Inspection on 28/04/08 for Delapre House

This inspection was carried out on 28th April 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

Delapre House 11/08/06

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Delapre House 109 Magna Road Bearwood Poole Dorset BH11 9NE Lead Inspector Jo Palmer Unannounced Inspection 28th April 2008 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.V362063.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.V362063.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 F/P01202 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.V362063.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 either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 10 11th August 2006 Date of last inspection 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 £595 to £725 a week. Delapre House DS0000061562.V362063.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. The inspection took place on 28th April 2008 between 10.00 and 15.00. Judith Bell owner of Bell Social Work (BSW) Ltd was present, BSW Ltd is the company registered to provide care at Delapre House. Judith Bell takes responsibility for the day-to-day management of the home along with a competent senior staff team. The main purpose of this key inspection was to check that the residents living in the home were safe and properly cared for and to review the homes performance against the key National Minimum Standards. Registered for 10 places, there were two vacancies, 8 residents were living at the home. Five residents, the owner, two relatives and two members of staff were spoken with, relevant records were examined and a tour of the premises also informed this inspection visit. What the service does well: The home understands the importance of ensuring they have all the information necessary concerning a persons health and welfare prior to them moving in and of the persons rights to know all about the service before they make the decision to move. Based on assessment information prior to the person moving to the home, a care plan is devised detailing how care needs are to be met, care files are regularly reviewed and updated to ensure care can be delivered satisfactorily and that all care needs are addressed in the daily routines. Residents at Delapre House have access to healthcare services from local surgeries and are supported in meeting appointments with other health care professionals. Medication is well managed in the home. People living in the home are encouraged to make choices and decisions about their own lives and are able to pursue their preferred level of activity and recreational pass-times. Residents maintain good levels of contact with friends and family and the local community. Residents living at the home are protected by the home’s policies regarding adult protection and complaints and can be assured that any concerns will be taken seriously and acted upon. Delapre House DS0000061562.V362063.R01.S.doc Version 5.2 Page 6 The home provides comfortable clean and well maintained accommodation. There are sufficient numbers of trained staff on duty to meet resident’s needs; the recruitment process ensures that all staff employed are suitable to work with vulnerable adults. Delapre House is well managed and Mrs Bell has a good understanding of the principles and focus of the service, Mrs Bell is supported by the homes senior staff team and it was evident from discussion that the management systems are transparent. 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. Delapre House DS0000061562.V362063.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 Delapre House DS0000061562.V362063.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): 3 (standard 6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A pre admission procedure is in place and assessments are routinely undertaken to ensure that only residents whose needs can be met by the home are offered places there. EVIDENCE: Two pre admission assessments were seen; the needs of the resident are assessed prior to them agreeing to move into the home using a set format that has been developed to take into consideration their health and welfare needs. The records indicated that the needs and circumstances of the people had been properly taken into account. It was evident where appropriate that the resident or their representative had been consulted regarding the pre-admission assessment. Delapre House DS0000061562.V362063.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. 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. Systems are in place to provide staff with the information they need to meet the health, personal care and social needs of residents. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The information contained in pre-admission assessments is used to help compile a detailed plan of care. A series of assessments carried out on arrival at the home including risk assessments, also feed into the care plan. Care plans provide concise information about the needs of the resident and how these needs are to be met in a manner that is respectful of the resident’s own choices and individual needs and it was clear that reviews were being undertaken and plans updated with changes. Care plans for four residents were reviewed, two of these were for residents with higher-level care needs and it was evident that, as Delapre House is not registered to provide nursing care, where a residents needs increase, appropriate care is sourced. Care pans Delapre House DS0000061562.V362063.R01.S.doc Version 5.2 Page 10 inform staff at Delapre House of the care they need to provide to support and maintain the nursing care given by the community care team. For residents with lesser needs, the care plans are also informative providing care staff with details of how each individual need is to be met in respect of the personal and social well-being of each resident. Staff complete a care summary at the end of each shift, a review of these supported the delivery of care to residents and fed into the regular reviews of care plans. These records demonstrated an inherent respect for each resident’s individual needs. Medication records are well kept and evidenced that residents are in receipt of any medication as prescribed by their GP, storage of medicines in the home was safe and in order. A monitored dosage system is in place administered by the dispensing pharmacist, the system provides medication administration records (MAR) for completion by the home. Most medicines are issued from the supplying pharmacist in blister packs (MDS), those that are not suitable for this type of dispensing are issued in their original containers, stocks of medicines held audited with recorded information. Some anomalies were noted with medication recording although as soon as this was pointed out, the owner, Judith Bell and the senior carer immediately investigated the issue and set about ensuring that systems were in place to ensure against recording errors. Residents spoken with said that they were treated well and that staff were kind and friendly. Staff were seen to treat residents with extreme courtesy, patience, kindness and respect. Delapre House DS0000061562.V362063.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The level of activities provided are tailored to individual residents needs and people are encouraged to make choices about their life style and to maintain contact with their family and friends. The meals in this home are wholesome and varied and are served in a pleasant environment EVIDENCE: Assessments of residents social, cultural and psychological welfare are in place to ensure staff have a basic understanding of individual need. Care plans, produced from assessment provided staff with instruction on how needs are to be met and were noted to include individual one to one time with reference to patience and respect, the expected level of contact with family and friends, some group activities and the resident’s preferences for self directed recreation. Care plans would indicate a resident’s preferences for which newspaper they liked to read and other lone activities such as reading, listening to music, bible readings and television. Residents spoken with confirmed that there was sufficient activity and stimulation in the home and that they were able to have ‘alone’ time if they wanted. Residents are able to Delapre House DS0000061562.V362063.R01.S.doc Version 5.2 Page 12 maintain links with the local community where able, one resident had been out on the morning of inspection and in later discussion with the resident it was evident that this was the norm with at least two trips out each week. Two relatives spoken with confirmed they are able to visit freely and had confidence that the residents were treated respectfully and with dignity. The relative confirmed they were always made to feel welcome and were kept informed regarding their relatives care progress. The main meal of the day is served at lunch time, this was observed during the inspection and noted to be a social affair with residents sitting around a large, pleasantly laid dining table with staff in attendance for assistance and waiting as appropriate. The meal was unhurried and all the residents spoken with confirmed that they enjoyed the meals in the home. The cook was spoken with briefly who confirmed that a two week rotating menu is used from which meals are prepared, residents are asked daily their choice for the next day’s meal and records seen supported this, and although residents spoken with could not always remember what they had ordered they all stated that the meals were of a good standard, appetising and plentiful. The meal on the day of inspection was shepherds pie with mashed potato and fresh vegetables. Cook and residents confirmed that there are sufficient fresh fruit and vegetables used in the preparation of meals. Breakfasts are served by individual choice in each resident’s room although two have breakfast in the dining room, residents confirmed that breakfast is provided at a time which suits them. One resident spoken with who prefers to take meals in her room confirmed that if she feels like something different, she is able to order a takeaway which is delivered, staff support her decisions in this. Delapre House DS0000061562.V362063.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. 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. Policies, procedures and staff training programmes are in place to protect the residents living at the home; residents can be assured that they can express any concerns they may have and that any incidents will be managed appropriately. EVIDENCE: A complaints procedure is available to residents and visitors to the home. A complaints and compliments file is held, a review of this showed it to hold numerous greeting cards and letters from satisfied relatives of residents who have lived at the home. Any complaints received have been dealt with accordingly and letters on file addressing the issues raised evidence that management at Delapre House take such matters seriously and work toward a satisfactory resolve. Adult protection procedures are in place detailing the correct action to be taken should any concerns or allegations be made. The home holds a copy of local authority and Department of Health guidance on adult protection matters and all care staff have received training in adult protection and recognising abuse. Delapre House DS0000061562.V362063.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. 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. Delapre House provides residents with a comfortable environment in which to live where they are safe, warm and have suitable facilities to meet their needs. EVIDENCE: Residents spoken with confirmed that they are comfortable in their rooms and are able to bring personal effects to make their space more homely; a tour of the premises viewing some rooms evidenced that they were clean, well maintained and homely. Bedrooms have en-suite toilet and wash facilities and shared bathrooms are available with suitable aids and adaptations to assist residents. Communal areas of the home include the lounge, dining room, a small lounge and conservatory and the rear garden is accessible when the weather permits. All communal spaces were seen to be homely, well furnished and decorated. Delapre House DS0000061562.V362063.R01.S.doc Version 5.2 Page 15 The home was clean and well maintained at the time of inspection; infection control procedures are in place with suitable hand washing facilities for staff in respect of infection control procedures. Residents spoken with confirmed that the laundry systems in the home work well and that their clothing, bedding etc is returned promptly, clean and in good condition. Delapre House DS0000061562.V362063.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. 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 numbers of staff are on duty to meet resident’s needs. Training is provided to staff in order that they have the skills and are competent to do their jobs. Safe staff recruitment practice is used. EVIDENCE: A four week staffing rota seen demonstrated that there are two care staff on duty daily supported by a senior carer, additionally the owner/manager is present in the home at various times throughout the week. Day shifts are worked between 8am and 2pm, and 2pm and 8pm. The night shift is between 8pm and 8am where there is one member of care staff with a second sleeping in/on call. Residents spoken with confirmed that staff are available when they need them. Additionally, there is a housekeeper and cook on duty daily. Three care staff have attained NVQ level 2 and five have attained level 3, one is in the process of obtaining NVQ level 4. Several of the staff have nursing qualifications obtained overseas and although not registered to practice nursing in the UK, Mrs Bell confirmed that here qualification has been confirmed as NVQ level 3 equivalent. Delapre House DS0000061562.V362063.R01.S.doc Version 5.2 Page 17 Staff files seen demonstrated the extent of training courses attended by staff. All staff have attended training in the following and updates and refresher courses are booked where necessary: • Moving and handling • First Aid • Health and Safety • Food Hygiene • Fire safety • Infection control • Adult protection • Medication management • Induction traiing Three staff have also attended training events in Mental Capacity Act, Dementia care and HIV awareness Recruitment files examined for four recently appointed members of staff demonstrated that safe practices are used. Each applicant completes an application form detailing their work history and qualifications, references are sought, POVA first and CRB checks are made and verification of the persons identity is held, where necessary, work permits are held on file with evidence of the persons visa. Two of the files examined were for staff members who were due to commence employment at Delapre House when all appropriate paperwork had been returned. Delapre House DS0000061562.V362063.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Bell takes responsibility for the day to day management of the service and is aware of the basic processes set out in the National Minimum Standards and of the need to keep up to date with practice and to develop the service. Quality assurance systems are being developed. People are supported to manage their own money where possible and health and safety policies and procedures are in place for the protection of residents. EVIDENCE: Bell Social Work Ltd is the Registered Provider with Judith Bell taking the role of manager of Delapre House on a day to day basis; Mrs Bell has a social work Delapre House DS0000061562.V362063.R01.S.doc Version 5.2 Page 19 and management qualification although confirmed at this inspection, she has appointed a person to manage the home, this person will be applying to the Commission for registration although will complete a trial period of employment before taking full responsibility. Mrs Bell said she will continue to be actively involved in the management of Delapre House although will be able to concentrate more on developments of the service. Standard 33 was not assessed during this inspection, the Commission for Social Care Inspection sent the home an annual quality assurance assessment (AQAA) in 2007 which was completed and returned providing necessary information to assist with the Annual Service Review (ASR) undertaken by the Commission in August 2007. The report of the ASR is available to interested parties via the Commission’s web site www.csci.org Mrs Bell also completed an internal quality assurance programme in 2006 and confirmed during this inspection that this was to be reviewed and updated to include views of residents now living at the home, Mrs Bell confirmed that residents views would be sought via questionnaires that are to be sent out in the summer of 2008 In order to protect residents, it is the policy of the home not to have any involvement with their personal finances. Therefore, any resident unable or not wishing to handle their own affairs has a relative or other representative to deal with their personal affairs and finances. A Fire Risk Assessment seen dated October 2006 and reviewed in April 2008 was satisfactory, and other records were seen relating to regular testing and maintenance of fire fighting equipment, alarms and emergency lighting systems. All staff receive fire safety and awareness training regularly. Risk assessments are in place on residents files demonstrating action necessary to reduce or eliminate identified risks such as accidental scalding and falling, hazards in the garden and outside venues to which residents have been taken on trips have also been assessed in relation to any risks or hazards. Delapre House DS0000061562.V362063.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 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Delapre House DS0000061562.V362063.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Delapre House DS0000061562.V362063.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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