Inspection on 13/02/07 for Delph House

This inspection was carried out on 13th February 2007.

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

Delph House 04/02/09

Delph House 27/07/06

Delph House 16/11/05

Delph House 28/06/05

Delph House 21/09/04

Delph House 24/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Delph House 40 Upper Golf Links Road Broadstone Poole Dorset BH18 8BY Lead Inspector Catherine Churches Unannounced Inspection 13th February 2007 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 Delph House DS0000020458.V329242.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. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delph House Address 40 Upper Golf Links Road Broadstone Poole Dorset BH18 8BY 01202 692279 01202 658210 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) Mrs Jacqueline Lesley Haigh Mrs Janice Anne Jenkins Care Home 39 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (39) of places Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate a maximum of 24 service users who require nursing care. The home may accommodate a maximum of six service users under the category DE(E) at any one time. 27th July 2006 Date of last inspection Brief Description of the Service: Delph House is registered with Commission for Social Care Inspection to provide accommodation for a maximum of 39 older people, some with nursing needs and some with a diagnosis of dementia. It is owned by Mrs J L Haigh and managed by Mrs J Jenkins. The home is situated in a pleasant residential area of Broadstone, Poole. Accommodation is on two floors accessed by a lift. Nursing care is provided in the older part of the home and residential care in the newer purpose built unit. Each area has a lounge and conservatory. There is a small dining room in the residential unit. Delph House is set in small, well-tended garden that is accessible to service users. Fees range from £405 to £650 per week. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key, unannounced inspection undertaken on 13th February 2007. The inspection took place as part of the regular, programmed inspection schedule for the home. The last inspection was July 2006. The purpose of this visit was to monitor the homes compliance with National Minimum Standards and compliance with recommendations made during the previous inspection. Also, to check that the home is run in a satisfactory manner and that the people who are living in the home are properly cared for. The premises were inspected and a number of records examined. Time was also spent time observing routines within the home and talking with residents, visitors and staff. This report refers throughout to “residents” meaning to include persons accommodated in the residential units of the home, patients in the nursing units and the overall term “service users”, which is the preferred term of the Commission. What the service does well: What has improved since the last inspection? Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 6 Three requirements and three recommendations were made as a result of the last inspection. The requirements related to the quality of ingredients used in the kitchen, safe recruitment of staff and maintenance of fire protection and prevention systems. All matters have been satisfactorily dealt with therefore improving the resident’s general safety both in the building and from unsuitable staff as well as improving their diets. He recommendations related to care planning and recording of medication. Again, these have been satisfactorily actioned resulting in improving information regarding care needs and how they are met and safer management of medicines. 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. Delph House DS0000020458.V329242.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 Delph House DS0000020458.V329242.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents needs continue to be satisfactory. This means that residents can be certain that the home is aware of their requirements prior to their admission to the home and that the staff will therefore be able and prepared to meet these needs. EVIDENCE: Documentation for four residents was examined as part of the case tracking procedure used during this inspection. All of these residents had been newly admitted to the home since the last inspection. The pre-admission assessments were viewed. They contained good information about each persons needs and a letter was also available on file to confirm, Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 9 that having carried out the assessment, the home could meet the persons needs. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care Plans for residents who live at Delph House are detailed and informative. This means that staff have sufficient information to provide a good level of care and the home can also demonstrate the care that has been provided. The home ensures that resident’s healthcare needs are met through seeking appropriate input from GP’s and other healthcare professionals. Medication in the home is well managed, promoting good health. The ethos in the home is one of respect for the residents living there. This means that the residents feel settled at the home and their privacy is respected. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care Plans and related documentation regarding care for 4 residents were examined. Files were well laid out and risk assessments had been undertaken. Reviews were being undertaken on a monthly basis or more frequently if changes dictated this. Evidence was available on file and through discussion that GP’s, district nurses, specialist nurses and other health professionals are called upon whenever the need arises. Medication systems were examined. Appropriate recording systems are in place and all staff responsible for administering medication have received up dated training. Medication was stored and secured appropriately. During conversations with a number of residents, they confirmed (where they were able to) that they were happy with the care they received and that either they or their representatives are involved in reviews. They also confirmed that they feel respected by staff and are able to maintain their privacy when receiving personal care or visits from professionals such as GP’s and solicitors, family and friends. It was observed that staff knock on doors before entering and that residents preferred form of address is recorded and used. The home has a good policy for the promotion of privacy and dignity but not all staff and had signed to confirm that they had read this Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities are dependent on individual preferences and the resident’s capacity for involvement. Open visiting arrangements are in place enabling residents to retain contact with families and friends. Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. Dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and needs. EVIDENCE: The home employs an activities organiser for 24 hours per week over 4 days, Monday to Thursday. This person organises various group activities such as Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 13 quizzes and bingo and also undertakes one to one sessions with those who are unable or choose not to leave their rooms. The home also arrange for visiting entertainers to come to the home to provide exercise classes and music/singing sessions. Comprehensive records were available to support this. Residents are encouraged to maintain contact with family and friends. The visitor’s book showed that there is a constant stream of visitors to the home and discussions with staff confirmed this. Discussion with residents and staff as well as examination of records and observation during the inspection evidenced that residents are assisted to exercise choice and control over their lives. The home employs a full time chef. At the time of the inspection the Chef was on annual leave and the weekend cook was filling in. Lunch was observed both during its preparation and whilst residents were eating. It looked appetising and those residents spoken to confirmed that they enjoyed their meals. Food stocks were examined: it was noted that the quality of foods purchased has improved since the last inspection. Food records were satisfactory. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Delph House has a satisfactory policy and procedure for the making of complaints. This means that residents and others involved in the home that may wish to make a complaint should feel confident that they would be listened to and matters of concern will be acted upon. Arrangements for protecting service users from abuse were satisfactory. This means that Delph House is a safe environment that will protect residents from abuse. EVIDENCE: The complaints procedure is included in the Service Users Guide/Terms and conditions of residence that is given to all residents/representatives and also available in the main entrance area of the home. No complaints have been made to CSCI or to the home since the last inspection. Policies and procedures for adult protection and whistle blowing were checked and found to be satisfactory. Staff have all had copies of the homes policy and procedure for recognising and preventing abuse as well as specific training in this matter. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 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 very well presented: it is nicely decorated and furnished and has a homely atmosphere. The grounds are also well maintained, providing lots of colour and interest as well as a variety of places to sit and relax. The home maintains a good standard of hygiene and all areas seen were clean and free from offensive odours. EVIDENCE: A tour of the premises confirmed that the home is well decorated, furnished and equipped. Dorset Fire and Rescue Service has visited the home and confirmed that it complies with their requirements. Since the last inspection a Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 16 number of areas have been redecorated and a new through floor lift has been installed. This demonstrates ongoing investment in the property. Bedrooms are nicely furnished and residents have brought personal items such as furniture, pictures, photographs, ornaments and other items to help them personalise their rooms. The lounges and dining room are nicely decorated and furnished with a choice of seating available to residents. Staff had a good understanding of infection control procedures and the relevant protective clothing was available. There was a detailed infection control policy in the home that covered all of the required areas and staff confirmed that they had received training in this area. Training records were also available to support this. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well staffed ensuring that residents receive the care and attention they need in an unrushed manner. Staff clearly enjoyed working in the home, there was a positive atmosphere and residents had a happy, relaxed relationship with the manager and staff. Staff have experience in caring for the elderly, a number have already achieved the minimum vocational qualification and others are undertaking training to further develop their abilities and competencies. Recruitment procedures are satisfactory and this gives further protection to residents. Induction of new staff is undertaken within the timescales and to a good standard. This means that staff have the necessary skills to enable them to undertake all aspects of their role competently. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 18 EVIDENCE: Examination of the staff rota and observation throughout the inspection demonstrated there was a sufficient number and skill mix of staff to meet the needs of residents. Staff and residents spoken with confirmed that they were satisfied with staffing levels. Ten of the twenty-seven care staff have achieved NVQ level 2 and a further 2 are studying the qualification. Staff records were examined for three members of staff. These demonstrated that appropriate recruitment practices are in place: application forms were completed; interviews documented and appropriate evidence of identity and qualifications had been obtained. References, Criminal Records Bureau and POVA checks had also been completed as required. The new Skills for Care induction programme has been implemented in the home and evidence that new staff were undertaking this was available. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Jenkins has completed the necessary training and has the relevant experience. She is a competent, committed and approachable manager and both residents and staff confirmed this. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents, staff and relatives. Sound practices and procedures are in place regarding resident’s finances. The health, safety and welfare of residents and staff is protected by the systems that the home has in place for staff training, maintenance and risk assessment. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 20 The health, safety and welfare of residents and staff is protected by the systems that the home has in place for staff training, maintenance and risk assessment EVIDENCE: Mrs Jenkins has a number of years experience in a management capacity of a care home with nursing, is a qualified nurse and has also undertaken the NVQ level 4 in management and the Registered Managers Award. All staff and residents spoken with spoke positively about her and were comfortable with approaching her if they needed to. The home has detailed policies and procedures for the promotion of quality assurance in the home. Mrs Jenkins confirmed that annual surveys and analysis is due to undertaken again later in the year. Mrs Jenkins confirmed that residents are encouraged to retain control of their own finances for as long as possible. Where they state that they no longer wish to or they lack the capacity to do so then the home ensures that either family or other representatives such as solicitors take on this role. Cash is held for a few people. A sample number of records and balances were checked and found to be satisfactory. Fire records, staff training records and accident books were examined and found to be up to date and detailed. Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 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 3 X 3 X X 3 Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N0 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 Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Delph House DS0000020458.V329242.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!