Inspection on 16/06/08 for Dawood House

This inspection was carried out on 16th June 2008.

CSCI found this care home to be providing an Good service.

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

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Dawood House Victoria Road Bentley Doncaster DN5 0EZ Lead Inspector Janet McBride Key Unannounced Inspection 16th June 2008 09:20 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 Dawood House DS0000070918.V366354.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. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dawood House Address Victoria Road Bentley Doncaster DN5 0EZ 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) 01302 873 455 01302 822 259 dawood.house@btconnect.com Dawood Care Ltd Mrs Marilyn Hoolihan Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 40 NEW 2. Date of last inspection Brief Description of the Service: Dawood House is a 40-bedded care home for older people providing personal care and accommodation. The home provides single room accommodation on two floors; there is a stair lift and shaft lift available to enable service users to access all parts of the home. The bedrooms on the older part of the home all vary in shape and size, those rooms in the new purpose built extension are modern and provide en suite facilities. There is a long drive leading to the home, and service users are able to enjoy an attractive garden to the front of the home, it is well stocked with shrubs and plants and has attractive seating areas. There is ample car parking facilities. Fees range from £390:14 to £407:00per week, as at June 2008,and additional charges are made for hairdressing, Chiropody, and any special toiletries. For further information contact the home. The Statement of Purpose and the Service User Guide, which is available on request, this as information about the services available to people and their families. The home published inspection report will also be available for people to read. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was the first key inspection of this newly registered service, which took place on the 16th June 2008 starting at 09:20 and Finishing at 17:00 hours. Prior to the inspection the home submitted an Annual Quality Assurance Assessment this gives information regarding the home and services provided. Pre-inspection work was carried out on the information received and other relevant documentation, for example analysis of statutory notifications and complaint records. During the inspection, documentation and records were examined, for example medication, complaints, accident records, staff rotas and staff training files. Three care plans were cross-referenced with other relevant documentation relating to those people who use the service, to evaluate how well their care needs were met. Information was gathered from as many different individuals as possible that had contact with people within the home, including individual interviews with manager and four members of staff. Four people within the home were also spoken to and two relatives. Ten surveys were sent to relatives prior to the inspection and nine were received back. They were asked to comment on the standard of care, staff skills, attitude, and how the needs of people using the service needs were met. Some judgements about quality of life and choices were taken from discussions with relatives, feedback on surveys, observations on the visit, followed by discussion with staff and examination of records held at the home. We would like to thank all the staff, relatives and people receiving services within the home for their co-operation in the inspection process. Balanced positive feedback as well as any issues or concerns that were raised were discussed with the manager at the end of the inspection. What the service does well: There was a good atmosphere within the home; it was evident from surveys and discussion with staff, people within the home and relatives that the manager communicates a clear sense of direction and leadership, which staff and people can understand. Positive comments from relatives who said “The Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 6 home is well managed”. “Staff have a good attitude and are friendly and efficient in their work”. All surveys confirmed that people were aware of the complaint procedure and knew how to make a complaint. Discussion with families indicated that action is taken to address any issues that they raise. Care plans provided staff with sufficient information to meet the needs of people who use the service. People were assisted and supported by staff to make decisions and choices about all daily living needs. Good staffing levels and well-trained staff enable the home to provide a good standard of consistent care. Comments from relatives “My Father is well cared for and his content”. My relative is always clean and looks well kept”. “Staff keep me well informed of any issues and I have been involved in the care plan for my Mother”. 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. The summary of this inspection report can be made available in other formats on request. Dawood House DS0000070918.V366354.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 Dawood House DS0000070918.V366354.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 &6. People who use the service experience outcomes Good in this area. We have made this judgment using a range of evidence, including a visit to this service. People who use the service had information about the home and services provided. People were individually assessed prior to admission to ensure their needs could be met. EVIDENCE: The home provides a statement of purpose and service users guide, the manager as updated some of the information regarding the new company. The company are to update service user guides and contracts to enable people to have up to date and accurate information. Residential and respite care is provided but not intermediate care. All surveys received confirmed that people who use the service were provided with sufficient information before moving into the home. The scale of charges was discussed with the manager, any extras that people pay for, are documented on page 5 of this report. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 9 Records showed that people who use the service were fully assessed prior to moving into the home, with other professionals involved if required. Surveys and people spoken to said they had the opportunity to visit prior to admission. Surveys from relatives confirmed that they feel the home met their relatives care needs on person commented, “My relative is well cared for”. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 & 11. People who use the service experience outcomes Good in this area. We have made this judgment using a range of evidence, including a visit to this service. Care plans provided staff with sufficient information to meet the needs of people who use the service. People were assisted and supported by staff to make decisions and choices about all daily living needs. Medication policies and procedures were well managed; this ensured the safe administration of medication. EVIDENCE: Three care plans were checked these set out in detail healthcare, personal and social care needs in an individual plan of care. All contained up to date information that reflected people’s needs as detailed in their assessments, including dietary needs were clearly recorded in each persons care plan. Religious beliefs were documented including some people’s wishes after death these are discussed when appropriate and documented in peoples care plans. This ensured that staff know the care required and that peoples needs were identified and met. Good health records were maintained and it was evident that people within the home were registered with a GP and had access to health care facilities. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 11 Medication policies and procedures were discussed with the manager and observation of the person responsible for administering medication that day. The Home uses a monitored dosage system and records showed that these were maintained properly. Examination of medication records were found to be fully completed and contained the required entries and staff signatures. Records showed compliances with the receipt, storage and safekeeping of medication within the home, with management monitoring compliances. All staff that administers medicines had completed appropriate medication training. Feedback from people within the home, their families and observation on the day showed that staff treats people with respect and dignity. People were encouraged to make choices and decisions about all daily living activities and supported to remain as independent as possible. Typical comments included: “ The individual care for each person is first rate.” “We as a family are very happy with the care given to our relative”. “ My mother is well cared for she sees her GP when necessary and medication given as prescribed”. The District Nurse said “ The care staff always contact me quickly and appropriately and always carry out my instructions for individual care plans.” Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15. People who use the service experience outcomes Adequate in this area. We have made this judgment using a range of evidence, including a visit to this service. People were offered a wholesome and appealing balanced diet with a varied selection of food available reflecting people’s tastes and choices. People within the home were provided with very little stimulation and interesting activities at the present. Therefore improvements are needed as this may affect the quality of care provided for people who use the service. EVIDENCE: An activities coordinator is employed by the home although they are on long term sick. Therefore opportunities to join in various activities that will offer some interest and stimulation were not available on the day. Care staff does try to arrange some activities and relatives come into the home to help with bingo on a weekly basis and entertainers are booked twice a month. Comments from relatives said, “With a member of staff missing, people miss exercises and quizzes to keep them entertained”. The manager said they hope to employ another activities person. Religious beliefs are supported, two people said they were they join in all the church activities and go to church every Sunday. Relatives confirmed that family and friends were welcomed in the home that they were able to visit at any time. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 13 Menus were discussed with the cook, who confirmed the food budget was sufficient and that food and drinks were available at all times. She said she kept well informed of people’s nutritional needs and if they require any special diet or fortified drinks or snacks. Lunchtime was observed on all dining areas, people had a choice where to sit it either in the dining rooms or the sun lounge or a tray in the lounge or their own bedroom. Lunchtime was unhurried and relaxed, dining tables were set with tablecloths and cutlery. Plate guards were being used as this assists people to eat their meal independly. People were offered seasoning and choice of drinks. Feedback regarding food was very positive. It was evident that a choice of good quality food was provided in a clean and welcoming environment. People felt their preferences were respected and special dietary needs catered for. Fresh fruit and vegetables were prominent on the homes menus. Typical comments included: “Food is very good and varied”. “I like the meals and have a good choice”. “I enjoy a cooked breakfast every day”. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18. People who use the service experience outcomes Good in this area. We have made this judgment using a range of evidence, including a visit to this service. The complaints procedure was accessible and displayed within the home. Policies and procedures were in place on adult protection, this promoted and protected people who use the service. EVIDENCE: The home had a complaint procedure and was displayed in various locations around the home. No complaints have been recorded since the new owners have been registered. All surveys confirmed that people were aware of the complaint procedure and knew how to make a complaint. Comments from relatives “Never had to complain, but would speak to the manager if necessary”. People were asked if they had raised concerns to the home and whether they had they responded appropriately,” Any concerns I raised were always answered”. Policies and procedures were in place regarding the protection of vulnerable adults. Staff records showed that staff have received adult protection training and discussion with staff demonstrated a good understanding of adult protection issues and were able to describe the action they would take on receiving any allegations. Manager confirmed she was aware of referring any allegations or incidents to adult safeguarding and would inform the Commission for Social Care Inspection of any issues. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24 &26. People who use the service experience outcomes Good in this area. We have made this judgment using a range of evidence, including a visit to this service. People who use the service live in a safe and comfortable environment. The home was clean and tidy, however some areas of the premises required some minor refurbishment. However comments from people who use the service and relatives thought the home was a comfortable environment. EVIDENCE: Since the last inspection the home as had some building work to extend the property to create additional bedrooms and communal space. The home had a large lounge, small lounge and a sun lounge giving people a choice of sitting quietly, meeting family and friends in private or being with other people in the larger lounge. A tour of communal areas within the home found them to be clean and tidy but with some areas of the premises requiring some minor refurbishment. For example corridor carpets worn and stained. Dining room furniture in the sun lounge very worn and chipped. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 16 All bedrooms are single rooms with a call system in each bedroom. Tour of the bedroom facilities found the bedrooms in the older part of the home to vary in shape and size, those bedrooms in the extension are modern and provide ensuite facilities. personalised by individual people. Bedrooms looked very comfortable and it was confirmed people could bring personal furnishings with them on admission, most were found to be homely or There are assisted baths on the ground floor with a shower facility on the first floor. All bathrooms and communal toilets had soap dispensers and paper towels. Laundry facilities are on site at the home and appear satisfactory. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30. People who use the service experience outcomes Good in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff had the skills and knowledge to fulfil their roles within the home; a stable staff group ensured continuity of care for people who use the service. Recruitment policies were followed promoting the safety and protection of people who live at the home. EVIDENCE: The home has a very stable staff group, staffing was discussed with the manager and the duty rota examined. This clearly identified staff within the home and their role, gave a clear line of accountability of management and ancillary staff. The manager is supernummary with identified deputy manager. They have no administration support at present but are in the process of recruiting for this post. Observation on the day of inspection and checking of duty rotas confirmed there were sufficient staff to meet the needs of people who use the service. There were robust recruitment and selection procedures including an equal opportunities policy. New staff recruitment files were examined, these confirmed that all the required employment checks had been undertaken prior to staff being employed, including Criminal Record Bureau (CRB) Protection Of Vulnerable Adults (POVA) checks. This ensured people who use the service were safe and protected. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 18 Training and development of staff was discussed with the manager and staff, who confirmed what training had been completed. Training records indicated that a number of the staff team had accessed various courses, for example dementia, basic first aid, moving and handling, mental capacity training and equality and diversity courses. Development of staff was evident by 50 of staff achieving National Vocational Qualification (NVQ) level 2 or 3 in care with other members of staff continuing to work towards attaining this qualification. Comments from relatives were very positive about staff they said, “that they feel staff had the skills and experience to look after their relatives”. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 &38. People who use the service experience outcomes Excellent in this area. We have made this judgment using a range of evidence, including a visit to this service. People live in a home that is run in their best interest, with good leader ship and management. Good policies and procedures were in place to protect and safeguard people who use the service. The financial interests of people were safeguarded, good health and safety procedures ensured they were protected. EVIDENCE: Management structure at the home consisted of a registered manager, and deputy manager. The homes registered manager has completed the Registered Managers Award. She has significant experience of managing services and undertakes a range of short courses to update her skills and knowledge. She was fully aware of her responsibilities and it was evident from discussion with staff that she communicates a clear sense of direction and leadership, which staff and people within the home can understand. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 20 Since the new company have taken over they had introduced a number of quality assurance systems to monitor the quality of care and services within the home. Evidence was available to show what audits were completed and if any issues were raised what action had been taken. Surveys are sent to relatives to monitor their satisfaction with the home on a six monthly basis. A number of meetings were held at the home, residents and staff meeting all with minutes taken and available to read, these showed various issues were discussed. The company carry out monitoring visits, and completes regulation 26 reports (copies were available at the home). These state what was found during this visit and who was spoken to. Staff said they received supervision on a regular basis and that they discuss any care issues and training and development. Records required by regulation are maintained; a number of these were checked during the inspection and found to be accurate and up to date. Checking of records confirmed that people’s finances were recorded, receipts kept and audited on a regular basis. Very detailed records were found and every person had an individual wallet and most had bank accounts set up. Some people control their own finances, with the help of their families. Maintenance and service records were examined, these were up to date with current certificates. The required health and safety policies and procedures and the relevant notices were displayed throughout the home. Fire safety procedures were in place; records examined showed they were current and up to date. This keeps people living and working at the home safe. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 3 3 3 Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 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 OP19 Regulation 23(b)(c) Requirement Premises all parts of the home must be kept reasonably decorated and in a good state of repair. • Carpets must be replaced in the identified areas. • Replace dining furniture as identified. Timescale for action 01/10/08 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 OP1 OP2 Good Practice Recommendations The registered person should ensure that people have up to date information about the services and facilities provided. Each person should be provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). DS0000070918.V366354.R01.S.doc Version 5.2 Page 23 Dawood House 3 OP12 A programme of recreational activities should be available to meet people’s needs, which offer people stimulation and interesting activities that are varied, for them to participate in if they wish. Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Dawood House DS0000070918.V366354.R01.S.doc Version 5.2 Page 25 - 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!