CARE HOMES FOR OLDER PEOPLE
Delph House 40 Upper Golf Links Road Broadstone Dorset BH18 8BY Lead Inspector
Catherine Churches Unannounced 28 June 2005 10:00 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 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 D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Delph House Address 40 Upper Golf Links Road, Broadstone, Dorset, BH18 8BY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01202 692279 01202 658210 Mrs J L Haigh Mrs Janice Anne Jenkins Care Home with Nursing (N) 39 Category(ies) of OP - 39 registration, with number of places Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: The home may accommodate a maximum of 24 service users who require nursing care. Date of last inspection 21 September 2004 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 D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 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 and early afternoon of Tuesday 28th June 2005. The inspection took place as part of the regular, programmed inspection schedule for the home. Prior to the visit, time was spent analysing previous reports and reviewing previous requirements and recommendations. The Registered Manager, Mrs Jenkins was present throughout the inspection. Whilst at the home the manager, a number of staff and residents, and three visitors were spoken with, records were inspected and a tour of the premises was undertaken. The CSCI Pharmacy Inspector, Miss C Main attended the home for part of the inspection in order to carry out a detailed inspection of the management of medicines in the home. What the service does well:
The home now either fully meets standards or is very close to full compliance. All of the requirements and recommendations made at the last inspection have been fully met and only 2 recommendations are made as a result of this inspection. Delph House provides a good standard of care and accommodation and has a homely and welcoming atmosphere. The home is nicely decorated and furnished and is surrounded by attractive gardens. Resident’s rooms vary in size but were all well maintained and many residents had taken the opportunity to personalise their rooms with personal items of furniture, furnishings, pictures, plants etc. A number of residents and staff were spoken with and all had positive comments to make about the home whether it was regarding the care, staff, food, management or training. A good level of staffing was provided: care staff were well supported by ancillary staff responsible for cooking, cleaning and laundry, which means that care staff can concentrate on caring for residents. The home also employs a supernumerary floor manager who oversees the work of care staff and liases with the trained staff, GP’s, District Nurses and other health professionals as necessary. It was evident during the inspection that residents feel settled and comfortable in their environment and have good relationships with the staff.
Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 6 Staff were observed to be respectful and to have good relationships with residents. One comment received about the staff was “they are a lovely team of girls who always come (to me) when they are needed”. Residents also spoke positively about the food at Delph House. Lunch on the day of the inspection was observed. The meals looked appetising and staff were discreet in offering assistance where this was required. The Pharmacy Inspector comments “The home has a good photo cards for separating residents’ medicine charts and recording all relevant information, including allergies. Records of administration of medicines were good.” What has improved since the last inspection? What they could do better:
The Pharmacy Inspector comments “Staff need to take appropriate action if the reading on the medicines refrigerator thermometer is too high and storage for Controlled Drugs (CDs) should be improved.” This is because medications can only be at their most effective if stored correctly. Controlled drugs must be kept securely.
Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 8 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 Standards Statutory Requirements Identified During the Inspection Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 9 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 standard(s) 3, standard 6 is not applicable to this home. Assessments of residents and their needs, prior to their admission, were satisfactory. This means that residents and their representatives should feel confident that the home is aware of all the needs of the person and is able to meet them. EVIDENCE: Pre-admission assessments for 4 residents, accommodated in the home, were examined. It was found from these records that a comprehensive system has been introduced which meets the requirements of the National Minimum Standards. A number of the residents whose documentation was examined were spoken with and they confirmed that pre-admission assessments had taken place with their involvement. Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 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. The home has systems in place for the administration of medication to promote resident’s health and well being. The ethos in the home is one of respect for the residents living there. This means that the residents feel settled and at home and their privacy is respected. 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. Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 11 All of the residents whose documentation was examined were spoken with. 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 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. Records of administration of medicines agreed with the audit trail. Staff countersign handwritten entries on the Medicine Administration Record (MAR) charts and medicine labels agreed with the MAR chart. The care plan for one diabetic included arrangements for monitoring blood sugar levels. The maximum and minimum temperature of the medicines refrigerator is monitored but several readings recorded were slightly higher than the recommended maximum. This was probably due to the location of the probe, which was improved at the time. The manager reported a few days later that the temperatures were in the correct range. Some Controlled Drugs were not stored in the CD cupboard. This was resolved at the time but the space is very limited. Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. The social and recreational activities provided by the home meet the expectations of residents. Open visiting arrangements are in place enabling residents to retain contact with families and friends. EVIDENCE: Records showed that there is some form of activity planned for part of each weekday. Activities included visiting musicians and singers, bingo, videos and quizzes. Those residents that were spoken with confirmed that they are happy with the social activities that are provided within the home. The manager advised that a big barbecue was being planned for July to include all residents, relatives and staff. There was already quite an air of anticipation in the home regarding this. Food records and discussions with residents confirmed that a suitable and varied diet is provided in the home. Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 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 should feel confident that they would be taken seriously and that matters of concern will be acted upon. EVIDENCE: The complaints procedure was displayed in the main hallway of the home and included in the Service Users Guide that is given to all residents. Those spoken to, including visiting relatives, confirmed that they knew how to make a complaint should the need arise. Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The home is very well presented. Residents live in a safe, well-maintained environment, which was also clean, hygienic and free from offensive odours. EVIDENCE: A tour of the premises confirmed that the home is well decorated, furnished and equipped. Resident’s rooms were personalised. Dorset Fire and Rescue Service have visited the home and confirmed that it complies with their requirements. Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 Recruitment procedures are satisfactory and this gives further protection to residents. Improvements to the way staff are trained have been made which is leading to an increased competency amongst the staff. EVIDENCE: Analysis of 3 staff files confirmed that appropriate recruitment procedures had been followed. This analysis also confirmed that all new staff had undertaken in house training which met TOPSS induction and foundation standards and records demonstrated that this had been done within the required timescales. Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 New quality assurance system has been introduced thereby helping to ensure that the home is run in the best interests of the residents. 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: The manager has reviewed the systems in the home for seeking residents and relatives views: new questionnaires have been developed and at the time of the inspection, 39 questionnaires had been sent to relatives and replies were beginning to be received. The manager explained that once replies were received she would analyse responses, plan any necessary action and also make public the analysis together with any actions that are taken. Fire records, accident books and risk assessments were examined and found to be up to date and detailed.
Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 x 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x x x 3 Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 18 no Are there any outstanding requirements from the last inspection? 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 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. 1. Refer to Standard 9 Good Practice Recommendations A procedure for the action to take when the medicine refrigerator temperature is outside the recommended range should be included in the medicine policy and communicated to staff. The space for storing CDs should be increased. The work started on the quality assurance systems for the home must be completed and then reviewed as required by the National Minimum Standards. 2. 33 Delph House D55 S20458 Delph House V220793 280605 Stage 4.doc Version 1.20 Page 19 Commission for Social Care Inspection 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
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