CARE HOMES FOR OLDER PEOPLE
Delph House 40 Upper Golf Links Road Broadstone Poole Dorset BH18 8BY Lead Inspector
Catherine Churches Unannounced Inspection 10:00a 16 November 2005
th 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.V251289.R01.S.doc Version 5.0 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.V251289.R01.S.doc Version 5.0 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 Old age, not falling within any other category registration, with number (39) of places Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may accommodate a maximum of 24 service users who require nursing care. 28th June 2005 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. 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 by service users. Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the morning of 16th November 2005. The inspection took place as part of the regular, programmed inspection schedule for the home. This report should be read in conjunction with that from the inspection in June 2005 as all key inspection standards are reported on in these two reports. The purpose of this visit was to check that recommendations made during the last inspection have been acted upon, that the home continues to run in the same satisfactory way 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 and staff. Mrs Jenkins, the registered manager, was present throughout the inspection. What the service does well:
Delph House provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home is well presented and has beautifully maintained gardens that residents reported they enjoyed very much. The home has maintained good standards with regard to compliance with the National Minimum Standards for the last two inspections. The home now meets 18 of the 21 key inspection standards, once the three recommendations made in this report are complied with then all key standards will be met. The home is positively managed and well staffed. The staff group is stable and were observed to be respectful, helpful and caring. All residents spoken with were very positive about the care and attention that they receive. Feedback cards from relatives also indicated a high level of satisfaction and staff spoken to during the inspection indicated that they enjoyed their jobs. Residents are supported in maintaining contact with family and friends and appropriate assistance is given to enable them to retain their rights to exercise choice and control over their lives wherever possible. Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 6 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. Delph House DS0000020458.V251289.R01.S.doc Version 5.0 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.V251289.R01.S.doc Version 5.0 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): None of these standards were assessed on this occasion as standard 3 was assessed at the last inspection and found to be met. Standard 6 is not applicable to Delph House EVIDENCE: Delph House DS0000020458.V251289.R01.S.doc Version 5.0 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): 9 There are satisfactory arrangements in place for the management of medication, therefore ensuring that residents are protected. EVIDENCE: Following the last inspection two recommendations were made regarding the storage of medication and recording of the medication fridge temperatures. Examination of the drug cupboard and fridge temperature records confirmed that these recommendations have been acted upon. Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 10 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): 13 and 14 Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. Open visiting arrangements are in place enabling residents to retain contact with families and friends. The home also places great emphasis on involvement with the local community, particularly as the majority have spent much of their lives in the area. EVIDENCE: The visitor’s book showed that there is a constant stream of visitors to the home and discussions with staff and residents confirmed this as well as the fact that many residents are taken out by visitors. There is a communications book in the main reception area that enables visitors to leave messages for staff, confirm visits etc and request any special arrangements. This was well used and was clearly a useful document for all parties. There were notices around the home of upcoming events and, following a successful summer party for all residents and their families, a similar Christmas party was being planned. Discussion with residents and staff as well as examination of records evidenced that residents are assisted appropriately to exercise choice and control over their lives.
Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 11 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 satisfactory system for making complaints. This means that residents and others involved in the home that may wish to make a complaint can feel confident that they would be listened to and matters of concern will be acted upon. Whilst, in practice, staff knowledge and skills should protect residents from abuse, records of training and policies and procedures were out of date. EVIDENCE: Since the last inspection one anonymous complaint has been made to CSCI regarding Delph House. This was passed to the manager of the home to investigate using their complaints investigation procedure. Mrs Jenkins undertook a comprehensive investigation and provided a detailed report of her investigation and suitable evidence to support her investigation. The complaint was found to be unsubstantiated. The homes policies regarding the protection of service users from abuse and whistle-blowing were out of date. Both referred to the NCSC, which no longer exists, and neither contained the name and contact details of CSCI. Whilst from discussions with the manager and staff, it was evident that staff had received training in recognising, preventing and dealing with abuse, records did not support this. The policy regarding abuse was also very complex and it was recommended that a flow chart type document also be produced so that it was clear to staff what actions they should take, if they suspect abuse is taking place.
Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 12 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 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. 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. Training records need to be improved in order to provide evidence that such training has taken place.
Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 13 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 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. 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. Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 14 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 and 38 Mrs Jenkins has been registered as the manager of Delph House for a little over one year. In this time she has improved standards of care and increased the level of compliance with the National Minimum Standards and Care Homes Regulations. She is a competent, approachable and committed manager. This results in a well run home where residents, staff and visitors feel supported and consulted. Management practices, with regard to the financial interests of residents, are satisfactory and demonstrate that appropriate safeguards are in place. Residents, staff and visitors to the home are potentially being put at risk due to poor practice in relation to some areas of fire prevention. Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 15 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. Since the last inspection, Mrs Jenkins has completed a quality monitoring review of the home, this involved questionnaires to residents and families as well as other stakeholders in the home. The results of these questionnaires have been analysed. As a result of the analysis an informative report has been written and actions taken where issues have been identified. This recommendation has therefore been met. 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. At present Mrs Jenkins is the appointee for one resident at the request of the local social services department. Records and balances were checked for this resident and they were found to be satisfactory. It was recommended that Mrs Jenkins obtain a second signature to witness any transactions she undertakes on this persons behalf. The accident book was examined and found to be up to date and detailed. Records of the regular maintenance of the fire warning system by a contractor were satisfactory as was the weekly test of the alarm system. However the monthly visual check of fire fighting equipment had not been undertaken, nor had the monthly check of the emergency lighting system. As with other training records, whilst it was evident from discussion that fire training had taken place, records did not clearly demonstrate this. Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 17 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 OP18 Good Practice Recommendations Policies for the Protection of Service Users from abuse and for Whistle blowing must be updated to include the CSCI address and contact details. Policies should be clear and easy to understand. Training records must be clear and up to date to demonstrate that staff have received training in infection control. Training records must be clear and up to date to demonstrate that staff have received training in fire prevention and the action to take in the event of a fire. Monthly checks of the emergency lighting system and fire fighting equipment must be undertaken to ensure that the health safety and welfare of residents and staff is promoted and protected. 1 2 3 OP26 OP38 4 OP38 Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 18 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 Delph House DS0000020458.V251289.R01.S.doc Version 5.0 Page 19 - 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!
