Inspection on 14/03/06 for Delaware House

This inspection was carried out on 14th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Delaware House 20/06/07

Delaware House 20/06/06

Delaware House 24/08/05

Delaware House 24/02/05

Delaware House 09/07/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Delaware House Maplin Way North Shoeburyness Essex SS3 9PS Lead Inspector Michelle Love Unannounced Inspection 14th March 2006 09:00 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 Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 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. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Delaware House Address Maplin Way North Shoeburyness Essex SS3 9PS 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) 01702 588501 johnhase@southend.gov.uk Southend on Sea Borough Council Manager post vacant Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (24) Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Personal care and accommodation to be provided to no more than twenty-four (24) service users over the age of 65 (OP). Personal care and accommodation to be provided to no more than six (6) service users with a Mental Disorder (MD). Number of service users to whom personal care and accommodation is to be provided shall not exceed twenty-four (24). 24th August 2005 Date of last inspection Brief Description of the Service: Delaware House is owned by Southend on Sea Borough Council, and provides residential care for up to 24 older people. In addition the category of registration enables the home to accept those older people who have a formal diagnosis of dementia. The care home is situated within a residential area of Shoeburyness. The area benefits from good public transport links. Shops and other local amenities are a short distance away. The home has large grounds surrounding the property and there is on site visitors parking. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection undertaken by Michelle Love over 8.5 hours. As part of the inspection process a range of records and documents were inspected and a tour of the premises undertaken. Additionally a number of residents and staff were spoken with during the inspection. The manager was present for the majority of the inspection, however in the afternoon the inspection was conducted with the assistance of the senior in charge of the shift. What the service does well: What has improved since the last inspection? What they could do better: A programme of activities/meaningful stimulation must be provided for all residents (especially for those with complex needs). The registered provider Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 6 must ensure that sufficient hours are provided for an activities co-ordinator and that the hours are flexible. Gaps pertaining to some mandatory and specialist training courses for care staff/senior staff must be identified and provided on an on-going programme. The manager must look at ways of managing his filing systems and decluttering his office with paperwork and documents. Once completed this may well ensure that paperwork is close to hand and easily accessible. The home’s care planning processes need to be improved upon i.e. more detailed and comprehensive. The Commission for Social Care Inspection recognises that a new care plan format is currently being implemented and that care plans are being rewritten. 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. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 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 Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 Prospective residents are formally assessed prior to admission. Prospective residents continue to have the opportunity to visit the care home prior to admission so as to make an informed choice as to whether or not Delaware House is a care home they wish to live in. Some gaps exist in relation to training for staff. EVIDENCE: Pre Admission Assessments were evident for those newly admitted residents to Delaware House. It was positive to note that all assessments had been completed prior to individual’s admission and these were detailed, comprehensive and informative. Evidence was available to indicate that some family members had visited the care home prior to their relatives’ admission and residents undertook trial visits wherever possible. No dependency profiles were completed depicting residents High, Medium and Low needs. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 11 A plan of care is devised for all residents depicting their individual care needs. Care planning processes are better but still inconsistent in some cases. The systems for resident consultation provide little evidence to indicate that resident’s views are sought and acted upon. EVIDENCE: On the day of inspection five individual care plans were inspected. Records were inconsistently completed, whereby some elements of the care plan were detailed and informative, whilst other elements were not completed or lacked detail and clarity i.e. the care plan for one newly admitted resident had several elements not completed (continence management, personal aids or equipment, social/emotional needs, activity plan, personal care plan-day and night and night time preferences). Life histories were not completed for all residents. It was positive to note that risk assessments had been devised for all areas of assessed/identified risk for the newest residents. Little or no evidence was available in most cases to detail that care plans had been reviewed. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 10 Daily care records were written each day and after each shift. Some additional information is required pertaining to staff’s interventions i.e. the records for one resident indicated on several occasions that the individual exhibited aggressive behaviours. No information was recorded pertaining to the specific nature of the aggression or how staff provide, intervention strategies and support to the individual. It was sad to note that records for one resident (25.12.2005) did not detail how the resident had spent Christmas Day, whether or not they enjoyed Christmas dinner or whether they received any Christmas presents. Information relating to funeral arrangements/terminal care were not documented within all random samples of care plans inspected. Formal assessments relating to manual handling and falls were readily available, however no assessments were evident relating to pressure sores, continence and nutrition. Throughout the inspection, interaction and rapport between care staff and residents was seen to be positive. Staff spoken with demonstrated a very good understanding and awareness of individual resident’s needs. The homes medication systems were seen to be appropriate and no issues of concern were highlighted. The senior in charge of the afternoon shift was observed to administer medication to individual residents safely and in line with Royal Pharmaceutical Guidelines. No omissions of medication were highlighted at this inspection. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 No progress appears to have been made since the last inspection in relation to residents having the opportunity to participate within meaningful activities. EVIDENCE: On the day of inspection no formal activities were offered to residents. Care plans detail in some cases, resident’s personal preferences relating to their interests and hobbies. Daily care records do not always detail activities undertaken by residents. One resident spoken with confirmed that there is a lack of activities available and that the majority of their time is spent watching television. It was evident during the inspection that care staff and senior staff are very busy with providing personal care to residents and do not have specific time available to initiate activities for residents. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 12 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 The home has a complaints and protection of vulnerable adults policy and procedure. The home’s procedures appear to protect residents from abuse and harm. EVIDENCE: Since the last inspection the home has received no complaints. It was positive to note that several compliments, i.e. cards and letters were readily available and were complimentary regarding the care provided at the home and the quality of staff employed. No protection of vulnerable adults issues have been highlighted since the last inspection. Training records evidence that since the last inspection 20 members of staff have undertaken protection of vulnerable adults training. In addition 3 members of staff have received PRICE (Protecting Rights in a Care Environment) training. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 13 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 The home environment provides residents with a safe, clean and comfortable home in which to live in. EVIDENCE: On the day of inspection the home was observed to present no health and safety issues. All areas of the home were clean, tidy and odour free. It was positive to note that since the last inspection some carpets have been replaced and a non-slip/washable floor covering has been purchased for the main dining area. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 14 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 Staffing levels within the home are generally appropriate for the current needs of residents residing at Delaware House. Residents are protected by the homes robust recruitment procedures. Some gaps exist in relation to training for staff. EVIDENCE: On inspection of four weeks staff rosters these evidence that staffing levels are being met on most occasions, however the roster details on some occasions that there have been insufficient staff on duty. The manager was unable to clarify as to which members of staff had been deployed to cover the shifts. Current staff vacancies include (1x team leader and 2x care staff). The manager was advised that the staff roster needs to detail the full names of all staff working at the care home, including agency staff. Since the last inspection 3 members of staff (domestic staff) have been recruited. It was positive to note that the home has robust recruitment procedures in place. Only three issues were highlighted at the inspection pertaining to staff recruitment files. One employment file indicated that an agency member of staff working at the home holds a student visa. A student visa enables the employee to work a total of 20 hours per week, however the staff roster detailed that over a one week period in January 2006 they worked 28 hours. Another person’s file indicated that their work permit had expired in September 2005. Lastly it was evident that one person’s Criminal Record Bureau check was from their last employer and not their current one. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 15 On inspection of a staff training matrix, this details that since the last inspection some staff have received training relating to dealing with residents aggression/inappropriate behaviours, protection of vulnerable adults, manual handling and medication. Some gaps exist for some mandatory courses i.e. basic first aid, health and safety, COSHH (Control of Substances Hazardous to Health) and fire safety. Additional specialist training is required relating to those conditions associated with older people i.e. catheter care, pressure care, nutrition, diabetes and mental disorder. This was highlighted at the last inspection to Delaware House. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 16 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): 33, 35 and 36 The home appears to be well managed. Resident’s finances are appropriately managed. No quality assurance system has been devised and implemented. Staff supervision has restarted. EVIDENCE: Of those staff spoken with all were complimentary regarding the management of the home. A random sample of resident’s monies, were inspected and all records/receipts were noted to tally correctly. The home’s storage facilities for resident’s monies were seen to be appropriate. No quality assurance system has been devised and implemented to seek residents, their relatives/representatives and visiting professional’s views. Regulation 26 visits are conducted to the home, once monthly by the Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 17 registered provider and a report forwarded to the Commission for Social Care Inspection. Records indicate that staff supervision has been reintroduced since January 2006. The home’s filing system for documentation was observed to be very muddled and a number of records had not been placed into staff’s individual files. The manager advised the inspector that it is hoped that staff appraisals will be completed by March 2006. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 18 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 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 X 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 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 2 X X Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation 18(1) Requirement The registered person must ensure that the home can meet the assessed needs of residents and ensure that staff are provided with training to enable them to meet these needs. A comprehensive and detailed care plan must be written for all residents. This must detail how all aspects of residents needs are to be met. Previous timescale of 01/02/06 not met. The registered person must ensure that care plans are kept under review and regularly updated. The registered person must ensure that information pertaining to terminal care/funeral arrangements must be documented within individuals care plans. Previous timescale of 01/03/06 not met. Ensure that suitable arrangements are made for all residents to receive a varied programme of `in house` and DS0000059047.V286606.R01.S.doc Timescale for action 01/09/06 2. OP7 15 01/06/06 3. OP7 15(2)(b) 01/06/06 4. OP11 12(2) 01/06/06 5. OP12 16(2)(m) and (n) 14/05/06 Delaware House Version 5.1 Page 20 6. OP27 18(1)(a) 7. OP33 24 community based activities. Previous timescale of 01/02/06 not met. Ensure that at all times there are sufficient numbers of staff on duty. Previous timescale of 14/11/05 not met The registered person must ensure that a formal quality assurance system is devised and implemented. 07/04/06 01/06/06 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. 2. 3. Refer to Standard OP7 OP28 OP31 Good Practice Recommendations Daily care records should include and detail staff’s interventions. 50 of care staff should achieve NVQ Level 2 The registered manager should attain NVQ Level 4 in Care and Management. Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Delaware House DS0000059047.V286606.R01.S.doc Version 5.1 Page 22 - 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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