Inspection on 29/06/05 for Dalling House

This inspection was carried out on 29th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dalling House 04/06/07

Dalling House 12/12/06

Dalling House 14/02/06

Dalling House 13/02/05

Dalling House 12/10/04

Dalling House 27/02/04

Dalling House 06/01/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Dalling House Croft Road Crowborough East Sussex TN6 1HA Lead Inspector James Houston Unannounced 29 June 2005 8:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dalling House Address Croft Road Crowborough East Sussex TN3 1HA 01892 662917 None None Aspenglade Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Roy Williams Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (OP), 21. of places Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of twenty one residents to be accommodated (21) 2. The people accommodated will be aged sixty five years or over on admission Date of last inspection 13 February 2005 Brief Description of the Service: Dalling House is close to Crowborough town centre, within walking distance of shops, churches and buses. The home is registered for 21 older people. There is a through dining room and lounge with a sun room that looks out to a wellmaintained rear garden, with a water feature. There is a passenger lift for easy access to all communal and private accomodation in the home. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of the twenty ninth of June 2005. Before the inspection papers held by the Commission for Social Care Inspection were read, and those sections of the standards to be assessed prepared. The inspection in the home took five hours. A tour was made of the whole home, and the provider was spoken to by telephone. The inspector met the manager, eight residents, five relatives and three staff. There were nineteen residents accommodated on the day of the inspection. What the service does well: What has improved since the last inspection? Residents’ weight is recorded in their care plan. A list of initials and staff signatures has been produced to assist with medication monitoring procedures. Staff training on adult protection and prevention of abuse has been arranged. Staff now have access to a copy of the Brighton and Hove and East Sussex Multi-Agency Policies and Procedures for the Protection of vulnerable Adults document. The home has a training matrix for the training needs of staff. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 and 6. The home fully assesses prospective new residents. The different forms used should be reviewed. The home meets the needs of the current resident group. EVIDENCE: Records inspected showed that the home conducts its own assessment of prospective residents. Several different forms have been in use, and it is recommended the manager reviews practice. Discussion with the manager, staff, residents and their relatives and the reading of a range of records indicates that staff individually and collectively have the skills to meet the needs of residents. Intermediate care is not offered in the home. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 11. The process of ensuring all care plans contain risk assessments and risk management strategies for the prevention of falls has not yet been completed. Care plans need to be reviewed monthly and note the involvement of relatives. Healthcare needs of residents are well met. Medication systems are generally thorough but the record of drugs administered was incomplete. Good systems exist to ensure that the wishes of residents about arrangements to be made after their death are met. EVIDENCE: Records inspected showed that the manager has worked to ensure that care plans have risk assessment and risk management strategies for the prevention of falls and this process is nearing completion. Care plans are still not reviewed monthly, nor is the involvement of relatives in the development and review of care plans fully recorded. Residents and their relatives said that thorough arrangements are made to meet the healthcare needs of residents. Records inspected confirmed this, including that residents are weighed regularly. The manager said that relationships with local health professionals are good. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 10 The manager said that no controlled drugs are held for residents and that no residents self-administer. Residents said that the medicine administration system works well. The manager said that a local pharmacist who does spot checks on their system visits the home regularly. The manager has a list for staff initials and signatures to assist with medication monitoring procedures, and staff spoken to had signed this. Staff said that they had had relevant training. The record of administration of medicines contained recent unexplained gaps and it was unclear what had been administered. The home has a policy on death and dying of which a staff member was aware. The manager said that the home endeavours, with the advice and support of healthcare professionals, to enable residents to die in the home, and to enable families to be present. Records inspected showed that the wishes of residents and families about arrangements to be made after their death are clearly recorded in their care plans. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Meals and mealtimes provide daily interest for residents. EVIDENCE: Residents confirmed that they could eat in their rooms or in the dining room. Breakfast is usually taken in rooms. Residents said that they are pleased with food served. The cook on duty said that the home caters for medical and other diets. Residents said that they are given an alternative if they do not want to have the main meal on offer, and records inspected confirmed this. The main meal served during the inspection was attractively presented and in ample portions. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a suitable complaints procedure. The home’s procedures, processes and training for staff are designed to protect residents in the event of any abuse or allegation of abuse. EVIDENCE: The home has a clear complaint procedure. Residents said that they are aware of the right to complain. The home has received no complaints since the last inspection, and the Commission for social Inspection has received none. The home has a system for dealing with any issues raised with it. The home has appropriate adult protection policies in place. The manager has since the last inspection obtained a copy of the Brighton Hove and East Sussex Multi-Agency Policies and Procedures for the Protection of Vulnerable Adults document and will make this available to all staff. Staff said that they had had appropriate training and there was written evidence that the manager has arranged a further session with an outside trainer on 4th July 2005. The manager said that no incidents causing the adult at risk procedures to be invoked have occurred. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 and 24. The home provides accommodation to a good standard. Communal areas and bedrooms are well presented, providing pleasing accommodation. EVIDENCE: The location and layout of the home are suitable for its stated purpose. It is situated in a residential part of Crowborough, five minutes walk from the town centre. The home has a maintenance system to rectify minor matters needing attention, with records kept. The home is accessible to residents. There is a passenger lift to all floors and ramped access into the well-kept garden, where residents sitting out said they were enjoying the sunshine. The home has a dining room leading through to a lounge and a separate sun lounge. These communal areas are furnished and decorated to a high standard. Lighting is domestic in character. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 14 Residents said that they like their rooms, and confirmed that they had been able to bring their own possessions in to the home. All bedroom doors are lockable. Residents said that they have not chosen to hold a key but one resident said that she liked the fact that if she was away from the home her room would be secured until she returned. The manager said that if a room becomes vacant, it is re-decorated and re-carpeted. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 30. A competent staff team meets residents’ needs. The home has not achieved the recommended level of 50 of staff with NVQ level 2 by 2005. The home has a training matrix for staff. EVIDENCE: The home has a staff rota that was made available to the inspector. Residents said that there are enough staff on duty and that staff respond quickly and willingly when they ask for help. There are additional staff on duty at peak times during the day. Ancillary staff are employed in sufficient numbers. Residents and staff said that staff turnover is not high and staff said that agency staff are not used. The manager said that she is on call to staff, and that she can contact the owners if she needs to. She said that any staff member left in charge of the home is always aged at least 21 years of age. Staff said that the home has staff meetings. It is recommended that these are minuted for the benefit of staff not present. The manager said that no staff currently have NVQ level 2, those with it having moved on. Five staff are currently doing level 2. The manager has a training matrix for induction of new staff, a copy of which was shown to the inspector. The owner said that the home has a training chart for staff that she is currently updating. This should be in the home available for inspection. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35.36,37 and 38. The home has a quality assurance policy. The home lacks suitable quality assurance processes. Residents and their representatives in general control their own finances. Formal supervision sessions must be restarted. Records are generally well kept. Fire safety is compromised by widespread use of wedges. EVIDENCE: Observation and discussion with residents and relatives showed that the home’s manager regularly talks with them. The home did not have evidence of formal consultation with residents, relatives or stakeholders on how the home is achieving goals for residents. The home does not normally hold money or valuables for residents, and was not doing so on the day of the inspection. The manager said that the facility to hold valuables exists, and a record of valuables deposited and withdrawn is kept. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 17 The manager confirmed that formal supervision sessions have not restarted. It is required that that care staff receive formal supervision. The recommended frequency is at least six times a year. Records seen were generally well kept except where mentioned elsewhere in this report. Residents said that they were aware that they could access their records but had chosen not to. The last inspection report required that fire doors in corridors were not wedged open, and that consideration be given ways of addressing this fire safety issue, i.e. by use of hold-open devices such as electro-magnetic retainers. At this inspection doors were again found to be wedged open throughout the home, and hold-open devices had not been installed. Three doors marked “keep locked shut” were not locked and the manager secured these during the inspection. Two fire doors did not close onto their stops. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 x x STAFFING Standard No Score 27 3 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 3 1 3 1 Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 13(4) Requirement Care plans to contain risk assessment and risk management strategies for the prevention of falls. (Prevous timescale of 1/4/05 not met) Review care plans monthly and record the relatives involvement in their development and review.(Previous timescale of 1/4/05 not met.) Ensure medication is administered correctly That the training matrix produced to monitor the training needs for all staff is available for inspection. Have in place an effective quality assurance system.(Previous timescale of 1/4/05 not met) Reintroduce formal staff supervision sessions(Previous timescale of 1/4/05 not met) Do not wedge open doors and consider ways of addressing this fire safety issue. Ensure fire doors close on their stops Timescale for action 31 August 2005 2. 7 15(2) 31 August 2005 3. 4. 9 30 13(2) 18(1)(a) Immediate 31 August 2005 31August 2005 31st August 2005 31st August 2005 10th July 2005 5. 6. 7. 8. 33 36 38 38 24 18(2) 24(c) 24(c) Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 20 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 7 28 Good Practice Recommendations Review the forms used for reviewing prospective residents health and welfare needs to ensure that the home can fully meet these needs. 50 of staff achieve NVQ level 2 or above. Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Dalling House H59-H10 S21085 Dalling House V229748 290605 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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