Inspection on 06/04/06 for Underhall Resource Centre

This inspection was carried out on 6th April 2006.

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 28/11/05

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 Denise Bate Key Unannounced Inspection 6th April 2006 01:15 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.V288020.R01.S.doc Version 5.1 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.V288020.R01.S.doc Version 5.1 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.V288020.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 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.V288020.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection which consisted of a site visit and two telephone calls with the manager who provided additional information. The inspection lasted approximately six hours. The deputy unit manager assisted the inspector for most of the inspection, A tour of the building took place. A number of records were examined, including risk assessments and care plans, health and safety documentation, staff files, Regulation 26 visit records 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. Five service users were spoken with during the visit and spoke positively about standards of care. Five members of staff were spoken to during the visit, staff were enthusiastic and knowledgeable. Two residents were case tracked, and the care plans of all residents were seen. What the service does well: What has improved since the last inspection? A system for the formal supervision of staff has been introduced. The appointment of a new part time manager to job share with the manager currently registered, enables staff supervision to be kept up to date, in addition to sharing other management tasks. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 6 A format for assessing all aspects of service users’ medication has been introduced which includes an assessment of service users capacity to self administer, as required at the last inspection. Further staff training has taken place. 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.V288020.R01.S.doc Version 5.1 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.V288020.R01.S.doc Version 5.1 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home have a system for assessing residents’ needs to ensure that the respite care provided can meet residents’ needs appropriately. EVIDENCE: Derbyshire County Council has recently introduced a new system of assessment and care planning. Documentation is brought together prior to a resident being admitted to short term care. Examples of this were shown to the inspector for some residents due to be admitted in the coming weeks. The information provided was satisfactory, although some gaps in information were identified and this further information will be obtained prior to admittance. On the day of inspection the deputy manager spent some time liaising with other professionals regarding the possible changing care needs of a resident who comes for regular short term care. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 9 Potential new residents are invited to spend a day at the centre with their relatives, and this is used to verify assessment information, provide the service user with information and choice, and undertake any further assessments. An evaluation is completed at the end of this visit, and examples of this were shown to the Inspector and provided useful additional information. The home is not registered for intermediate care so Standard 6 was not assessed. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans of relating to personal and social care needs of residents were not detailed and up to date and did not reflect the high quality of care actually being delivered. This has the potential to place residents at risk. EVIDENCE: All care plans were seen, and two residents were case tracked. Some of the assessment and care planning documentation was old and there was generally no evidence of regular reviews. Some residents had signed documentation indicating that care plans had been discussed with them, other plans had no signature. Some care plans were incomplete and did not give sufficient detail as to how residents’ care should be provided. It was noted that Derbyshire County Council is introducing a new care planning/assessment system, and care must be taken to ensure that the information provided is sufficient to meet national minimum standards. Daily logs were detailed and informative. There were records of contact with doctors, and health details were clearly identified on care plans. Daily logs referred to health issues and what Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 11 measures were taken to ensure residents had access to doctors and other health care professionals. Staff spoken to were aware of residents’ health needs. A new system of medication assessment has been introduced and includes assessment of a resident’s ability to administer their own medication. Medication records were seen and found to be accurate. Where one resident was being assisted in administering medication this was clearly recorded. The medicine trolley is inconveniently situated some distance away from the residential unit in what may be a temporary location, and is not in the designated residential area of the building. The trolley was securely attached to the wall. Residents spoke very highly of the staff and made positive comments, e.g. ‘they can’t do enough for you’, ‘ they are always kind and helpful’, ‘if you ring the buzzer they always respond straight away’. Residents confirmed that they are treated with respect and dignity. Four residents spoken to came for regular respite care and said they looked forward to it. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided within the day centre that generally suit the expressed preferences of residents. All assist in contributing to a pleasant atmosphere and the overall high level of satisfaction for residents. EVIDENCE: The day centre is attended by most residents, although they are able to use their bedrooms or the residential sitting room during the day if they prefer. The day centre has a full range of activities, and the stimulating activities and entertainment form an important part of the respite care for most residents. It was noted that since a quality assurance exercise was carried out, there are plans for regular outings in the summer. Residents confirmed that they could follow their own routines, and some preferences together with likes and dislikes were noted on some care plans. One resident confirmed that her family has visited recently and were made to feel welcome. Underhall is an established part of the community and local organisations, e.g. schools, choirs, etc., often come in to entertain at the day centre. Regular religious services are held. Most short stay residents are from Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 13 the local rural community. The home would make arrangements to meet the cultural needs of residents from different religious or cultural backgrounds. The home follows Derbyshire County Council’s Equal Opportunities Policy. Menus were seen and found to be appropriate. Residents take lunch in the day centre; breakfast and tea are taken in the residential unit which has a small kitchen. Residents are offered a choice of menu, and can discuss individual needs and preferences. Residents spoken to said the food was very good, and food seen on the day of inspection was of a high standard. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure in place, and this is made known to residents and visitors. There are systems in place which promote the protection of residents from abuse and neglect. The manager and deputies are aware of adult protection procedures and most staff have received training. 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. It was noted that following several complaints regarding the smoking area of the day centre, a no smoking policy was introduced after a survey was carried out. 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. Residents spoken to had no Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 15 complaints but said they knew who to go to with any concerns, and would have no hesitation in raising issues. A discussion took place with the Acting Manager, who is aware of adult protection issues. Most staff have had training in adult protection within and this is recorded on their individual training records. Staff spoken to showed an awareness of adult protection issues and would pass any concerns on to their line manager. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 16 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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are accommodated within a safe environment, which is generally kept in good order decoratively. The completion of outstanding requirements regarding electrical work, radiators, and electric sockets in bedrooms would be beneficial to residents’ health and safety. EVIDENCE: On the day of inspection all areas of the home were clean, tidy, and homely. Several residents spoken to commented that standards of hygiene and cleanliness were very good. Some bedrooms have been decorated and a new ¾ bed purchased. A garden project is planned to increase the attractiveness and accessibility of the garden area for residents’ enjoyment over the summer months. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 17 Six bedrooms have been fitted with further electric sockets but are not able to be used at present because they have not been activated. Two bedrooms need to have electric sockets fitted. The area where new sockets have been installed have had mirrors removed and need the mirrors put back and/or the decorating to be finished off. The fitting of more electrical points was a requirement at previous inspections, to meet the national minimum standard and reduce any health and safety concerns. Two timescales for action of this requirement have now expired. 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 a previous 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. Two timescale for action of this requirement have now expired. A bath which can accommodate service users who require assistance, has been fitted but the placement in the bathroom does not allow the use of a full range of disability aids, e.g. a rotunda. 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. Other toilet and washing facilities within the home are satisfactory. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 18 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Current staffing levels meet the dependency needs of residents currently accommodated within the home. EVIDENCE: The rotas were seen and found to provide adequate staffing to meet residents needs. Staff spoken to were responsible and enthusiastic, and were observed being responsive to residents needs and aware of issues of safety. There is a team approach to work, and staff said they feel well supported. Staff files seen had evidence of CRB checks, copies of contracts, and references, indicating that recruitment procedures are robust. Staff training records were seen which indicated a rolling programme of training to ensure that all staff had mandatory training. Recent training has included moving and handling updates, first aid and basic food hygiene. Staff could benefit from training in infection control. Information on how many staff have completed or are undertaking NVQ2 was not available on the day of inspection and the home have agreed to write to The Commission for Social Care Inspection with this information. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 19 It was noted that Derbyshire County Council has achieved the Investors in People Award. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 20 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, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: A recommendation from a previous inspection was that the registered manager should have more protected time for managerial work. The inspector was informed that currently the registered manager is working 30 hours per week, Most of these hours are rostered shifts, although 6.5 hours a week and one flexi-shift of 8 hours every three weeks allocated for managerial duties, It was noted that the manager has responsibility for the running of the day centre Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 21 and support to the flats as well as the residential home. However, a part time manager has recently been appointed to work 15 hours a week and the inspector was informed that both managers will be sharing responsibility for the residential service, including staff supervision. Previously the managerial hours allocated made it difficult to provide formal supervision to staff, informal supervision was provided as and when required but not formally noted. There is now a system in place for care staff to receive formal supervision. This is recommended at least six times a year. The staff supervision arrangements will be looked at again at a future inspection. Staff spoken to felt well managed and supported. Residents spoke positively of the manager and would feel comfortable raising any issues with her. The home is visited regularly by a representative of the registered person and Regulation 26 visit reports were made available to the inspector. These indicated that matters of day to day management are dealt with in a timely fashion (apart from the matters highlighted in the Requirements), and the Service Manager regularly consults with residents about the quality of the service provided. Residents had been formally consulted during a quality assurance exercise, ‘Your views, Our Actions’. 86 of residents judged the service as ‘excellent’, 14 as good; 63 or relatives/friends judged the service as excellent, 33 as good. Among the comments included were the following:- ‘staff are helpful and committed to providing a good service, ‘ staff give 1 to 1 time’, the service provides ‘peace of mind’. The day centre (which most short term care residents attend) has been awarded a Chartermark for providing a good quality service. On the day of inspection the home was not looking after any finances on behalf of residents. However, the records were looked at and found to be appropriate. A variety of health and safety records were looked at, including domestic health and safety audits (February 2006), which identified minor issues to be resolved. Gas safety testing; portable electrical appliance testing and other maintenance documents were seen: all were satisfactory apart from the electrical hard wiring where minor work remains to be carried out. 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.V288020.R01.S.doc Version 5.1 Page 22 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 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X 2 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 x 2 Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 23 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 OP24 Regulation 23 (2) Requirement Additional electric sockets must be provided in bedrooms and must be in working order so that plug boards are not needed (previous requirements to address the matter – timescales 31 December 2005 and 28 February 2006 not met) CSCI to be notified in writing when requirement has been complied with. For the comfort of service users the heating must be adjustable in each service users bedroom. (previous requirement to address the matter – timescales 31 December 2005 and 28 February 2006 not met). CSCI to be notified in writing when requirement has been complied with. Remedial work to address the hard wiring survey must be completed. (previous requirement to address this matter – timescales 30 July 2005, 31 October 2005 and 31 January 2006 not met) CSCI to be notified in writing when requirement has been DS0000035715.V288020.R01.S.doc Timescale for action 30/05/06 2 OP24 23 (2) 30/08/06 3 OP38 23 (2) 30/05/06 Underhall Resource Centre Version 5.1 Page 24 4 OP7 15 5 OP31 7 complied with. Care plans must be up to date, detailed, and have evidence that they have been discussed with the service user. The newly appointed part time manager must apply for registration as a fit person. 30/06/06 30/06/06 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 Refer to Standard OP9 OP21 OP30 Good Practice Recommendations The provider should provide information on permanent arrangements for the location of the medication trolley. The current bath hoist is limited in its turning capacity and does not allow a full range of disability equipment to be used, e.g. rotunda. Staff could benefit from training in infection control. Underhall Resource Centre DS0000035715.V288020.R01.S.doc Version 5.1 Page 25 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.V288020.R01.S.doc Version 5.1 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!