Inspection on 27/09/05 for Dalvey House

This inspection was carried out on 27th September 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 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 11/04/05

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 Dorset BH6 3DD Lead Inspector Chris Gould Unannounced Inspection 27th September 2005 09:30 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 Dalvey House DS0000052636.V252939.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. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 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 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) Norlington Care Limited Mrs June Tempany Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2005 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 assessable 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 DS0000052636.V252939.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over four and a half hours on one day in September 2005. This inspection assessed 16 standards and outstanding requirements from the previous inspection. Mrs Tempany the registered manager was present throughout the inspection. A tour of the premises took place and three staff files and three residents care records were inspected. Fourteen of the seventeen residents were spoken with two 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. Comment cards had been sent to service users, relatives/visitors, care manager/placement officers and general practitioners since the previous inspection in April 2005. The information from the completed comment cards has been included in this inspection. This report should be read in conjunction with the report of the previous inspection that took place in April 2005. What the service does well: Residents are offered a menu that provides a varied and well balanced diet that is served in pleasant surroundings. The residents who commented on the food said it was ‘good’, ‘excellent’ and ‘no-one could complain about the food, it’s first class’. One resident after eating her lunch commented ‘it was lovely as usual’. Residents spoken with were aware of how to make a complaint and felt that they would be listened to. Residents have access to all indoor and outdoor facilities that are safe and comfortable. Residents confirmed that the garden is very well used when the weather is appropriate. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Dalvey House DS0000052636.V252939.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 Dalvey House DS0000052636.V252939.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): 2, 3 and 4 Residents are provided with written contract/ terms and conditions of the home. The systems in place ensure that the resident knows that the home they are moving into will meet their needs. EVIDENCE: All residents are provided with a statement of terms and conditions or a contract if purchasing their own care. This was confirmed by residents spoken with and three signed contracts/terms and conditions were viewed. Individual records are maintained for each of the residents. Inspection of the records for three residents contained a detailed pre admission assessment of care needs including information from professionals previously involved in providing their care. Discussion with staff confirmed that they were aware of the resident’s needs at the time of their admission. A letter is provided to the prospective resident advising them that following assessment the home is able Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 9 to meet their needs. This was confirmed by the residents and visitors spoken with during this inspection. The home does not provide intermediate care therefore standard 6 is not applicable. Dalvey House DS0000052636.V252939.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): 7 and 10 All residents have individual care plans to meet their health, personal and social needs. Residents’ feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Since the last inspection the detail provided in the resident’s care records has been increased and now provides sufficient detail to reflect the actual care provided to meet the assessed needs of the residents. The three resident’s records viewed had been reviewed at least monthly and had been signed by the resident. The residents spoken with were all in agreement that staff were aware of their needs and the help they required. Since the last inspection continence products that had been on view to anyone visiting the room are now stored appropriately and the information relating to the residents personal care needs have been removed from bedroom walls. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 11 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. The residents who completed a comment card agreed that their privacy is respected. Dalvey House DS0000052636.V252939.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): 15 Residents are offered a menu that provides a varied and well balanced diet that is served in pleasant surroundings. EVIDENCE: All the residents who commented on the food said it was ‘good’, ‘excellent’ and ‘no-one could complain about the food, it’s first class’. The residents who completed a comment card all answered ‘yes’ to the question ‘do you like the food’. One resident after eating her lunch commented ‘it was lovely as usual’. As well as the main menu there is always a choice. The menus were viewed and found to be varied and well balanced offering at least five pieces of fruit and vegetables a day. One relative commented ‘I have been impressed by the quality of the cooking’. Meals are served in the ground floor dining room but can be served in the resident’s bedroom if that is their choice. This was confirmed by a resident who chooses to remain in his own room. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 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 the following standard(s): 16, 17 and 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 are in place to ensure residents’ legal rights are protected. Systems for protecting residents from abuse are not satisfactory placing them at possible risk of harm. EVIDENCE: The home has a comprehensive complaints procedure including the address of the CSCI and timescales. Residents’ and visitors spoken with said that they were aware of the procedure and what to do if they had a complaint. Residents who completed a comment card agreed that they know who to speak to if they are unhappy with their care. No complaints have been received by the home or CSCI since the last inspection but residents and visitors spoken with agreed that if a situation did occur then they would be listened to and action taken. Viewing residents care records and speaking with residents confirmed that they have representatives including family and solicitors to manage their affairs and act as their advocate. Adult protection training has been provided since the last inspection but has still to be undertaken by all staff. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 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 the following standard(s): 20 and 21 Residents have access to all indoor and outdoor facilities that are safe and comfortable. Sufficient toilets and washing facilities are available to meet the residents’ needs. EVIDENCE: The communal space consists of two rooms linked by an archway with one area used for dining and the other as a lounge. There is sufficient space and seating available in both areas to accommodate nineteen residents when the home is full. A passenger lift provides access to the first floor. The residents’ who completed a comment card all answered ‘yes’ to the question ‘do you feel safe here’. The garden is readily accessible and residents confirmed that it is very well used when the weather is appropriate. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 15 The home provides three bathrooms/toilets and one separate toilet. The toilets have frames placed around them and some have raised toilet seats to assist residents to remain independent. All residents’ rooms have a wash hand basin and eight have en-suite toilets. The residents confirmed that they are assisted by the care staff to take a bath as required. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 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 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, 29 and 30. The number and skill mix of staff available is 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: Talking to residents, staff and viewing staff rotas confirmed that the number of staff on duty meets the needs of the present dependency levels of the residents at the home. There are additional ancillary staff to cover the kitchen, cleaning, maintenance and gardening. The care staff maintain the laundry. Residents spoken with commented that staff were ‘very kind’, ‘caring’ and ‘always there if needed’. A relative who completed a comment card said that ‘the staff are all professional, approachable, kind and take time to talk to the residents. Three staff files contained the information required to evidence that the home is operating a recruitment procedure to protect the residents including an application form, two written references, proof of identity, a health questionnaire, a job description and contract. A satisfactory Criminal Records Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 17 Bureau check had been received prior to the member of staff commencing employment. Staff spoken with said they felt they were well trained to do their job but training records demonstrated that the training programme developed since the last inspected has still to be fully implemented. The home is working towards developing an induction programme to be implemented when further recruitment takes place. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 18 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): 36 and 38 Systems in place do not ensure that staff are appropriately supervised. Arrangements are in place to ensure that the welfare of residents is promoted and protected. EVIDENCE: An annual appraisal system has been developed and will now be further developed to ensure that staff receive appropriate supervision. Staff records and discussion with staff confirmed that appraisal had taken place and that they thought it ‘very useful’. Fire records inspected showed that all checks on fire warning, fire fighting equipment, drills and staff training had been completed. Accidents are recorded and filed appropriately. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 19 Records viewed evidenced that all gas installations, central heating, electrical wiring and appliances and equipment used to meet service user needs has been checked. Policies and procedures are available relating to health and safety, Control of Substances Hazardous to Health (COSHH), infection control, manual handling and first aid. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 20 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 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 x 3 3 X X X X x STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 2 X 3 Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP18 Regulation 13(6) Timescale for action The registered person shall make 31/12/05 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. Timescales of 31-01-05 and 31-07-05 not met The registered person must 31/12/05 ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform including structured induction training. The registered person shall 31/12/05 ensure that persons working at the home are appropriately supervised. Requirement 2 OP30 18(1) (c)(i) 3 OP36 18(2) Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 22 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 OP22 OP31 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 NVQ level 4 in management or equivalent. Dalvey House DS0000052636.V252939.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole 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. 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