Inspection on 31/01/06 for Dolphin Lane

This inspection was carried out on 31st January 2006.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dolphin Lane 09/02/07

Dolphin Lane 13/10/05

Dolphin Lane 24/11/04

Dolphin Lane 06/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Dolphin Lane 1 Dolphin Lane Thorpe Wakefield West Yorkshire WF3 3DN Lead Inspector Karen Westhead Unannounced Inspection 31st January 2006 09:00 Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 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 Dolphin Lane DS0000001444.V279117.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 Adults 18-65. 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. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dolphin Lane Address 1 Dolphin Lane Thorpe Wakefield West Yorkshire WF3 3DN 01924 872080 01924 872620 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) J C Care Ltd Care Home 13 Category(ies) of Learning disability (13), Physical disability (13) registration, with number of places Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 Brief Description of the Service: Dolphin Lane is owned by J C Care, which is a subsidiary of Craegmoor Health Care. The home is managed by Angela Galloway. Mrs Galloway has not yet submitted an application for registration with the Commission. The home is situated in its own grounds and parking is available to the front and rear of the property. The care home is on Dolphin Lane and is within easy walking distance of the main road. The area is well served by public transport. There are a number of local facilities and residents make good use of these. The care home is registered to provide accommodation and care services for up to thirteen residents, who have a learning disability. The home is spread over three floors, the basement being used for laundry facilities, maintenance office and a games/recreation room. There is a second laundry (domestic in style) on the ground floor. There is no passenger lift, however some ground floor bedrooms are available. There are five single bedrooms on the first floor, six on the ground floor and one double bedroom. The double room was not occupied on the day of the visit. The manager is to review the occupancy of this room dependent on the referrals received. Staff are provided throughout the day and night. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the Commission for Social Care Inspection (CSCI) is required to undertake a minimum of two inspections of all regulated care homes. This was the second inspection of this home for the 2005/2006 inspection year. One inspector undertook the inspection, which was unannounced. The visit started at 9.00am and finished at 1.45pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. The last inspection of this service was in on 13th October 2005. At that time two requirements were highlighted with no recommendations. These have now been addressed. During the course of the visit, the inspector spent a large proportion of time speaking with residents, staff members and the newly appointed manager. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. All staff on duty were spoken to and observed carrying out their work. Individual and group discussions were held with residents. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. After completion these are returned to the CSCI. In addition, information leaflets were given to residents with a brief description of the CSCI function and details of how to contact the lead inspector. Feedback about the findings from the inspection were given to the manager at the close of the visit. What the service does well: The level of care and support for residents is good. Residents spoken with confirmed their satisfaction with the way of life in the home and spoke positively and frankly about their experience to date. Residents have access to a range of groups and individuals who are able to provide advocacy and third party assistance as appropriate. Staff take a common sense approach to risk taking and enable residents to fulfil their wishes as appropriate. The level of involvement in the community, whether residents access this through independent means or not, fulfils their individual wishes. In view of the complex nature of some of the resident Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 6 needs, staff are able to manage well in accessing educational placements and recreational pastimes and incorporate the type of supervision required. The atmosphere in the home is relaxed and staff approach daily activities flexibly. The staff team were observed to deal with situations in a calm and competent manner. Residents said they were happy with the staff looking after them. Residents spoke frankly about their relationships with staff and felt they got enough guidance and support. The manager operates the home well, she encourages staff to take on responsibility and help with any decisions affecting the lives of residents. 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. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Prospective residents are fully assessed before coming to stay at the home and they are given an opportunity to visit Dolphin Lane prior to them making a decision about moving in. All residents have a contract with the home and know what services are to be provided. EVIDENCE: Throughout the inspection visit the inspector was talking and interacting with residents. Their level of satisfaction with the care provided ranged from those who were generally happy but had future plans to move on and those who were content at the home and wished to stay for the foreseeable future. No complaints were raised with the inspector. The inspector viewed a random selection of files. The file pertaining to the most recently admitted resident was purposefully selected. Those seen contained an up to date contract, plan of care, evaluation and review. Appropriate progress had been made with the records relating to the new resident. The complaints procedure has been modified using pictures and symbols. This method could be used in other key documents to assist people with limited communication skills. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 9 The admission procedure for planned admissions is good. The procedure allows for residents and their families, if appropriate, to visit the home as many times as needed before a decision is made about the placement. The visits vary in duration and the timescale is determined on an individual basis. However, the usual plan is for residents to share meals and leisure time at the home to familiarise them with the routines and give them the opportunity to meet other residents and staff. The staff see this as a two way process. They take the opportunity to assess the needs of the resident and ensure the home can cater for any specialist requirements as well as the general care needs of the person. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Residents personal files and supporting documentation is maintained appropriately and reflects the care and attention being provided. Staff take a reasonable and commonsense approach to risk taking. EVIDENCE: Care plans looked at during the course of the inspection were found to be completed appropriately. It was evident when talking to residents and subsequently to staff, that risk assessments were in place and that a common sense approach was used when determining the level of supervision and support residents required when going about their daily lives. This was seen during the visit. The staff on duty gave clear guidance to residents and gave residents the opportunity to voice their views. Situations in the home were dealt with in a calm and professional manner. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 16 Residents have appropriate support from staff, outside agencies and other professionals in order for them to lead a fulfilling lifestyle inside and outside the care home. Educational, social and recreational activities provide a good balance and allow the opportunity for personal development. Family links are maintained and residents are able to develop intimate and personal relationships with people of their choice where appropriate. Assistance and guidance is provided in these areas, often involving advocacy and other professionals. EVIDENCE: Written evidence on file and in the daily notes showed that residents were maintaining outside links and being given help, reassurance and assistance to engage in meaningful and fulfilling relationships with people of their choice. All residents have a key to their rooms. The inspector noted that residents respected each others belongings. The inspector was given permission to Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 12 inspect bedrooms by residents who were at home. In all cases the resident accompanied the inspector. Residents are involved in household tasks and this is distributed on a rota basis. Residents who are reluctant to engage are given support. Some residents were proud of their achievements and enjoyed showing the inspector around their home and bedroom. A number of residents can access community facilities unescorted. This includes services locally and out of area. Other residents are escorted. Staff are proactive in their efforts to ensure residents attend leisure activities, educational placements and therapeutic recreation. Overall there is good organisation around leisure. During the course of the visit residents were seen interacting with staff about their days activities. Appropriate support was being offered and the inspector gained the impression that this practice was the norm. Residents with specific and complex needs are provided with specialist support from other agencies. Residents, who were able to share their experiences, confirmed they were satisfied with the levels of activity provided/organised. Those residents with limited understanding and speech were supported appropriately and systems were in place to monitor their involvement in organised and ad hoc events. Residents were pleased with the delivery of a ‘people carrier’, which is to be used for their benefit. Some residents informed the inspector about their forthcoming holidays. A short trip to Rome, Paris and Skegness were mentioned. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 21 A policy relating to care of the dying is in place. Residents are given the opportunity to self administer medication in a way which promotes their independence. Medication records were being maintained appropriately. EVIDENCE: There is a policy in the home, which relates to care of the dying. Where possible the wishes of residents in this area have been documented. For residents with limited understanding, staff have made enquires with either family members or representatives to make sure records are accurate. At the last inspection the medication records were not being kept accurately. These were checked during this visit and improvements had been made. The manager said a cabinet to store controlled drugs had been ordered and delivery and fitting was expected in the near future. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a robust adult protection procedure and all staff have been trained to understand the subtle aspects of abusive behaviour and the action to be taken if suspected abuse is reported to them. EVIDENCE: All staff have been trained in the protection of vulnerable adults. Training varies from base line in house training to a one-day session provided by an external trainer. In the last six months there has been one adult protection issue in the home. This resulted in an investigation being initiated by the registered provider, Craegmoor. At the time of writing this report the outcome had not been decided. No complaints had been received since the last inspection. Staff on duty were able to describe the action to be taken in the event of concerns being raised or if they observed bad practice. They were fully aware of the whistle blowing and complaints procedure. Residents said they were confident if they complained about anything it would be dealt with without a fuss. The manager must ensure that bank staff have been trained appropriately. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 and 30 The premises are well maintained. Attention is given to detail and the homely atmosphere. The home was found to be clean and tidy. The laundry room floor covering needs replacing. All residents have an ensuite. There is a ramped access. However, none of the current resident group require any particular aids or adaptations to allow them to use the facilities comfortably. EVIDENCE: Dolphin Lane is a no-smoking building. Staff support residents in their efforts to keep the home clean and tidy. The range of tasks undertaken rely on the skills and abilities of the resident. However, staff are aware of their duty of care and make sure thorough cleaning is undertaken where necessary. Over the course of the visit, a number of residents were involved in showing the inspector around the building. Appropriate systems are in place to check the fire safety equipment. The floor covering in the laundry has split near the entrance. This must be replaced to make sure the health and safety of residents is not compromised. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 16 All bedrooms have an ensuite comprising of a toilet, handwash basin and shower. Residents also have access to a communal bathroom and a variety of toilets are situated on each floor. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 and 36. Staff have clear roles and responsibilities. The manager must make sure all staff are appropriately trained including bank staff. There are sufficient staff on duty to cater for the needs of the current resident group. EVIDENCE: The manager confirmed that the overall staffing levels were good. At the time of the visit there were vacancies for a full time support worker and a senior support worker. These posts had been advertised. Whilst speaking to staff it was clear that they felt well supported by the manager and senior team and that they were an effective team. Staff have attended a number of courses, some routine and others more client focused. However, the manager must not assume that the bank staff currently working in the home have been trained. Staff were seen carrying out their respective duties. They were found to be knowledgeable, competent and committed to their work. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 43. Dolphin Lane is operated well. Residents are aware of the management structure. The homes policies and procedures are written in a way, which is resident-focused and protects their best interests. EVIDENCE: The manager is competent and runs the home well. It is noted that her application to register with the Commission is overdue and must be submitted without further delay. This was discussed during the visit. The fire records were checked and found to be in order. Risk assessments are carried out and action taken to reduce risks. The actions taken appear to promote independence rather that impose undue restrictions on peoples’ lifestyles. The organisation has adequate insurance cover in place. Senior managers within the organisation have a business plan and managers in the home are expected to contribute to this. Managers present their budget forecasts and Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 19 discuss the needs of each home as part of the overall financial plan. At the time of the visit the manager did not raise any problems with the financial viability of the home. The home is visited on a monthly basis by an official from the main office. A report about the running of the home is completed and a copy forwarded to the Commission. Residents were sent a questionnaire by the home in September last year. Eleven residents completed them and their comments were analysed and any necessary actions taken to address matters raised. It was noted that the level of satisfaction was in fact high. Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 3 28 x 29 3 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 x 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 x LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 2 x 3 3 x x 3 Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 21 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. 2. Standard YA32 YA24 Regulation 18 16 and 23 Requirement The registered person must make sure that all staff have received the required training. The registered person must replace the floor covering in the laundry area. Until this is replaced remedial steps must be taken to prevent the area becoming a trip hazard. The registered person must make sure the Manager submits an application to register with the Commission for Social Care Inspection. Timescale for action 10/04/06 17/04/06 3. YA37 8 and 9 17/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Dolphin Lane DS0000001444.V279117.R01.S.doc Version 5.1 Page 23 - 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. 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