users are able to hand over their monies and valuables if they so wish which are locked in the safe for safekeeping and records and receipts kept. However on the day of inspection the centre was holding no service users monies or valuables. Within each bedroom seen, lockable cabinets were provided for service users to keep any money or valuables in as they chose. Of the service users money sheets/ financial transactions seen all had two staff signatures and the service user signature next to each entry, this demonstrates good practice and safeguards service users financial interests. A requirement from the last inspection was to address the remedial work required from the electrical hardwiring survey. This work has not yet been completed, this survey was seen and found to have been undertaken over 12 months ago, although the work to be completed stated that it was low priority this work must be undertaken to bring the electrical certificate up to date and ensure safe working practices are in place. Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 18 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X 3 X X 2 2 X STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 1 x 2 Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 19 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 9 Regulation 13 (2) Requirement There must be a safe risk assessed and fully documented system for service users wishing to retain responsibility for their own medication (previous requirement to address the matter – timescale 31 July 2005). Additional electric sockets must be provided in bedrooms so that plug boards are not needed (previous requirement to address the matter – timescale 31 December 2005). For the comfort of service users the heating must be adjustable in each service users bedroom (previous requirement to address the matter – timescale 31 December 2005) Care staff must receive formal supervision. Remedial work to address the hard wiring survey must be completed (previous requirement to address this matter – timescale 30 July DS0000035715.V268741.R01.S.doc Timescale for action 31/01/06 2 24 23 (2) 28/02/06 3 25 23 (2) 28/02/06 4 5. 36 38 18 23 (2) 28/02/06 31/01/06 Underhall Resource Centre Version 5.0 Page 20 2005 and 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 21 Good Practice Recommendations Provision of a shower should be made, in addition to the current bathing facilities once clarification has been sought regarding the area of the centre that is registered as respite services. 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. 2 3 31 38 Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office 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 Underhall Resource Centre DS0000035715.V268741.R01.S.doc Version 5.0 Page 22 - 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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