Inspection on 11/04/05 for Dalvey House

This inspection was carried out on 11th April 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

Dalvey House 29/05/07

Dalvey House 30/05/06

Dalvey House 27/09/05

Dalvey House 22/09/04

Dalvey House 24/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Dalvey House 35 Belle Vue Road Southbourne Bournemouth BH6 3DD Lead Inspector Chris Gould Unannounced 11 April 2005 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. Dalvey House Version 1.10 Page 3 SERVICE INFORMATION Name of service Dalvey House Address 35 Belle Vue Road Southbourne Bournemouth Dorset BH6 3DD 01202 423050 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) Norlington Care Limited Mrs J Tempany CRH - Care Home only 19 Category(ies) of OP - Old Age registration, with number of places Dalvey House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 22nd September 2004 Brief Description of the Service: Dalvey House is a care home that provides personal care and support for up to nineteen older people. It is a large detached house that has been adapted to provide residential care. The service user accommodation is situated on two floors with a passenger lift providing access to the first floor. All service users at Dalvey House have single rooms eight of which benefit from en-suite facilities. There are separate lounge and dining areas and an easily accessible rear garden with level pathways. The house is situated on a bus route and is within half a kilometre of shops and other community amenities including the cliff tops at Southbourne. Car parking space is available at the front of the house. Dalvey House was closed by the previous owners in June 2003 and reopened by Norlington Care Limited in March 2004. Mrs Tempany and her son Gary Tempany are the registered Directors of Norlington Care Limited. Mr Gary Tempany is the responsible individual and Mrs Tempany the registered manager at Dalvey House. Dalvey House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five and a half hours on one day in April 2005. The previous inspection had taken place six months ago in September 2004. This inspection assessed 22 standards and outstanding requirements from the previous inspection. A tour of the premises took place and four staff files and four residents care records were inspected. Sixteen of the seventeen residents were spoken with four in their own rooms and twelve as a group in the lounge. Three visitors to the home and the staff on duty were also spoken with during the inspection. What the service does well: What has improved since the last inspection? The home has improved their record keeping to ensure that all residents receive their medication. Work has continued to improve the safety and comfort of the residents including the fitting of radiator guards and an extractor fan in the bathroom. Residents meetings are now taking place and a newsletter produced so that people are kept informed of what is happening and are able to have a say in the running of the home. Dalvey House Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dalvey House Version 1.10 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 Dalvey House Version 1.10 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) 1, 3, 4, 6 The home’s Statement of Purpose and Service User Guide ensure residents have the information they require before moving into the home. Without a detailed assessment there is no assurance that the resident knows that the home they are moving into is able to meet their needs or that care needs will be met. Dalvey House does not provide intermediate care therefore this standard is not applicable. EVIDENCE: The statement of purpose and service user guide provides information relating to the services provided and the facilities and resources available. Individual copies of the service user guide are available in the resident’s room. A number of residents spoken with were unaware of the guide and those that were had not read it. Dalvey House Version 1.10 Page 9 Individual records are kept for each of the residents and three of the four records inspected contained a pre admission assessment. The records did not contain sufficient detail to make the decision as to whether the placement is appropriate to meet the resident’s individual needs. One resident’s records did not include a pre admission assessment. Dalvey House does not provide intermediate care. Dalvey House Version 1.10 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 standard(s) 7,8,9,10 Progress has been made to ensure that the care needs of residents are met although limited detail in some areas has a potential to place residents at risk. Systems in place for dealing with medication are good and ensure that residents’ medication needs are met. Residents feel they are treated with respect but this is not consistently reflected in the home’s care practices. EVIDENCE: All residents have individual plans of care. The four care records inspected had all been reviewed monthly. The care plans did not consistently contain sufficient detail or reflect the actual care provided as described by residents and staff. One resident whose care plan recorded that two members of staff were required for all transfers had now been re assessed to require one member of staff. A resident described how they had improved since admission to the home but this was not reflected in their care records. Residents’ care records did not include an assessment or a plan of care relating to social care needs. Dalvey House Version 1.10 Page 11 Records contained actions such as ‘needs regular toileting to maintain continence’ but no further information relating to continence. The requirement from the previous inspection relating to the recording and administration of medication were assessed and had been met. Residents who were able confirmed that they received their correct medication at the right time. A number of the residents’ rooms contained continence products on view to anyone visiting the room. There was also information relating to the residents personal care needs fixed to bedroom walls. Discussion with residents confirmed that they are asked what name they wish to be addressed by and that this was always used. Staff were seen to knock on residents’ doors and wait for a reply before entering. Residents care records contained the dates and reason for the visit of GP’s, District Nurses, Chiropodists and Opticians. A District Nurse visited a resident on the day of inspection. Dalvey House Version 1.10 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 standard(s) 12,13,14 A flexible approach is taken in the running of the home and residents are helped to have a choice over their lives. Social activities provide variation and interest for the residents living in the home. Residents are able to maintain contact with their family and friends and to go out into the community if they wish and are able. EVIDENCE: Residents spoken with agreed that the social activities provided had improved during the last few months. Residents said that they particularly enjoyed the singing and the exercises. One resident said that she enjoys the arranged activities but also playing cards, reading and completing jig saw puzzles. A newsletter has been introduced and includes the forthcoming entertainment programme. The book in the reception area contained the names of residents visitors to the home and a relative spoken with said that they are made very welcome whatever time they visit. Residents said that they are able to go out on their own if able or with a relative or friend. One resident commented ‘my daughter doesn’t visit very often but she ‘phones me’. A flexible approach is taken in the running of the home. On the day of inspection two service users had chosen not to get out of bed as early as usual. This request was respected and they were assisted to get up later in the morning. Dalvey House Version 1.10 Page 13 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) 16,18 Residents are aware of the procedure to follow if they have a complaint and feel that any complaint would be listened to and acted upon. Arrangements for protecting residents from abuse are not satisfactory placing them at possible risk of harm. EVIDENCE: The home has a detailed complaints procedure that is included in the service user guide and posted at various sites throughout the home. Residents’ spoken with said that they were aware of the procedure and what to do if they had a complaint. One resident commented ‘they always listen to me about other things so I’m sure they would if I had a complaint’. No complaints have been received by the home or CSCI since the last inspection. The home does not have a procedure for responding to allegations of abuse and staff training has not been provided. Dalvey House Version 1.10 Page 14 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, 24, 25, 26 The standard of the environment is good providing the residents with a comfortable, safe, clean, well maintained and homely place to live. Residents are able to personalise their own rooms. EVIDENCE: Since purchasing the home in March 2004 a programme of refurbishment has been undertaken. The bedrooms and communal areas have all been painted and with the number and size of windows is very light. Residents agreed that there was a very homely atmosphere not ‘starchy’. The residents’ bedrooms had been personalised with their own small personal effects. Since the previous inspection an extractor fan has been fitted to the first floor bathroom, all radiators have had a guard placed over them and the laundry floor and walls have been painted so that they are now impermeable. A bed side table with lockable space has been ordered for each service user. Dalvey House Version 1.10 Page 15 Residents spoken to all said that they were ‘pleased’ or ‘happy’ with their own room. One resident said that ‘it was nice to have somewhere you can go to be alone when you want to’. Residents were looking forward to the warmer weather so that they could go out into the garden. Dalvey House Version 1.10 Page 16 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) 27,29,30 The number and skill mix of staff available is not consistently sufficient to meet the needs of the residents. To protect residents systems are in place to ensure that all checks are undertaken before a member of staff is employed. Not all staff have received the training required to ensure that they are competent to do their jobs. EVIDENCE: At the time of inspection the occupancy of the home was seventeen service users. A number of residents spoken with said that although the staff are always very kind and willing to help they were often short staffed. A cleaner is employed on three days a week for four hours, a cook for six hours seven days a week and a kitchen assistant for four hours three times a week. The care staff cover the remaining domestic duties including all the laundry. Four staff files contained the information required to evidence that the home is operating a recruitment procedure to protect the residents. Six care assistants have achieved NVQ level 2 in care and three are currently undertaking the training. The training records did not evidence that all care staff have received training in health and safety, first aid, manual handling, food hygiene and infection control. A member of staff spoken with said that she had not received food hygiene training although she is sometimes involved with providing the residents afternoon tea and evening meal. Dalvey House Version 1.10 Page 17 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 The systems for consultation with residents in this home are good and residents’ views are sought and acted upon. Residents personal monies are kept secure and with appropriate records ensure financial interests are safeguarded. EVIDENCE: Residents spoken with all agreed that the registered manager is very approachable and easy to talk to. A relative commented ‘the owner will do all she can for people, very easy to talk to’. Staff agreed that the manager would always listen and provide help when needed. The home has introduced residents meetings and those spoken with agreed that it was ‘a very good idea’. A residents’ questionnaire has been used and the results collated. It is planned to extend the quality monitoring to include residents representatives and other visitors to the home. Dalvey House Version 1.10 Page 18 Pocket money is held for a number of residents and the three records checked were all correct. The money is kept in secure facilities. Residents confirmed that the home keep some money for them to pay for hairdressing, chiropody and anything else they may want to buy. One resident commented ‘it’s safer than me keeping it. I know how much I have.’ Dalvey House Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 x x 3 x 3 x x x Dalvey House Version 1.10 Page 20 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 3 Regulation 14(1)(a) Requirement The registered person must ensure all prospective residents are admitted only on the basis of a full comprehensive assessment undertaken by people trained to do so, and to which the prospective resident, his/her representatives (if any) and any relevant professionals have had access. The assessment must be documented in the service users records. Timescale of 31 January 2005 not met The registered person shall confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and safety. Timescale of 31 January 2005 not met. The registered person shall ensure that residents care plans contain sufficient detail to provide clear guidance to staff on the actions to be taken to meet their care needs. The registered person shall make Version 1.10 Timescale for action 31 July 2005 2. 4 14(1)(d) 31 July 2005 3. 7 15(1) 31 July 2005 4. 10 12(4)(1) 31 July Page 21 Dalvey House 5. 18 13(6) 6. 27 18(1)(a) 7. 30 13(4)(5) suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of residents. The registered person shall make arrangements, by training staff and implementing robust procedures to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. Timescale of 31 January not met The registered person shall, ensure that at all times the numbers and skill mix of the staff deployed are sufficient to meet the needs of the residents. The registered person shall make suitable arrangements for the training of staff in first aid, manual handling and infection control. Timescale of 31-01-05 not met. 2005 31 July 2005 31 July 2005 31 July 2005 8. 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 22 31 Good Practice Recommendations It is recommended that an assessment is carried out by an Occupational Therapist to demonstrate that the home meets the needs of the residents. It is recommended that the registered manager plans to achieve NVQ level 4 in management. Dalvey House Version 1.10 Page 22 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole, Dorset BH17 0NF 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 Dalvey House Version 1.10 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!