Inspection on 27/12/06 for 1 & 2 Dalby View

This inspection was carried out on 27th December 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 & 2 Dalby View 08/12/08

Similar services:

The Highlands

Blenheim House

1 Lanark Close

Beaconsfield Court Care Home

Ann Charlton Lodge

The Gardens Care Home

Westmoor View Nursing Home

Ashlea Mews Residential Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 & 2 Dalby View Coulby Newham Middlesbrough TS8 0TW Lead Inspector Derek Stow Key Unannounced Inspection 27th December 2006 10:15 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 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 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 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 Adults 18-65. 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. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 & 2 Dalby View Address Coulby Newham Middlesbrough TS8 0TW 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) 01642 596664 P/F 01642 596664 Saint John of God Care Services Mrs Jennifer Bell Care Home 8 Category(ies) of Physical disability (8) registration, with number of places 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual who has learning and physical disabilities is allowed to reside in the home. This is the first inspection since the change in the name of the organisation to St John of God Care Services was registered with The Commission For Social Care Inspection on 4th September 2006. Date of last inspection Brief Description of the Service: 1 & 2 Dalby View are two modern, purpose built bungalows opened in 1993. The buildings are set back from the main road in their own grounds and are close to local shops and amenities. Accommodation is provided in eight single bedrooms, each of which provides facilities for the individual service users. No bedrooms have en-suite facilities but there are communal baths, showers and toilets. Some bedrooms have electronic systems, enabling residents to be as independent as possible. The bedrooms are decorated and furnished to the tastes of the service users. Each bungalow has a spacious and comfortable lounge and a kitchen/dining area. Both bungalows have laundry facilities that are available to service users. The home is located near to the Coulby Newham centre where there are shops and leisure facilities. Nearby there are churches and pubs. A bus route, to Middlesbrough and Stockton, is close to the home and the local buses which run every 10 minutes are wheelchair friendly along with the local taxis. The Home also has a specially adapted minibus with a hydraulic lift. Cost of service at 1 & 2 Dalby View. On the date of this inspection the fees for care ranged from £788-42 to £90286 per week. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at 1 and 2 Dalby View was unannounced and took five hours. The inspection included a tour of the building, examination of various records and time spent talking with three residents, two care staff and the manager. The inspection also took account of information gathered about the service over the year including a pre-inspection questionnaire completed by the manager. This inspection looked at those standards, which the Commission for Social Care Inspection regard as Key minimum standards. The details of any issues identified as requiring action together with recommendations for improvement are to be found at the back of this report. What the service does well: What has improved since the last inspection? What they could do better: Residents’ contracts must be kept up to date. The records in residents’ files must all be appropriately dated and medication records must be accurate. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 6 The maintenance issues detailed in the report must be addressed and the recommendations made will further help to strengthen the quality of service provided. 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. The summary of this inspection report can be made available in other formats on request. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 5. Quality in this outcome area is (Adequate). Individual aspirations and needs are assessed before admission. Not all residents’ contracts are up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six of the eight residents at Dalby View have lived there for over 12 years. The last two people to be admitted was over 3 years ago. The files of two residents were looked at in detail and both held a great deal of detailed assessment information including multi-disciplinary care management assessments obtained prior to admission. The Manager showed individual contracts and explained that these were currently being updated but not all had yet been completed. In discussion with the manager it was agreed that all contracts must be kept up to date and it was recommended the Service user Guide and other information made available to residents is reviewed to ensure that it complies with The Care Standards Act 2000 (Miscellaneous Amendments) Regulations 2006. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is (Adequate). The residents at Dalby View make appropriate decisions about their lives and are involved in the assessment and planning process. Residents are supported in taking risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents were spoken with during the inspection and they all confirmed that they are at the centre of planning their daily routines and life plans and take full part in reviews. The records examined held detailed daily records, care plans and review documents, which together with appropriate risk assessments gave evidence that residents are supported in enjoying an independent lifestyle. However not all records were appropriately dated. In discussion with the manager it was agreed records in residents files must be strengthened by ensuring that they are all appropriately dated. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is (good). Residents are empowered to fulfil their rights and responsibilities and are supported in taking part in appropriate activities in the local community as well as maintaining personal relationships. A varied and balanced diet is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records examined showed that each resident has a weekly diary of activities based around their wishes, choices and needs and four residents attend a day resource centre. The three residents spoken with gave accounts of what they enjoyed doing including going to music gigs, the local pub as well as enjoying holidays abroad. All three said that they were well supported by staff and felt treated with respect. One said, “ the best thing is the freedom”. Records showed that all the residents are in regular contact with families, friends or carers. The home has a driver and a specially adapted mini-bus with a hydraulic lift available each day. Appropriate menus are in place and are planned with the residents. The three residents and two staff spoken with all said that the food at Dalby View was very good. Staff said that residents meetings are held every month. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is (Adequate). The residents receive personal and healthcare support in a way that is agreed and medicines are stored and given safely. However records must be accurate and up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ files contain a great deal of information about their individual needs and preferences. Detailed information is recorded of people’s care needs and how help and support should be given. Care plans as well as discussion with the manager and staff showed that the home has good links with external professional services needed by the residents to make sure that people get the help they need. Two staff give out medicines and the manager said that 14 of the 16 care staff are trained to give medicines and that this is up-dated inhouse every 3 months. In addition the manager signs that each member of staff is competent. The medicine record sheet that was checked was found to be correct. However there were several other records of individual residents medication found on files that did not tally with the official record. This could cause confusion and in discussion with the manager it was agreed that this area of practice be reviewed and all records of medication must be accurate and up to date. It was also recommended an audit trail for all non-monitored dosage medication is created with a clear start date being recorded. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is (good). Residents at Dalby View are confident that the manger and staff listen them to and they are protected from abuse and neglect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home has a complaints and compliments policy and procedure in place, which includes a picture version. No complaints have been recorded at the Home since the last inspection. The residents spoken with said that they were confident in staff dealing with any concerns that thy might have. The policy and procedure should now be updated to make it clear to residents and relatives that the responsibility to receive, resolve and investigate complaints is with the management of the Home and those agencies such as Social Services and Primary Care who contract or commission services on behalf of individual residents. The Commission for Social Care Inspection is primarily a regulator of services and not a complaints investigation body. However residents, relatives and members of the public can still report any concerns about the running of a particular service to the Commission who will consider the issues and whether the service is meeting the required standards and regulations. The protection of vulnerable adults policy and procedure is in place and Staff spoken with during the inspection all knew what to do if they suspected abuse of residents and had undertaken training. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26 and 30. Quality in this outcome area is (good). The residents who live at 1 & 2 Dalby View live in a homely, comfortable and safe environment, which is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the building took place with the Manager and was found to be generally well decorated, furnished and maintained to a high modern standard. Residents’ bedrooms were personalised, decorated and equipped to the individual choice of residents with such things as televisions and sound systems. The manager said that all bedrooms are re-decorated every year. Two residents have full electronic environmental control systems to assist independence. Both units in 1 & 2 Dalby View have newly fitted kitchens and new disability bathing facilities. The buildings appeared clean and hygienic. There were two maintenance issues, which must be addressed. Some tiles need to be re-placed and some boxing in of pipe work in one of the bathrooms and in one of the residents’ rooms the drawers need to be repaired or replaced. The residents spoken with said that they were happy with their bedrooms. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 & 36. Quality in this outcome area is (good). A team of properly recruited and supervised staff who are qualified and well trained supports residents at Dalby view. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager said that all care staff are now qualified to NVQ2 or above and that several staff hold NVQ 3. The staff records that were checked had proper evidence of identity on file together with 2 references. Although the manager said that Criminal Record Bureau checks had been made this was not supported by full documentary evidence as she had been advised that records of disclosures could no longer be held. In discussion with the manager it was advised that a record should be kept of the date received, reference number and a record of any decisions made in considering relevant issues. Two staff who were spoken with said that they were well supported by management, received supervision six times a year as well as annual appraisal and had good access to training opportunities and staff meetings. Both staff said that they had undertaken training in adult protection and whistle blowing. The three residents spoken with said that the staff are good and that they receive the support they need. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is (good). The residents of Dalby view benefit from a service which is well run and managed. Quality monitoring systems are in place and the health, safety and welfare of the residents is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager of Dalby View is experienced and is qualified in Care and Management. There are several quality assurance systems in place which focus on the needs of the residents including care planning, review, monthly resident meetings, regulation 26 visits, involvement of relatives, advocates, annual survey and the Annual Service Plan. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 16 A number of health and safety records were examined to confirm that up to date maintenance/checks and records were in place relating to hot water temperatures, electrical wiring. A fire risk assessment had also been carried out as well as fire training and fire drills. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 x 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 18 Are there any outstanding requirements from the last inspection? NO 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. 2. 3 4. 5. Standard YA5 YA6 YA20 YA24 YA24 Regulation 5 17 17 Schedule 3 23 23 Requirement Residents’ contracts must be kept up to date. Residents file records must be appropriately dated. All Medication records must be accurate and must reflect the actual medication given. The maintenance issues in the bathroom must be addressed. The drawers in one of the resident’s bedrooms must be repaired or re-placed. Timescale for action 31/01/07 01/01/07 01/01/07 31/01/07 31/01/07 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. Refer to Standard YA22 YA20 Good Practice Recommendations Update the complaints information and service user guide. It is recommended that the manager develop a clear audit trail for all non-monitored dosage system medicines. 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 1 & 2 Dalby View DS0000068417.V325041.R01.S.doc Version 5.2 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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