Inspection on 11/08/06 for Delapre House

This inspection was carried out on 11th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Delapre House 28/04/08

Delapre House 02/11/05

Delapre House 27/06/05

Delapre House 18/10/04

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 Delapre House 109 Magna Road Bearwood Poole Dorset BH11 9NE Lead Inspector Debra Jones Unannounced Inspection 11th August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Delapre House DS0000061562.V308434.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. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delapre House Address 109 Magna Road Bearwood Poole Dorset BH11 9NE 01202 570800 01202 570800 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) Bell Social Work Ltd (BSW Ltd) Miss Judith Bell Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2005 Brief Description of the Service: Delapre House is registered to provide accommodation for ten older people in an attractive converted house. It is set back from a main road on the northern borders of Bournemouth and Poole. Local bus services provide easy access to the town centres and Wimborne. The home has some car parking at the front and plenty of on road car parking is available. There is a large well-maintained garden to the rear. The accommodation for residents in the home is over the ground and 1st floors with a passenger lift between. There are a variety of aids and adaptations around the building to allow residents to move about more independently. There are 10 single rooms all of which have en suite facilities. There are additional communal toilets and bathrooms around the home. Situated on the ground floor is the service users lounge, which overlooks the garden. A new conservatory provides an additional seating area and access to the newly created dining room. There is also another small quiet lounge that overlooks the garden. Current fees at the home range from £550 to £650 a week. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 11 August 2006 and was the anticipated key inspection of the year. The 1 requirement and 1 recommendation made at the last inspection were followed up to see if there had been any progress made towards meeting them. There had. During the inspection a number of records were looked at. The Inspector walked around some of the building and met and chatted with residents in the lounge who spoke positively about the home. Ms Bell – the Proprietor / Manager assisted the inspector in her work. Prior to the inspection the Commission asked the home to send out a number of comment cards to get people’s views of the home. Eleven people responded. Three were from residents, 5 from relatives and 3 from General Practitioners. The majority returned were very positive about the staff and service provided at the home. The few negative comments were discussed and related to issues that had since been resolved. ‘A helpful and caring home who have / are helping my aunt recover from a fall.’ (a relative) ‘They all have a good sense of humour’ (a resident) ‘Since living at Delapre House I have been well looked after by caring staff.’ (another resident) ‘Staff are very kind, very helpful and very caring.’ (another resident) ‘I cannot commend Delapre House too highly for all aspects of care of their residents.’ (a relative) ‘My mother requires assistance in eating, walking and personal hygiene. This is provided readily with discretion, respect and affection. They have encouraged by mother to improve her walking abilities no end’. (another relative) ‘I cannot give enough praise for the professional care and TLC which x received during her year as a resident with Ms Bell and her staff. They nursed my sister in law through her terminal condition and at all times we were encouraged to spend time with her during her last few days, although she was heavily sedated and drifting in and out of consciousness. Never at any time was it suggested that they could not / would not cope with her illness, and we were never made to feel ‘in the way’ in these final days. It has always been a pleasure to visit Delapre House and I shall continue to do so, even though I no longer have need, as I feel that such a small residential home has even more need of ‘friends’ than larger establishments.’ (another relative) ‘Extremely caring towards all residents……………very pleasant staff to work with.’ (a GP) Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 6 What the service does well: Delapre House aims to provide a family atmosphere and does so successfully in a house decorated and furnished in a homely way. The home is well organised and the care and contentment of residents is clearly at the heart of the way the home is run. A good admissions procedure is in place. Prospective residents get relevant written information about the home and what it has to offer, are properly assessed by people from the home and have opportunities to visit the home to see if they like it. Care plans and notes are thorough and regularly updated to make sure that all staff know how to care for the residents living at the home. Care staff at the home are supported in caring for residents by a range of community health professionals. Medication is well managed and residents can have confidence that staff will look after their medicines well and administer them properly. Residents are well cared for, treated with respect and dignity and are able to exercise choice and control over their lives. Residents are able to do as they wish at the home and join in or not with the activities on offer. Visitors are made welcome at the home and can come whenever it suits the residents. Meals are varied and planned around the likes and dislikes of the people who live there. Mealtime arrangements are flexible enough to accommodate individual preferences. The complaint and adult protection procedures reassure residents that their well-being and comfort are important to the home and that any concerns or complaints raised will be properly responded to, investigated and where possible resolved. The home is homely, well maintained and comfortable for the residents living there and anyone visiting. The home is kept clean and smells pleasant. Sufficient care staff are on hand at all times to meet the current needs of residents. Staff have access to a range of training relevant to looking after residents. Thorough pre employment checks are carried out on prospective staff to ensure that only suitable people work at the home. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 7 The proprietor / manager, Ms Bell, has the skills, qualifications and experience needed to run a home of this nature. The home does not handle any finances or hold any valuables belonging to residents. Systems are in place and records kept, that demonstrate the homes commitment to keeping residents safe. What has improved since the last inspection? What they could do better: Some residents have bed rails on their beds at night to prevent them from falling out of bed. These are already subject to risk assessments but there is need for an assessment to be carried out and regularly reviewed as to why they are in use. As this equipment could be used to restrain people it is important that the assessment extends beyond staff at the home and appropriate persons give permissions for use. As the main kitchen fridge is used to store some medication it is important that the home purchase and use a thermometer that can tell them the maximum and minimum temperature that the fridge reaches every day to ensure that the medicines are stored at the correct temperature at all times. All medication administration records should be marked with details of any allergies that residents have. If they don’t have any this should also be noted. It would be good if 50 of the care staff at the home had a National Vocational Qualification (NVQ) at level 2 in care. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 8 There must be a recent photograph of every resident on the premises. 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. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 9 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 Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 10 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 excellent. This judgement has been made using available evidence including a visit to this service. Information provided about the home and a good admissions procedure enable prospective residents to make informed decisions about admission to the home and ensures that only service users whose needs can be met by the home are offered places there. EVIDENCE: Some files of recently admitted residents showed that prior to them moving to the home their needs were fully and thoroughly assessed by the home. Assessments were clear as to where information about the prospective resident had been obtained and how far the person had been involved in their assessment. The prospective resident is given the opportunity to visit the home, as are their representatives. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 11 Records showed that the home had confirmed in writing to prospective residents that following their pre admission assessments the home would be able to meet their needs. All residents are given terms and conditions. Of the 3 residents who returned comment cards all said that they had enough information before they moved in to the home so they could decide if it was the right place for them and two remembered being issued with a contract. ‘I actually found the home on an internet site and was fortunate that there was a space available for my late sister in law. My sister in law was given and signed a contract in my presence and the contents were explained to her.’ (a relative) Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. There is an excellent care planning system in place to make sure that staff have the information they need to meet the needs of the residents. The health needs of the residents are well met with evidence of good support from community health professionals. The medication at this home is generally well managed promoting the good health and well being of residents. Residents are treated with dignity and their privacy is respected. EVIDENCE: Care plans seen were of an excellent standard. They flowed from the assessments made by the home, were easy to read, to the point and informative about the needs of the resident and how the home was to meet their needs. Language used was sensitive and respectful and preferences, likes and dislikes were all noted and built into the plan of care. Information contained in the care plans was relevant plans are reviewed monthly. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 13 Thorough risk assessments are also in place for residents. Some residents have bed rails on their beds. A risk assessment is in place for this but not an assessment of need outlining why they are in place or any permissions for their use. Accidents are recorded and pertinent information from these feed into the updating of care plans. When asked ‘do you get the care and support you need?’ all of the 3 residents who returned comment cards prior to the visit replied ‘always’. ‘ I cannot speak too highly of the care and support given by Delapre House during my sister in law’s time as a resident.’ (a relative) When asked ‘do the staff listen and act on what you say.’ All three residents who responded said ‘yes.’ All the relatives who responded by comment card said that they were informed of important matters in respect of their relatives and consulted about their care. The GPs who returned comment cards said that if they gave any specialist advice this was incorporated into the care plan. Daily notes support and evidence the delivery of care to residents. These give a good picture of the daily lives of residents, the care that is delivered to them by staff in the home and by visiting community health professionals such as District Nurses. Residents are accessing other community health services such as opticians, dentists, physiotherapists and chiropodists. Ms Bell said that the support that the residents got from these services was very good. One resident regularly goes out to a local stroke club. Two residents who returned comment cards said that they ‘always’ received the medical support they needed with the other saying this was the case ‘usually’. The 3 GPs who returned comment cards to the Commission said that the home communicated clearly, worked in partnership with them and took appropriate decisions when they could no longer manage the care needs of residents. Two of them said that staff demonstrate a clear understanding of the care needs of residents. One GP commented ‘The residents are well cared for. The home is clean and the staff seem to be empathic to the needs of their residents. We did have some difficulties accessing staff via phone but this has now been rectified.’ The home has a medication policy has recently been reviewed and expanded. Patient information leaflets are available in the home about the medication in use. All care plans include a section on medication which is regularly reviewed along with the general plan and with GPs. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 14 Medication at the home is only administered by the proprietor / manager and experienced staff who are all confident in carrying out this task. Medicines were tidily stored in the medication cupboard and trolley. Medication records sampled were up to date and well completed, matching the medicines in the home. Staff properly record the date that medicines are opened/ brought into use when they are not in the blister packs. Not all medication administration records included details of allergies. Sample signatures of staff administering medicines are not held on file and it is suggested that this is done. The temperature of the fridge used to store medication is currently monitored, but not the maximum and minimum as recommended. Only eye drops are being stored in the fridge at present. The home does not currently carry out audits of their medication administration and it is suggested that this is introduced. Staff are introduced to the principles of promoting privacy and dignity during their induction. They are also referred to in their job descriptions and in the staff handbook. Staff were seen to be treating residents in a respectful and dignified way througout the inspection. Care plans echo the ethos of the home to treat people respectfully and staff are encouraged to spend enough time with residents to ensure that they are able to do things at their own pace. All those who returned comment cards to the Commission confirmed that they were able to see residents in private when they visited. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 15 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. Residents’ lives are enriched by the activities on offer at the home and the social opportunities afforded by their visitors. Residents are helped and encouraged to exercise choice in their daily lives at the home. The meals in this home are very good offering both choice and variety and are served in a pleasant environment. EVIDENCE: Friends and relatives are made welcome at the home, with some residents having visitors most days. Residents can receive their guests in the communal areas, their own rooms and the garden. On the day of inspection one resident went out with a family member to the hospital and then out for lunch. The visitors’ book confirmed the number and range of visitors to the home. All four relatives who returned comment cards to the Commission all said that they felt welcome in the home. Delapre House is very much the home of the residents and is run in a manner that supports them to live their lives as they choose. Information is collected Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 16 about residents’ interests and previous occupations. There are both structured and spontaneous activities centred around residents’ interests and abilities either in groups or 1-1s. An entertainer is arranged monthly and a Church of England service is held at the home once a week. Staff organise quizzes, skittles and exercises. Nails and facials are available and birthdays are always celebrated. The home keeps a record of activities and references to visits, outings and activities are made in daily notes. Of the 3 residents who returned comment cards one said that it was ‘always’ the case that there are activities arranged by the home that they can take part in; 1 said that this was true ‘usually’, and 1 said this was never the case ‘through my own choice.’ Most residents at the home are able to express their likes and dislikes and spend their days as they choose. Residents talked with the inspector about how they liked to spend their days. Staff are clear that Delapre House is the home of the residents and they are there to support them to lead the lives they wish. When people move into the home they are asked about what they like to eat. Residents are well able to say what they enjoy and to make their preferences clear. Menus are based both around the known likes and dislikes of the residents, on providing a good wholesome, varied diet reflecting the time of the year. Meals are planned around what food is in season and the appropriateness of the meal to the weather. Residents are offered meal choices the day before. The meal served on the day of inspection was plaice fillet in breadcrumbs or chicken pie and gravy, served with either new potatoes or french fries and vegetables. There is always a choice and scope for a change of mind at the last minute. How much residents like to eat / have on their plate is also taken into account. Special diets are accommodated e.g. diabetic and gluten / wheat free. All residents spoken to said the food was ‘very good’. Residents can have meals where it suits them. The home has recently created a pleasant dining room that residents can eat in if they wish. Staff are encouraged to sit with residents at meal times and eat with them. Drinks, including fruit juices, are available throughout the day and jugs of water are in each room. A cook is employed. Prior to the inspection three comment cards were received by the Commission from residents. Two of the three said that they ‘always’ liked the meals at the home and the other one said that they liked them ‘usually.’ Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Any concerns and complaints made to the home are listened to and investigated under the home’s complaints procedure. The home’s adult protection policy and staff training in this area demonstrate the homes commitment to understanding abuse and of protecting the residents in their care. EVIDENCE: The home has a complaints policy / procedure that is available to residents and all visitors. The Commission has not received any complaints about this home since the last inspection. Complaints dealt with by the home have been properly responded to, investigated and resolved in a timely fashion. No residents or relatives have raised any complaints. The comment cards sent to residents asked the question ‘Do you know who to speak to when you are not happy?’ Three residents sent back cards, all answered ‘always’ to this question. In respect of knowing how to make a complaint all said yes ‘always’. The relatives who returned comment cards all said that they were aware of the complaints procedure. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 18 The home’s adult protection policy demonstrates an understanding of abuse and of how residents are protected. Staff receive training in this area as part of their induction. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 19 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 home is well–maintained and a comfortable and safe environment is provided for the residents living there and anyone visiting. Bedrooms are well decorated, well furnished and personalised to suit the residents. Adequate facilities are available to meet the number and needs of the people living there. The home is kept clean and smells pleasant for all living there and visiting. EVIDENCE: Delapre House has a warm and homely atmosphere. The home is well decorated throughout. The lounges and new dining room are well and comfortably furnished. A quiet room is available just off the main lounge, where residents can listen to music, entertain guests or just sit quietly. A new conservatory overlooking the garden is an attractive addition to the ground floor area. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 20 The garden is well maintained, attractive and accessible. Residents sitting in the main lounge, conservatory and quiet lounge have a good view of it. Garden furniture is available for those wishing to sit outside. Residents are mostly mobile and can choose where they spend their days. Some need a little assistance to get about. There are a number of communal bathing areas in the home. All bedrooms have en suite facilities, some with showers. Aids and adaptations are available throughout the home and some residents with particular needs have their own personal equipment to assist with their independence. Where residents need equipment to aid independence such as zimmers and rollators the equipment was seen to be to hand. Other useful aids and adaptations are around the home for use by all e.g. raised toilet seats and grab rails. Residents are able to personalise their rooms with furniture and general belongings. There is a passenger lift in the home, enabling easy access between the ground and first floor. There are emergency alarm call bells throughout the home. Residents are able to have keys to their bedroom doors and all have lockable storage in their rooms for personal belongings of importance. The home was clean and there were no unpleasant odours. The home was alerted to the new Department of Health Infection Control guidance (June 2006). All three residents that returned comment cards said that the home is ‘always’ fresh and clean. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Sufficient care staff are employed and deployed at the home to ensure that the care needs of residents can be met. Robust recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home. Staff have access to a good body of training to further support them in developing their knowledge and skills in caring for residents. EVIDENCE: Staffing rosters are in place that show who is on duty and when. Rosters include all staff on duty, their full names and their designations i.e. what job they do. A member of staff with emergency aid training is always on duty at the home. There are two carers on duty between 8am and 8pm every day. Ms Bell is in addition to this. The cook works between 10am and 1pm every day. A cleaner is employed between 9am and midday weekdays only. Overnight there is one member of care staff on duty with another member of care staff sleeping-in in case of emergency. The manager or a senior carer are always on call. Residents were asked are the staff available when you need them? All three who responded said ‘always.’ Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 22 All of the relatives who returned comment cards to the Commission said that in their opinion there were ‘always’ sufficient numbers of staff on duty. A recruitment procedure is in place at the home and staff files demonstrate the recruitment process in action. All documents required by law before and after employment were on file including CRB disclosures and POVA 1st checks. Staff have contracts of employment and are issued with staff handbooks. The handbook includes the whistle blowing procedure which has the contact details of the Commission for Social Care Inspection. The home employs some workers from abroad. It was clear from the files reviewed that the home is obtaining the right sort of information about people’s rights to work in the country and any restrictions on that work. Training is taken seriously at the home. Staff mostly either have or are studying for National Vocational Qualifications. Out of the 17 care staff employed at the home 7 have NVQ level 2. One member of staff who already has NVQ level 2 is continuing her studies and doing NVQ level 3. In addition staff are properly and thoroughly inducted and have access to other training courses relevant to their work e.g. first aid, moving and handling, food hygiene, infection control, handling of medication, supervision development, personal development. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 23 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, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well organised and the daily management and running of the home centres round the care and contentment of residents. Good management practice, systems in place, and records kept, confirm the health and safety of all in the home. EVIDENCE: Ms Bell, the proprietor, continues to be in charge of the home on a daily basis. Ms Bell is an experienced manager and leads her staff by example. Senior care staff support her in running the home. The home opened in October 2004 and carried out their first quality assurance survey in April 2006, designed to find out what people think about the home. A full report has been written that includes the analysis of the results of the Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 24 survey along with the business plan and annual development plan for the home. This report is now available to any interested parties. Ms Bell was alerted to the recent amendment to the Care Home Regulations in respect of quality assurance. The home also sent out and made available comment cards for the Commission as requested prior to this inspection. Those that came back were mostly very positive about home. The home does not hold any money or valuables belonging to residents. All records kept in the home were made available to the inspector as requested, with the exception of a recent photograph of all residents. Records are appropriately stored An up to date insurance certificate was on display along with Delapre House’s registration certificate. A sample of records relating to health and safety were inspected. Accident records were reviewed. Accident records were excellently completed in that they were clear about how staff writing up accident reports knew about accidents e.g. if they came across someone who had fallen, if a resident told them of an accident or saw someone else having an accident or if they are alerted to an accident by a resident ringing their emergency call bell. The home is looking to improve the system in place for contacting the sleep member of staff in case of an emergency. Fire records were also looked at. An external company carries out quarterly checks of the fire equipment. Checks are also being carried out by the home to ensure that their fire equipment works and records are kept showing that this is being appropriately done at regular weekly and monthly intervals. Fire training, fire drills and fire evacuations are taking place. Fire training records for staff are easy to follow and it can be seen at a glance when individual staff last had fire training and when it is next due. Certificates are issued by the trainer to confirm the attendance of staff. The Dorset Fire Rescue Service last visited Delapre House in May 2005 and will be visiting again in August 2007. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 25 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 26 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 OP8 Regulation 13 Requirement Assessments must be made as to why bed rails are in use e.g. history of falling. These assessments must be kept under review. Appropriate permissions for use of this equipment must be sought and recorded. A photograph of all residents must be kept in the home. Timescale for action 01/10/06 2. OP37 17 01/10/06 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 OP9 Good Practice Recommendations The home should obtain a thermometer that registers the maximum and minimum temperature of the fridge used to store medication. Records should be kept of these temperatures. All medication administration records should include details of any allergies known or ‘none known’ if this is the case. Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Delapre House DS0000061562.V308434.R01.S.doc Version 5.2 Page 28 - 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. 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