Inspection on 24/11/09 for Dalemain House

This is the latest available inspection report for this service, carried out on 24th November 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dalemain House 05/01/06

Dalemain House 07/06/05

Dalemain House 03/11/04

Dalemain House 09/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Dalemain House 19 Westcliffe Road Southport Merseyside PR8 2BL     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Daniel Hamilton     Date: 2 4 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Dalemain House 19 Westcliffe Road Southport Merseyside PR8 2BL 01704568651 01704565832 glennmcnair@talktalk.net Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Glen Alan McNair care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Service users to include up to 24 OP Date of last inspection Brief description of the care home Dalemain House is a residential care home, which provides personal care and support for up to 24 older people. There were 19 residents accommodated at the time of the unannounced inspection. The home is owned and managed by Mr Glen McNair. The home is located in a residential area close to the town of Southport, which can be reached by the local transport services. The home is a large converted house and is decorated and furnished to a high standard. All areas are accessible by a passenger lift and there is ramped access to the front garden and small car park. Grab rails are available throughout. Call bell systems are in all rooms. Community facilities include a large comfortable lounge, dining room and a well maintained enclosed garden. Accommodation includes 11 single rooms, 9 with en suite and 5 en suite double rooms. Care Homes for Older People Page 4 of 32 Over 65 24 0 Brief description of the care home Information on the service is displayed in the reception area of the home in the form of a Statement of Purpose and Service User Guide. The cost for the service is £389.00 to £406.00 per week. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes. This unannounced inspection took place over one day and lasted approximately 9 hours. Nineteen residents were being accommodated at this time. A site visit took place as part of the unannounced inspection and a partial tour was conducted of the premises. A number of the homes care, staff and health and safety records were viewed. Discussion also took place with the registered provider / manager, care manager, administrator, three care staff, three relatives and nine residents. During the inspection three residents were case tracked (their care files were examined and their views of the home obtained). This process was not carried out to the Care Homes for Older People Page 6 of 32 detriment of other residents who also took part in the inspection process. Reference was also made to an Annual Quality Assurance Assessment (AQAA) which was completed by the registered provider / manager (owner). This document enables a registered person to undertake a self-assessment on the service, prior to an inspection. Survey forms were also distributed to a number of residents and staff before the inspection. Comments included in the report are taken from the survey forms and through discussions with residents during the visit. All the key standards were inspected and action taken in response to a recommendation made at the last inspection in December 2006 reviewed. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? This section is not applicable as only one recommendation was made at the last inspection concerning fire drills. A recommendation in regard to fire training for staff Care Homes for Older People Page 8 of 32 has also been made following this inspection. What they could do better: The Statement of Purpose and Service User Guide for Dalemain House should be updated and include the name and contact details of the Care Quality Commission. An holistic assessment of needs should be undertaken and kept under review for all residents living in Dalemain House to ensure all the needs of residents are identified and appropriately planned for. Care plans must also be kept under monthly review to ensure that the changing health, personal and social care needs of the people using the service are identified, planned for and met. The medication trolley should be attached to a wall when not in use to ensure the trolley is secure. Furthermore, all staff responsible for the administration of medication should complete external training and have their competency assessed periodically to ensure best practice. Declaration of wishes in regard to the administration of medication should also be available on each residents file to provide evidence that individual residents have been consulted on their wishes in regard to the administration of medication. The range of activities in the home should be expanded to ensure the social and recreational needs, expectations and preferences of the people using the service are met. Records of the activities provided, participants and facilitator(s) should also be maintained to provide an overview of the activities available to residents. A complaint log record should be established to provide an audit trail for any concerns, complaints or allegations. The complaints procedure should also be updated to include the name and contact details of the Care Quality Commission so that people wishing to complain are aware of the name and how to contact the regulator. A copy of the most recent local authority adult protection procedures should be obtained and staff should be reminded of the external reporting procedures to follow in the event of suspicion or evidence of abuse. A supply of paper towels should be available at all times in the laundry to ensure infection control and good hand hygiene. Documentary evidence of any relevant qualifications and training completed must be obtained to provide evidence that staff have completed all the necessary training for their roles. Staff should also be inducted in accordance with the Skills for Care Common Induction Standards to ensure compliance with National Training Standards. The registered manager should record the hours worked by himself to provide a clear audit trail as to the amount of management hours worked in the home. Furthermore, the service should refer to guidance issued by the department of health to assist in monitoring the dependency needs of residents and the resultant staffing levels to ensure best practice. Under no circumstances should any staff commence employment prior to receipt of two satisfactory references and an enhanded criminal record bureau certificate to safeguard the welfare of the people using the service. The application form should also be revised Care Homes for Older People Page 9 of 32 to provide more space for staff to record their full employment history. A certificate must be obtained and available for inspection for the fire alarm system. This will help to provide evidence that the fire alarm system has been routinely serviced and is operating correctly. Records should also be established to provide evidence that day staff receive fire instruction training every six months and night staff every three months to ensure safe working practice. Furthermore, the fire risk assessment should be kept under annual review and records established to verify that the temperature of hot water outlets accessible to residents are correctly regulated and checked on a monthly basis to ensure best practice. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are generally given information on the service and have their basic needs assessed before deciding whether to move into Dalemain House. This enables the service to identify needs and to determine whether care needs can be met. Evidence: A Statement of Purpose / Service User Handbook had been developed in a standard format to provide information on Dalemain House for prospective and current residents and their representatives to view. A copy of the documents were displayed in the main entrance hall together with a copy of the last inspection report. Photographs of events, thank you letters and other memorabilia were also on display in the reception area. It was noted that the Statement of Purpose on display was dated 2004 and was in need of review as the details of the Care Quality Commission had not been included. Care Homes for Older People Page 12 of 32 Evidence: The care manager advised that the service was planning to develop an information pack using visual and audio aids in the next twelve months. The service was also recommended to develop the Statement of Purpose and Service User Guide in alternative formats i.e. large print. Feedback received from the majority of residents and their representatives via surveys and through discussion confirmed that people had generally received sufficient information on the service before deciding whether to move into Dalemain House. Information received from the registered manager prior to the inspection via an Annual Quality Assurance Assessment (AQAA) confirmed policies and procedures were in place for referral and admission. The AQAA also highlighted that the preassessment package had been updated during the last 12 months to include a basic care plan form which is completed prior to admission and reviewed again within the first 6 weeks. Three assessments were sampled during the visit. Two were for residents who had been recently admitted and one was for a resident who had lived at Dalemain House for over nine years. One file viewed did not contain any assessment information. The other two files contained a functional (tick box) assessment form and a pre-assessment observation form which resembled a care plan. The format of the document outlined care needs, objectives and care instructions and covered a range of areas including physical and mental health, communication, environment, diet, personal hygiene, pressure areas, continence, mobility, sleep, social interests, finance / pocket money, preferred last wishes and identified risks. Some key areas of need for example medication usage, ethnicity, gender etc had not been assessed. Advice was given to the management team on how to improve the assessment process. Care Homes for Older People Page 13 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Dalemain House have their needs met and their care is provided in a manner that protects privacy and dignity. Evidence: The Annual Quality Assurance Assessment for Dalemain House confirmed that the service had policies and procedures in place covering Individual Planning and Review and the Control, Storage, Disposal, Recording and Administration of Medicines. Personal files relating to three residents were viewed during the visit. Two files were for residents who had been recently admitted and one was for a resident who had lived at Dalemain House for over nine years. Each file viewed contained a plan of care that outlined the same criteria and provided very similar information as to the preassessment observation form. Care plans viewed contained basic information on how the needs of residents were to be met and had been signed by residents or their representatives. Records highlighted that none of the care plans viewed had been kept under monthly review and action Care Homes for Older People Page 14 of 32 Evidence: should be taken to address this. The care manager was recommended to include information on the routine health care needs of residents within care plans. A range of supporting documentation including risk assessments, diary sheets (including information on the care provided), hospital transfer records, food preference sheets, personal life story information, declaration forms and weight and health records were also available for reference. Feedback received from residents and their representatives via Care Home Survey forms and through discussion confirmed the people living in the home received the medical support they required. Records viewed detailed that residents had received visits from: general practitioners, district nurses, chiropodists, opticians and hospital appointments etc subject to individual need. Medication continued to be dispensed by a local pharmacist via a blister pack system. Medication was stored in a medication trolley, which was stored in a hallway when not in use and a separate cabinet was in place for the storage of controlled drugs. Previous inspection records confirm a fridge was also in place for the storage of medication requiring refrigeration. The cabinet used for the storage of controlled drugs was securely fixed to the wall however advice was given regarding the need to secure the medication trolley to a wall when not in use. The care manager reported that herself and senior care staff were responsible for the administration of medication and that all had completed in-house medication training as part of their induction training and a workbook supplied by the dispensing pharmacist to review competency. It was recommended that all staff responsible for administering medication complete appropriate external training and periodically have their competency assessed to ensure best practice. A system had been developed to help staff correctly identify residents prior to administering medication and a staff signature checklist was available for reference. At the time of the visit none of the residents were responsible for self-administering their medication. No consent / declaration of wishes in regard to the administration of medication were available on residents personal files and this should be addressed. A sample of Medication Administration Records (MAR) was checked with the care manager during the inspection. Medication Administration Records viewed had been correctly completed to account for medication received and administered and systems were in place to ensure effective stock control. Care Homes for Older People Page 15 of 32 Evidence: Staff were observed to interact with residents in a positive manner and staff spoken with during the visit demonstrated an awareness of the principles of care and the needs of the people they cared for. Feedback received from residents regarding the standard of care provided was good and residents confirmed their privacy and dignity was respected and maintained. Comments included: I am being well looked after; Staff understand my needs. They are very good and I find the standard of care very good. Care Homes for Older People Page 16 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Dalemain House generally receive the support they need to live their chosen and preferred lifestyle. Evidence: At the time of the visit the service did not have an activities organiser in post as the person previously responsible for organising activities had left during May 2009. The care manager reported that the service had advertised for staff to cover this key role. A basic programme of weekly activities had been produced in standard print however this was not very easy for residents to view as it was displayed in a small hallway off the main reception area. Activities on offer included: one to one activities; discussions in the dining room; hand, foot and nail care; hairdressing; church focus groups; quizzes and television programmes such as Countdown and X factor. Other activities provided included trips out; garden parties; personal shopping and entertainers for parties and birthday celebrations. Representatives from the local methodist and roman catholic churches also visited residents in the home on a monthly basis subject to their individual religious beliefs and wishes. On the day of the visit residents were observed to watch countdown, participate in Care Homes for Older People Page 17 of 32 Evidence: board games and enjoy a nail manicure and foot massages. Records of activities provided and participants were not available to view and mixed feedback was received from residents regarding the activities on offer. For example, comments from three residents included: It would be nice to have more variety; Id like to see more activities more often. We dont seem to have as many activitities available as we used to and Overall Im satisfied with the social activities but it would be nice to go out more. Residents were observed to follow their preferred routines and receive visits from their family and friends throughout the day. The people living in Dalemain House reported that the home was a relaxed and friendly environment in which to live. There were no set visiting times and residents were able to maintain contact with people of their own choice both inside and outside the home. Rooms viewed had been personalised by residents and contained personal possessions including pictures and ornaments. On the day of the visit the registered provider / manager was responsible for cooking meals as the service had a vacancy for a cook. The registered manager reported that he held a basic food hygiene qualification and the service offered a four-week rolling menu offering a choice of meals. Records of daily meal choices had been recorded. It was not possible to evaluate the full range of meals provided during the inspection as the four week menu could not be located however a selection of daily menu plans were viewed which confimed a range of wholesome and nutritious meals were provided. A copy of the daily menu plan was displayed on a notice board outside the kitchen. Meals were served in the homes dining room which provided a pleasant and comfortable area for dining. Tables were equipped with tablecloths, table mats, napkins and condiments. Staff were observed to be present during mealtimes to offer support for residents as required. Additional drinks were also served throughout the day and residents were able to eat their meals in their rooms if they wished. Feedback received from residents via surveys and discussion on the standard of catering was generally good. For example, comments included: The food is excellent. I cant fault it; We have very good food. There is always a choice. The staff ask you what your meal preferences are before each sitting and You would never go hungry in this home. We are well fed and the standard of food is good. Care Homes for Older People Page 18 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall, the people who live in Dalemain House understand how to complain and systems are in place to safeguard people from abuse. Evidence: The Annual Quality Assurance Assessment (AQAA) for Dalemain House confirmed a concerns and complaints policy was in place and that no complaints had been received in the last twelve months. Likewise, the Care Quality Commission had received no complaints, concerns or allegations about the service in the last year. The management team were requested to update the complaints procedure to include the correct name and contact details of the Care Quality Commission. At the time of the visit it was not possible to verify the information in the AQAA as there was no complaint log in place to reference. The management team were requested to re-establish a complaints log as was noted to be in place at the last inspection. A record of concerns / grumbles received had been recorded on a monthly visit form. Two concerns were recorded. One concerned the food preference of a resident that was raised in a quality assurance survey and the other was a verbal concern expressed by a relative concerning the personal care of a resident. Feedback received via care home surveys and discussion confirmed the majority of people using the service and their representatives were aware of how to complain. Examination of internal policies and procedures confirmed Guarding Against Abuse Care Homes for Older People Page 19 of 32 Evidence: and Whistle blowing policies had been developed for staff to reference. A copy of the local authority adult protection procedures had also been obtained however this was not the most up-to-date version and this should be addressed. The AQAA for Dalemain Lodge detailed that there had been no adult protection referrals or investigations in the last 12 months. The training matrix viewed highlighted that the management and staff team had completed training in the protection of vulnerable adults from abuse and the manager and staff spoken with demonstrated a sound awareness of their duty of care to protect the welfare of the people using the service and how to recognise and respond to suspicion or evidence of abuse. Some staff spoken with were not clear about external alerting procedures and this should be reviewed. Care Homes for Older People Page 20 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Dalemain Lodge provides an attractive, well maintained and comfortable environment for residents to live in which contributes to a good quality of life. Evidence: A full-time handyman was employed to monitor the condition of Dalemain House and to undertake minor maintenance tasks with input from the registered provider / manager. Contractors were also hired as and when necessary to attend to specialised maintenance work and the servicing of equipment. A maintenance plan for the ongoing maintenance and refurbishment was not in place, as this was monitored by the registered provider and areas viewed during the visit appeared well maintained and homely. The gardens were also found to be well tended and attractive with an integral water feature. Examination of the Annual Quality Assurance Assessment (AQAA) for the service and a partial tour of the premises with the owner / manager confirmed the home was clean with no odours detected in any area. Records detailed that the environment had continued to receive ongoing investment and maintenance since the last inspection. For example, new external lighting had been fitted to illuminate the gardens at night, the trees at the front of the property had been trimmed to allow more light into the lounge area and some bedrooms had been redecorated and supplied with new soft furnishings as they became vacant. Care Homes for Older People Page 21 of 32 Evidence: It was noted that some parts of the external woodwork were in need of repainting and the registered provider reported that this would be reviewed next year. Work in need of attention was recorded in a maintenance book and key workers continue to conduct a daily check to ensure the residents have everything they need and any repairs are identified and addressed. The location and layout of the home was suitable for its stated purpose (please refer to the Brief Description of the Service section for more information on the premises). Residents were observed to have access to personal mobility aids as required and rooms viewed had been personalised with pictures and other personal belongings. A full-time domestic / laundry person was employed to ensure the environment was kept clean and hygienic. The laundry was sited away from food preparation areas and equipped with a sluice facility, two washing machines, three driers and hand washing facilities. At the time of the visit there were no hand towels in the laundry and this should be addressed to ensure best practice. The AQAA for Dalemain House confirmed that an action plan was in place to deliver best practice in prevention and control of infection and policies and procedures were in place for Communicable Diseases and Infection Control and the Control of Substances Hazardous to Health. Records showed that staff had access to infection control training and feedback received from the majority of residents and / or their relatives confirmed Dalemain house was kept clean and fresh. Care Homes for Older People Page 22 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff recruitment and training processes are in need of review to ensure that the wellbeing of residents is fully safeguarded. Evidence: At the time of the visit 19 people were living in Dalemain House. Examination of the staffing rota and discussion with the registered provider / manager and staff confirmed the care manager and three carers were on duty from 8.00 am to 6.00 pm and then two carers (one of which is a senior carer) were on duty from 6.00 pm until 8.00 pm. During the night two waking night staff were on duty. Ancillary staff were also employed for cleaning and maintenance. A staffing / dependency tool was not in place to monitor the changing needs of residents and the required staffing and the registered manager was requested to address this and to keep under review the staffing levels in the evening (between 6.00pm until 8.00pm). It was not possible to determine the hours worked by the Registered Provider / Manager as there were no details of the shifts worked on the rota. Furthermore the rota did not specify the capacity of staff. Discussion with residents and staff confirmed the registered manager was regularly on-site and very visible. Care Homes for Older People Page 23 of 32 Evidence: Feedback received from residents or their representatives via Care Home Survey forms and discussion confirmed people were generally satisfied regarding the standard of care provided by the staff team. Comments included; Ive been very happy since Ive been here and the staff are always so helpful; I am quite content with the way I am treatedand Happy and helpful staff. The Annual Quality Assurance Assessment (AQAA) for Dalemain House confirmed a policy had been developed for recruitment and employment. Furthermore, the document confirmed that all the people who had worked in Dalemain House in the past twelve months had completed satisfactory pre-employment checks. The AQAA appendix section on workforce questions detailed that nine care staff had left employment in the last 12 months. The personnel files of the three care staff who had commenced employment in the last year were viewed. Each file contained a copy of an application form and health declaration, two references and evidence that a Protection of Vulnerable Adult (POVA) and /or Criminal Record Bureau (CRB) had been undertaken. It was noted that there was limited space on the application form for staff to record their full employment history and one applicant / employee had not provided any previous employment history and had started work with only one reference. Likewise, another employee had started employment one day before the POVA check had arrived. The AQAA detailed that 16 care staff were employed within the service of which 12 staff (75 ) had a National Vocational Qualification in Care at level 2. Files viewed contained no evidence to verify that staff had been inducted in accordance with National Training Standards (Skills for Care - Common Induction Standards) and documentary evidence of training completed was not available on files viewed. Examination of the training matrix and discussion with staff confirmed staff had access to a range of training and development opportunities including; safe working practice, protection of vulnerable adults, equal opportunities, dementia awareness, medication and national vocational qualification training. Some gaps were identified and this should be addressed. Care Homes for Older People Page 24 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration systems are subject to ongoing development and review to ensure Dalemain House is run in the best interest of its residents. Evidence: The registered provider / owner (Mr Glen McNair) remains the registered manager and previous inspection reports confirm Mr McNair had several years experience in the care of older people. At the time of the visit Mr McNair also employed a care manager and senior care staff to support him in his role. Records confirmed that the registered manager had completed the National Vocational Qualification in Management at level 4 since the last inspection and other periodic training including Deprivation of Liberty, food hygiene, moving and handling, protection of vulnerable adults, principles of care, health and safety and first aid. It was noted that the registered manager had not completed a NVQ level 4 in Care and other key training relevant to his role e.g. medication and this should be addressed to ensure best practice. Care Homes for Older People Page 25 of 32 Evidence: Feedback received from residents staff confirmed the registered manager and care manager communicated a clear sense of direction and were approachable and supportive. Systems had been established to communicate with and monitor the views of key stakeholders and records of staff and resident and family meetings were in place. Records also provided evidence that the registered provider continued to commission an external consultant to undertake an annual quality assurance assessment. The last assessment had been completed during July 2009 which involved distributing questionnaires to residents and their representatives, to find out their views on the service provided. The Annual Quality Assurance Assessment (AQAA) for the service detailed that policies and procedures on the Management of Services Users Money, Valuables and Financial Affairs had been developed for staff to reference. The registered manager reported that he did not act as an appointee and that residents were encouraged to look after their personal finances independently or with support from family or personal representatives. An administrator was also employed who had responsibility book keeping, payroll and fees. At the time of the visit the service looked after the personal spending money of eleven residents. Records were maintained which detailed how the money was spent and receipts were obtained to account for expenditure. Cash balances checked were found to be correct. Pre-inspection records detailed that Health and Safety policies and procedures were in place and examination of the AQAA confirmed that test, maintenance and / or associated records were up-to-date for all key areas. Discussion with staff and examination of records confirmed staff had access to safe working practice training. Fire log and service records were checked during the visit. Fire log records viewed confirmed that the fire alarm system had been tested each week and the emergency lighting and fire extinguishers had been tested / visually inspected on a monthly basis. A fire risk assessment dated December 2007 was also in place which was in need of review. A sample of certificates were viewed during the visit. Documentation was in place to confirm the extinguishers and gas safety had been routinely serviced however a certificate for the fire alarm system could not be located. The last available certificate Care Homes for Older People Page 26 of 32 Evidence: was dated 16/09/08. This issue must be addressed. The owner / manager was also recommended to establish records to provide clear evidence that day staff receive fire instruction refresher training at least every six months and night staff every three months. Advice was also given regarding the need to monitor the temperature of hot water outlets on a monthly basis. Care Homes for Older People Page 27 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans must be kept under monthly review. This will help to ensure that the changing health, personal and social care needs of the people using the service are identified, planned for and met. 05/01/2010 2 30 19 Documentary evidence of 05/01/2010 any relevant qualifications and training completed must be obtained. This will help to provide evidence that staff have completed all the necessary training for their roles. 3 38 23 A certificate must be obtained and available for inspection for the fire alarm system. This will help to provide evidence that the fire alarm system has been routinely 05/01/2010 Care Homes for Older People Page 29 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action serviced and is operating correctly. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The Statement of Purpose and Service User Guide for Dalemain House should be updated and include the name and contact details of the Care Quality Commission. An holistic assessment of needs should be undertaken and kept under review for all residents living in Dalemain House to ensure all the needs of residents are identified and appropriately planned for. All staff responsible for the administration of medication should complete external training and have their competency assessed periodically to ensure best practice. The medication trolley should be attached to a wall when not in use to ensure the trolley is secure. Declaration of wishes in regard to the administration of medication should be available on each residents file to provide evidence that individual residents have been consulted on their wishes in regard to the administration of medication. Records of the activities provided, participants and facilitator (s) should be maintained to provide an overview of the activities available to residents. The range of activities in the home should be expanded to ensure the social and recreational needs, expectations and preferences of the people using the service are met. The complaints procedure should be updated to include the name and contact details of the Care Quality Commission so that people wishing to complain are aware of the name and how to contact the regulator. A complaint log record should be established to provide an audit trail for any concerns, complaints or allegations. 2 3 3 9 4 5 9 9 6 12 7 12 8 16 9 16 Care Homes for Older People Page 30 of 32 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 10 18 A copy of the most recent local authority adult protection procedures should be obtained and staff should be reminded of external reporting procedures to follow in the event of suspicion or evidence of abuse. A supply of paper towels should be available at all times in the laundry to ensure best practice in infection control and hand hygiene. The registered manager should record the hours worked by himself to provide a clear audit trail as to the amount of management hours worked in the home. The service should refer to guidance issued by the department of health to assist in monitoring the dependency needs of residents and the resultant staffing levels to ensure best practice Under no circumstances should any staff commence employment prior to receipt of two satisfactory references and an enhanced criminal record burea check to safeguard the welfare of the people using the service. The application form should be revised to provide more space for staff to record their full employment history. Staff should be inducted in accordance with the Skills for Care Common Induction Standards to ensure compliance with National Training Standards. Records should be established to verify that the temperature of hot water outlets accessible to residents are correctly regulated and checked on a monthly basis. The fire risk assessment should be kept under annual review to ensure best practice. Records should be established to provide evidence that day staff receive fire instruction training every six months and night staff every three months to ensure safe working practice. 11 26 12 27 13 27 14 29 15 16 29 30 17 38 18 19 38 38 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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