Inspection on 24/10/05 for Dalmuir Home

This inspection was carried out on 24th October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dalmuir Home 11/10/07

Dalmuir Home 01/02/07

Dalmuir Home 18/05/05

Dalmuir Home 30/09/04

Dalmuir Home 05/05/04

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 Dalmuir Home 25 Gresham Road Limpsfield Oxted Surrey RH8 OBU Lead Inspector Deavanand Ramdas Announced Inspection 24th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dalmuir Home Address 25 Gresham Road Limpsfield Oxted Surrey RH8 OBU 01883 715630 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) Mr Mike Noorbaccus Mrs Myrna Noorbaccus Mr Mike Noorbaccus Care Home 16 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (11), Learning disability over 65 years of age of places (2), Old age, not falling within any other category (16) Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the 16 older persons (OP) accommodated, up to 12 persons may fall within the category DE(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Of the 16 older people accommodated, 1 (one) may be in the category LD(E), learning disability and 1 (one) may be in the category LD(DE) and over 60 years of age. Of the people accommodated with dementia 1 may be under 65 4. Date of last inspection 18th May 2005 Brief Description of the Service: Dalmuir House is a care home for older people that is located in Oxted in Surrey. The property is situated in a quiet residential area close to the town centre and public amenities. The accommodation is provided on three floors and stair lifts are available. The home can accommodate sixteen service users in single and shared bedrooms some with en suite facilities. The home has a dining room, lounge, kitchen, laundry, bathing and washing facilities. The gardens are well maintained comprising of lawns, flowerbeds, mature fruit trees and a vegetable garden. Private parking is available to the front of the property. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over six hours. A partial tour of the premises took place and staff, service users and relatives were spoken to. Documents and care records were examined. The inspector would like to thank the manager, deputy manager, staff, service users and relatives for their contributions to the inspection. Feedback forms, comment cards and CSCI business card were left at the home for information. What the service does well: What has improved since the last inspection? What they could do better: Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 6 The home must ensure a test for legionella bacteria is carried out by a reputable company in order to maintain a safe environment for staff, service users and relatives. The home shall obtain a copy of the local authority policy (Surrey County Council) on the protection of vulnerable adults dated February 2005 to ensure the home have up to date information to protect and safeguard service users. 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. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4,5&6. The arrangements at the home for meeting the needs of service users are adequate ensuring service users are satisfied their needs will be met. The home offer trial visits enabling service users and relatives to assess the suitability of the home. EVIDENCE: The home has a policy on admissions dated 2002. The inspector noted the home had an initial assessment for new service users that was carried out by the manager and deputy manager. The inspector sampled a needs assessment dated 17.3.05 and noted needs were assessed and identified. The home has a policy on trial visits. The inspector noted this was stated in the terms and conditions of residency dated 2002. The manager commented the home offered a six-week trail period after which the placement is reviewed. The deputy manager remarked service users and relatives are encouraged to visit the home and assess the facilities before admission. It was recorded in the diary a service user visited the home on three occasions before admission to the home. A relative stated he visited and assessed the home before his Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 9 mother moved to the home. The manager stated the home does not offer intermediate care and this standard was not assessed. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9&11 The arrangements at the home for managing medications are adequate that promotes good health. The arrangements for handling dying and death are satisfactory ensuring service users and their relatives are treated with sensitivity and respect. EVIDENCE: The home has a policy on medications dated 2002. The manager stated staffs have been assessed in medications. The inspector sampled the training and assessment folder and noted staff had been trained and assessed in the administration of medications by the deputy manager who had done the trainers course in March 2003. The home had a medicine trolley and a medication cabinet that was in the office. The medication cabinet was secured to the wall. The inspector sampled medication record sheets and noted they were dated and signed by staff. The manager stated he had purchased a training manual from Mulberry on medication administration training. A relative stated staff are cautious about medications and always keep me informed about changes in medication. The manager stated the home had no controlled drugs. The home had a policy on care of the dying and bereavement dated 2002. The manager stated the home offered visitors the Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 11 opportunity to support service users who are dying. The deputy manager commented the home offered refreshments, the free use of the home telephone and assisted in making funeral arrangements. The inspector noted the manager had purchased a training manual on dying, death and bereavement training. The manager stated staff supported relatives during dying and death and the inspector noted a letter dated 22nd May 2002 describing staffs understanding of the death process. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13&14 The arrangements at the home to support service users to maintain contact with family and the community are adequate. The systems at the home for autonomy and choice are satisfactory ensuring service users have control over their lives. EVIDENCE: The home supports contact with family and friends that is stated in the homes brochure dated 2005. The manager remarked visitors could see their relatives in private in the office, bedroom or dining room. The home has involvement with a local church group and the inspector noted a volunteer was at the home doing a bingo session for service users. During an interview the volunteer stated he visited the home weekly and has been doing so for five years. He remarked the bingo sessions helped service users with improving their confidence and morale. A service user remarked she went by taxi to the local town centre to do shopping. The deputy manager stated service users go to the local Red Cross centre and transport was provided by dial a ride. The inspector noted a trip was planned on the 28.10.05 to the local theatre and it was recorded in the diary a priest would be visiting the home on the 2.11.05 at 3.15 pm. The manager stated two service users were supported to manage their finances and remarked the home had contact with advocacy partners that provided independent advice to service users. The deputy manager Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 13 commented service users are encouraged to bring their personal possessions to the home. The inspector noted some service users had their own tables, chairs, and televisions in their bedrooms. The manager stated it was not the policy of the home to manage service users monies and the home would invoice relatives on a six monthly basis for any cost incurred for hairdressing and chiropody care paid for by the home. The inspector noted the home kept a record of costs incurred by service users in a diary in the office. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 The complaint process at the home is satisfactory with complaints information available to staff, service users and relatives. The arrangements for the protection of service users are adequate ensuring service users are protected from abuse however the must obtain an up to date copy of Surrey multiagency procedure manual. EVIDENCE: The home has a complaint policy that was updated in 2005. The inspector noted a copy was displayed in the hallway for information. The manager stated the home kept a record of complaints. The inspector sampled the complaints folder and noted the last complaint was made in 2002 and management had taken action. The manager stated complaint information is available to service users that is in the service users guide. The home has a whistle blowing policy dated 2004. The inspector noted the home had a local authority procedure for the protection of vulnerable adult that was in need of updating. This was discussed with the manager and action has been required in respect of this matter. The manager stated no staff have been referred to POVA register. The manager stated all staff had Surrey multiagency training on the protection of vulnerable adults. The inspector sampled training files and noted one staff had attended training in May 2004. During a meeting a relative stated he was aware of the complaint and whistle blowing policies. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20&26. The arrangements for managing the premises are satisfactory ensuring service users live in a safe environment. The communal areas are adequate ensuring service users have access to a comfortable safe communal area. The systems for hygiene are adequate ensuring the home is clean and hygienic for service users. EVIDENCE: On the day of the inspection the home was clean, well ventilated and free from mal odour. The gardens were well maintained, private and secure with wheelchair access. The communal areas were well furnished with adequate tables, chairs and lighting. The inspector noted some new chairs were in the lounge and one service user stated the new chairs are nice and they provide good support. The lounge had a television, radio, books, magazines and a piano. The home had infection control measures and the inspector noted staff washed their hands regularly. Gloves, aprons and hand wash were available in the home. The home had a laundry room with a washing machine and a dryer and the inspector noted the floor was painted with masonry paint to make it Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 16 impermeable, easy to clean and maintain. The home had a contract with a waste disposal firm that provided bins for the disposal of clinical waste. A service user described the home as ‘A1 at Lloyds’ and remarked it was always nice and clean. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28&29 The arrangements for staffing at the home are adequate ensuring there are sufficient numbers of staff on duty to meet the needs of service users. The arrangements for staff training are excellent enabling service users to be supported by a skilled staff team. The systems for the recruitment of staff are adequate ensuring service users are protected at all times. EVIDENCE: The manager stated the home employed twenty three staff that included the managers, deputies, senior care staff, care staff, a cook, a housekeeper and a handyman. The manager commented the staffing levels were four in the morning, four in the afternoon and two at nights. The manager remarked the staffing level was agreed with the Commission and is adequate. He stated he regularly reviewed staffing resources using the residential forum formula that reflected the home was over its allotted weekly hours. The home had a staff rota that was sampled for the period October 2005. The inspector noted the roster reflected the numbers of staff on duty. The inspector noted the home did not use agency staff that was reflected on the duty roster. On the day of the inspection the staffing level was adequate. The manager stated the home had an Investor in People award and won an accolade sponsored by Community Care and Skills for Care as one of the best employers of an establishment employing less that 250 staff. The inspector noted confirmation of the accolade was displayed on a notice board in the staff office. The deputy manager stated all staff working at the home had the NVQ qualification. During a meeting staff confirmed they had NVQ qualifications and one staff stated he was waiting to enrol for NVQ Level 3 in Care. The home has a policy Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 18 on recruitment of staff dated 2002. The inspector sampled a staff file that had a completed application form dated September 2003, two references, a copy of terms and conditions dated 23rd October 2003, a police check from abroad dated 24th November 2003 and an official medical certificate. The manager stated staff files are stored securely and the inspector noted files were locked in a cupboard in the office. The inspector noted one employee had a work permit that was due to expire in December 2005. The manager stated he would make an application to the home office for an extension. It was positive to note at this inspection the home exceeded standard 28 of the national minimum standards in view of the manager’s commitment to training and development of staff, investors in people award, an accolade from skills for care dated 2005 and all staff having achieved an NVQ qualification. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35,37&38 The home regularly reviews aspects of its performance through a programme of consultations which includes seeking the views of, service users, staff and relatives. The home has financial arrangements in place that ensures service users are safeguarded. The home has systems in place to safeguard and protect service users monies. The arrangements for recording keeping are adequate ensuring service users rights’ and best interests are safeguarded. The arrangements for safe working practices are satisfactory however the home must ensure a legionella bacteria test is carried out without delay to protect the safety and welfare of staff and service users. EVIDENCE: The home had a policy on internal audit of the quality system dated 2002. The manager stated the home had a quality audit folder that was sampled. The inspector noted the folder contained some completed questionnaires dated 4th Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 20 April 2005. The home had a current business plan that reflected quality assurance in terms of managing care, managing the budget and the environment. The manager and deputy manager stated they encouraged feedback from service users and relatives about the home. The inspector noted letters from relatives were displayed in the office for information. The home had a certificate of liability insurance due to expire on the 31st August 2006. The home had a business plan dated April 2005 to March 2006. The manager stated the plan was reviewed monthly and a formal review would be undertaken in January 2006. The manager commented the policy of the home was to encourage service users to manage their own finances. This was reflected in the terms and conditions of residency dated 2002. The home has records and documents that are up to date. Care plans were sampled that were signed and dated by staff and training files had records that were up to date and correct. The home has a policy on health and safety dated 2002. The inspector sampled training records and noted staffs were trained on 4th and 6th July 2005 in moving and handling, health and safety legislation, back health and practical procedures. The inspector noted the home had an environmental health audit on the 26th May 2005. The report recommended that supervisory staff be trained to intermediate food safety standard and the inspector noted the deputy manager had completed the training. The home had a service inspection record for fire safety dated 22nd February 2005 and management had acted on the recommendations. The manager stated the home is in the process of arranging a legionella bacteria test that was discussed with the manager and action has been required in respect of this matter. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 X 3 2 Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 22 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. Standard NMS-OP-38 Regulation 12(1)(a) 13(4)(c) Requirement The registered person must ensure a legionella bacteria test is carried out without delay to ensure the health and safety of staff and service users. Timescale for action 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard NMS-OP18 Good Practice Recommendations The registered person shall obtain a copy of the local authority policy (surrey county council) on the protection of vulnerable adults dated February 2005 for information. Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Dalmuir Home DS0000013621.V259803.R01.S.doc Version 5.0 Page 24 - 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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