Inspection on 11/10/05 for Dolphin Manor

This inspection was carried out on 11th October 2005.

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

Other inspections for this house

Dolphin Manor 21/06/07

Dolphin Manor 07/12/04

Dolphin Manor 24/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dolphin Manor Stone Brig Lane Rothwell Leeds LS26 0UD Lead Inspector Kathleen Firth Unannounced Inspection 11/10/0 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 Dolphin Manor DS0000033250.V252705.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. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dolphin Manor Address Stone Brig Lane Rothwell Leeds LS26 0UD 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) 0113 2824942 0113 2824942 Leeds City Council Department of Social Services Mrs Sonya Williamson Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2005 Brief Description of the Service: Dolphin Manor is located in the Rothwell area of Leeds just a short walk from the shops and facilities in the town. There are public transport links with Leeds and Wakefield and parking spaces are available outside the home. The home is purpose built and all accommodation is provided on the ground floor. There is a safe garden to the rear of the building with a greenhouse, raised garden beds, fishpond and pleasant seating areas. The home is registered to provide care for up to thirty-five residents who have no specialist need. Nursing care is not provided but the home is well supported by the local healthcare teams. There is generous communal space in the home providing comfortable sitting and dining areas for the residents. There are small kitchenettes with tea and coffee making facilities as well as a specially set up visitors’ room. There is a bar in the home and staff provide a “shop” for the residents. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 3.75 hours by one inspector on Tuesday 11th October 2005. The inspector looked around the building and gardens, spoke with residents, visitors, management and staff, examined records including staff rosters, residents financial records and staff files. The manager, staff, residents and visitors were very helpful throughout the inspection and were happy to join in the process. Eight residents, manager, care officer; three staff and two visitors were spoken to. What the service does well: What has improved since the last inspection? Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 6 Staff make sure that all residents are aware of any activities and trips out by putting the information on the notice board and giving out flyers to everyone. The problem causing the smell of urine at the last inspection has been investigated and measures are being taken to resolve it. A new carpet will then be fitted. A price for extending the call system to all areas of the home has been obtained. Some extra people have been recruited to make sure that sufficient staff are always on duty. Staff working in the kitchen have changed their working hours so that care staff are not taken away from their duties at meal times. 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 Manor DS0000033250.V252705.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 Dolphin Manor DS0000033250.V252705.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): 2, 4, 6 All residents have an individual contract setting out the terms and conditions of the home. The home does not admit any resident unless they are sure that they can meet that person’s needs. EVIDENCE: Pre and admission assessments are present in the individual resident’s files along with information from the social worker involved in the person’s care. They contained sufficient information about the person’s needs for the manager and staff to make a decision about admitting them to the home. Where required risk assessments are carried out and recorded in the residents’ files. Prospective residents and their families are able to talk to the manager, ask any questions they may have about the home and visit if they so choose. All residents are given a licence agreement from the local authority. This contains all the terms and conditions of the home and what they can expect from the services offered. What is expected from them as a resident is also spelled out in this agreement. All financial arrangements are detailed in the Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 9 contract. The individual resident signs the agreement if possible otherwise someone does this on his or her behalf. These agreements are reviewed every six months. Intermediate care is not provided at the home although they do at times have residents admitted for respite or short-term care. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 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 the following standard(s): 8, 9, 10 Residents’ Healthcare needs are fully met at the home. Residents are treated with dignity and respect and their privacy is maintained at all times. EVIDENCE: The home is well supported by the local healthcare services and they enjoy a good working relationship with them. As many of the residents are local they are able to stay registered with their own GP. Often they have known the local district nurses and have built up relationships with them. Arrangements are in place for all residents to receive chiropody treatment. The home makes sure that all of the residents have an annual eye test. Obtaining dental treatment can be problematic and at present residents are taken to the community dental clinic in the village. This also provides an emergency service if required. If a resident becomes ill and it is agreed by everyone including the local healthcare team that it would be better to care for him or her at the home then this is done. Staff are very sensitive at all times but particularly at these times. Families are able to stay at the home as long as they need to and there Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 11 is a room where they can sit and have a drink and time to themselves. Religious ministers are able to visit at any time. Information about wishes following their death is obtained from residents on their admission and are carried out. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 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 the following standard(s): 13, 14 Residents are supported to maintain contact with family and friends and visitors are welcomed at the home. A good, nutritious and varied diet taking into account individual choices and needs is provided. EVIDENCE: Residents spoken to said that their relatives and friends are welcomed at the home at any time and are offered drinks. One relative spoken to said he feels “part” of the home and can always speak to someone if him or his wife has any concerns. If it has been agreed in their care plans residents are able to go out and about with their family and friends. One lady goes to church with her family every week. The local Church of England minister holds a monthly service that many of the residents enjoy. A member of the church is hoping to start weekly visits in the near future. The Salvation Army come to the home a few times per year and other church ministers visit individual people. The manager holds regular meetings with the residents and families can join in with these if they wish. A new chef has recently been appointed and is due to start work next week. The manager plans to hold a meeting with him and the residents to discuss and review the menus. Residents spoken said that they Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 13 are happy with the meals at the home. They said that they are very good and that there is always a choice offered. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents are protected from abuse and their rights are protected at all times. EVIDENCE: The home has appropriate polices and procedures in place to deal with complaints and adult protection. Staff have received Adult Protection training and know how to recognise the signs and symptoms of abuse. A copy of the complaints procedure with the appropriate telephone numbers and addresses on is given to all residents. A copy of this is also available on the notice board at the home. No complaints have been made about the home since the last inspection. Relatives spoken to said that they would feel able to speak with the manager and or staff if they had any concerns about anything. The manager said that she felt happy that residents are able to discuss any problems or worries with her or the staff. Residents spoken to confirmed that they are able to approach the manager and staff if they need to discuss anything. All the residents are registered to vote and the electoral register had recently been updated. Some prefer to use the postal vote system and others prefer to go to the polling booth. If required residents are given assistance to complete their postal vote. Detailed financial records were seen that included money paid in, paid out and the balances. Receipts were available for any monies spent. Two people check the financial records and confirm the balance each week. The Local Authority also carries out spot audits. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 15 Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 16 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, 20, 21, 22, 23, 25, 26 The home offers a safe, well-maintained environment for the residents and provides appropriate bathing and toilet facilities. EVIDENCE: The home is decorated and furnished to a high standard and there is evidence of a regular maintenance programme in place. Residents are able to access all areas of the home plus the garden and some of them were enjoying the late autumn sunshine at the time of the inspection. The home is looking into having pendant alarms for people to use to summon staff when they are sitting in the garden. The main door is locked with a keypad and residents able to go out can use this. There are sufficient toilets for the residents and assisted bathing facilities are available. One toilet has been modified for wheelchair users but one lady is now unable to use it. Occupational Therapists have assessed her in a different toilet and work will be done in this to make sure that she is able to retain as much independence as possible. Walking frames and hoists are available when Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 17 people have been assessed as needing them. The residents’ rooms are of a size suitable for their needs and are decorated in colours of their choice. Residents are encouraged to bring their own possessions and personalise their rooms. There was evidence of this throughout the home. The home was clean and tidy throughout with no unpleasant smells. No hazards were seen that could cause problems for residents, staff or visitors. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Residents are supported and protected by the recruitment procedures in place. Staffing numbers and skill mix ensure that the residents’ needs can be met at all times. EVIDENCE: More staff have been recruited since the last inspection although some of the residents said that they felt the staff worked very hard and did not always have enough time to do everything. Staff spoken to said they felt they had sufficient staff to meet the needs of the residents. Extra kitchen support staff have been recruited and the hours they work reorganised to make sure that care staff do not have to leave their duties to help at meal times. The staff team is very committed and morale is very high at the home. All staff said that they receive excellent support from their manager. Leeds City Council are moving towards a central recruitment procedure and home managers will be involved in rotation. Recruitment is carried out to comply with equal opportunities. Two written references, CRB, POVA, Visa and work permit checks are all required before staff can start working at the home. Training takes a high priority and all staff said they are able to access relevant courses. More than 50 of staff both day and night have achieved an NVQ. The manager has recently arranged training within the home and feels that staff have responded very positive to this. An Occupational Therapist has just completed a hoist refresher course with staff and a movement and handling Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 19 one is planned. Staff have also just completed a Control of Infection and Food Hygiene courses. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 20 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, 32, 34, 36, 37, 38 The home is well managed, the interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager holds the registered manager’s award and is working towards NVQ level 4 in care. She has worked in residential care settings for many years. Staff, residents and visitors said that they receive excellent support from the manager and can speak to her at any time. The manager holds regular staff meetings where there is an agenda and minutes are taken. She also holds regular meetings with the residents and their relatives and is always ready to listen to ideas put forward. Regular supervision sessions are in place for staff and records are kept of these. Health and safety is promoted for staff and residents through training and example. The manager and Care officer have attended fire awareness training Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 21 and are cascading this knowledge to the staff. Fire bells are tested every week and regular fire drills held. The manager is still the only certified first aider although staff have been trained in this subject. All record keeping was up to date at the home and policies and procedures in place to make sure that the residents’ rights are safeguarded. Their interests are always put first by the manager and her staff and the residents said that they could not live in a nicer place. Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 22 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 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 X 3 3 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 3 3 X 3 X 3 3 3 Dolphin Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP 19 Regulation Requirement Timescale for action 31/01/05 12, 14, 23 The emergency call system must be installed and easily accessed in all areas used by service users. (Previous timescale of 30.09.05. not met) 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 Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 24 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 Manor DS0000033250.V252705.R01.S.doc Version 5.0 Page 25 - 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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