Inspection on 30/05/06 for Dalvey House

This inspection was carried out on 30th May 2006.

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 27/09/05

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 Key Unannounced Inspection 30th May 2006 09:45 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 DS0000052636.V296952.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. DS0000052636.V296952.R01.S.doc Version 5.2 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 DS0000052636.V296952.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 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. 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. The present fees charged by the home range from £431 to £450. DS0000052636.V296952.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over five and a half hours on one day in May 2006. Mrs Tempany the registered manager was present throughout the inspection. A tour of the premises took place and three staff files, three residents care records and relevant documentation and policies and procedures relating to the running of the home were inspected. Nine of the eighteen residents, two visitors to the home and the staff on duty were also spoken with during the inspection. Comment cards had been sent to residents, relatives/visitors, care manager/placement officers and general practitioners since the previous inspection in September 2005. The information from the completed comment cards has been included in this inspection. What the service does well: Dalvey House provides a clean and well-maintained home where residents personal, health and social care needs are met. The residents describe the home as a very homely, friendly place to live where the staff are cheerful and approachable. The staff treat residents with respect and provide encouragement to pursue their own lifestyle, where feasible, and to make choices about their daily lives. There is a varied activities programme for those residents who want to participate. The staff encourage friends and relatives to visit and to maintain contact with the home. Both service users and relatives say that visitors are made welcome. 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 ‘I am very greedy, my plate is always cleared and I’m happy’. As well as the main menu there is always a choice of an alternative. DS0000052636.V296952.R01.S.doc Version 5.2 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. DS0000052636.V296952.R01.S.doc Version 5.2 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 DS0000052636.V296952.R01.S.doc Version 5.2 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place ensure that the resident knows that the home they are moving into will meet their needs. EVIDENCE: The records of a resident recently admitted to the home contained a detailed pre admission assessment of care needs including information from professionals previously involved in providing their care. A visitor spoken with confirmed that their relative had received an assessment by a representative from the home before they were admitted. Staff spoken with 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 to meet their needs. Dalvey House does not provide intermediate care therefore standard 6 is not applicable. DS0000052636.V296952.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care records are in place to ensure that residents health, personal and social care needs are met. The home has systems in place for managing residents’ medicines but some aspects of storage and medication records need improving to protect residents. Residents’ feel they are treated with respect and their right to privacy is upheld. EVIDENCE: The care records of three residents were viewed. The care plans clearly set out the resident’s needs and the actions required to meet the individual needs. Discussion with staff and residents confirmed that they reflected the actual care provided. DS0000052636.V296952.R01.S.doc Version 5.2 Page 10 The records identified that residents are visited by the district nurse and their General Practitioner as required. Residents spoken with confirmed that they receive foot care from a visiting chiropodist and one resident was attending an out patients appointment at the hospital on the day of the inspection. The home has a medication procedure in place and staff have received training on the administration of medication. The medication procedure needs amending to include the recording of the maximum and minimum temperature of the fridge daily when in use for the storage of medicines. The Medicines Administration Records (MAR) for two residents contained blank spaces where medicines had not been signed as administered. The home uses a monitored dosage blister pack system so it was possible to confirm that the medication had been given. A system for auditing medication not in the blister packs needs to be developed. The domestic refrigerator in the kitchen is used to store medication when this is required. The medication was stored in the door of the refrigerator. If stored in an unlocked domestic refrigerator the medication must be in a locked non corrosive box in the body of the refrigerator not the door as the temperature will be better controlled there. A maximum and minimum thermometer should be used to record the temperature range of the fridge when medicines are stored in it. The thermometer, or the probe, needs to be kept near the box in the fridge so that it is monitoring the area that the box is kept in. Staff induction includes respecting residents privacy and dignity. This was confirmed when speaking with staff. Staff were seen knocking on doors and waiting for an answer before entering residents’ rooms. Residents spoken with said that they were always addressed in the way they had requested and the staff are always polite. DS0000052636.V296952.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a varied programme of activities, thus providing a stimulating environment for residents. The flexibility of the home enables residents to retain control over their lives where feasible. Residents are able to maintain contact with their family and friends and to go out into the community if they wish and are able. Residents are offered a menu that provides a varied and well balanced diet that is served in pleasant surroundings. EVIDENCE: A programme of activities is provided for the residents including a garden party planned for June and making crowns to be worn to celebrate the Queen’s birthday. Talking to residents and comments included in the residents survey confirmed that activities are provided but it is the resident’s choice to decide if they wish to participate. A number of residents said they were looking forward to the DS0000052636.V296952.R01.S.doc Version 5.2 Page 12 warmer weather when they could go out in the garden. One resident commented ‘I am just happy to be here’. A number of residents said that they regularly go out with relatives and friends. Residents receive visitors whenever they wish. A record is maintained of all visitors to the home. The home encourages friends and relatives to keep in contact. Visitors spoken with confirmed that they are always made welcome by the staff. One relative commented that ‘it is like being part of a large family’. The majority of residents spend the greater part of the day in the lounge with a small number choosing to remain in their bedroom. Those residents who were able to articulate a view confirmed that they were able to make choices about such matters as what they ate and when they got up in the mornings and went to bed at night. Residents are able to “personalise” their bedroom with additional items of their choice. This was confirmed when visiting residents’ bedrooms. All comments received from the residents on the food were very positive including it was ‘good’, ‘excellent’ and ‘I am very greedy, my plate is always cleared and I’m happy’. As well as the main menu there is always a choice of an alternative. The menus were viewed and found to be varied and well balanced offering at least five pieces of fruit and vegetables a day. 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. DS0000052636.V296952.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. The procedure for protecting residents from abuse is 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. 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. The home has an adult protection procedure but this needs amending in line with the multi agency ‘No Secrets’ guidelines. Staff training has been provided. DS0000052636.V296952.R01.S.doc Version 5.2 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing the residents with a comfortable, clean and well maintained place to live. EVIDENCE: The home is comfortably furnished and well maintained. Residents spoken with agreed that it was a very homely, friendly place to live where the staff are cheerful and approachable. There are no outstanding recommendations resulting from the Dorset Fire and Rescue Service inspection in September 2005 and the Environmental Health Officers visit in February 2005. DS0000052636.V296952.R01.S.doc Version 5.2 Page 15 All areas of the home that were seen during the tour of the home were in a clean condition and free from unpleasant odours, residents and visitors confirmed that this is always the case. Residents confirmed that their bedroom was regularly cleaned. DS0000052636.V296952.R01.S.doc Version 5.2 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, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 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 is additional ancillary staff to cover the kitchen, cleaning, maintenance and gardening. The care staff maintain the laundry. The majority of the residents who completed the survey said that there is always staff available when you need them one commenting ‘yes always, even at a moments notice’. The other residents answered ‘usually’. 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 DS0000052636.V296952.R01.S.doc Version 5.2 Page 17 questionnaire, a job description and contract. A satisfactory Criminal Records Bureau check had been received prior to the member of staff commencing employment. Seven of the fifteen care staff have obtained an NVQ level 2 in care or equivalent and three staff are undertaking NVQ level 2 at the present time. A training programme is being implemented but there are still a number of staff with training needs including manual handling, health and safety and food hygiene. In addition specialist training is required to fully meet the needs of the residents including diabetes and dementia. The home has still to introduce a structured induction programme. DS0000052636.V296952.R01.S.doc Version 5.2 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): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced person who is able to discharge his duties fully ensuing that residents live in a home that is well run. Quality monitoring is used to demonstrate that the home meets the expectations of service users and achieves its stated aims and objectives. Residents manage their own finances or have a representative acting on their behalf to ensure their financial interests are met. Appropriate staff appraisals and supervision will determine their progress and ensure that they receive the training required to meet the needs of the residents. DS0000052636.V296952.R01.S.doc Version 5.2 Page 19 EVIDENCE: Mrs June Tempany is the registered manager with many years experience in running a care home. Mrs Tempany has still to obtain a qualification at level 4 NVQ in management and care or the equivalent. Staff and residents spoken with agreed that Mrs Tempany is very approachable and will listen. The views of residents and their representatives are obtained by using survey forms and holding regular residents meetings where minutes are recorded. When the results of the surveys have been collated action has been taken to address any issues identified. A monthly newsletter is produced. Family, friends or professional advisors assist all residents to manage their financial affairs. Pocket money is held for a number of residents and clear records are maintained. 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. The home has still to implement a structured staff appraisal and supervision programme. A programme of appraisal and supervision will not only monitor performance but will also identify future training needs. There is no evidence that all staff have an individual training assessment and profile. 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 are in place. Fire training, drills and fire safety checks have been completed as required. An accident book is maintained. An accident to a resident identified in their care records had been recorded in the accident book. DS0000052636.V296952.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 DS0000052636.V296952.R01.S.doc Version 5.2 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 OP9 Regulation 13(2) Requirement The registered person must ensure that medicines are stored at the correct temperature. The maximum and minimum temperatures of the medicines fridge must be monitored and recorded daily and corrective action taken if they are outside the recommended range (28 C). Staff must accurately record the administration of medicines at the time they are given. A clear audit trail for medicines e.g. dating packs when they are started or entering a carry forward balance on the MAR chart must be put in place for medicines not in blister packs. This must be monitored to ensure medicines are given correctly. Timescale for action 31/08/06 DS0000052636.V296952.R01.S.doc Version 5.2 Page 22 2. OP18 13(6) The registered person shall make 31/08/06 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 31-01-05 not met. The registered person must 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. A record of all training undertaken including induction training must be kept in the home. There should be evidence that all staff have an individual training assessment and profile. Timescale of 31-12-05 not met. The registered manager must arrange to undertake an NVQ level 4 in management and care or equivalent. The registered person shall ensure that persons working at the home are appropriately supervised. Timescale of 31-01-05 not met. 31/08/06 3. OP30 18(1)(c) (i) 4 OP31 10 31/08/06 5. OP36 18(2) 31/08/06 DS0000052636.V296952.R01.S.doc Version 5.2 Page 23 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 OP22 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. DS0000052636.V296952.R01.S.doc Version 5.2 Page 24 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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