Inspection on 21/06/07 for Dolphin Manor

This inspection was carried out on 21st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dolphin Manor 11/10/05

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 Catherine Paling Key Unannounced Inspection 21st June 2007 09:50 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.V326078.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 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.V326078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 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. Information about the service is available in a Statement of Purpose and Service User Guide as well as a brochure. These documents are reviewed regularly to make sure that the information is up to date. The fees range from £94.45 to £458.86 per week. There are additional charges for chiropody, toiletries, hairdressing outings and holidays. This information was provided by the service on the pre-inspection questionnaire completed in January 2007. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been quality rated. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by the people who live at the home. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and one inspector was at the home from 09.50 until 17.30 on 21st June 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live at the home and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the care officer in charge and the staff. A pre-inspection questionnaire (PIQ) had been completed before the visit to provide additional information about the home. Survey forms were sent to the home prior to the inspection for the manager to distribute providing the opportunity for people at the home and visitors to give comment, if they wish. Surveys were sent out to visiting General Practitioners and a number of these were returned. Some of their comments are included in the body of the report. Information given in surveys may be shared with the provider but the source will not be identified. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There needs to be a review of the staffing levels. Although they are adequate the current level of staffing during the day does not allow for a full range of activities and planned outings have been cancelled. The night staffing levels need to be reviewed to make sure that the care and safety of the people at the home is not being compromised. Although night staff do have fire training they do not take part in fire drills and the manager should make sure that they do. Recommendations have been made and appear at the end of the report. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. (Standard 6 does not apply to this service) People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People have enough information to be able to make a decision about moving into the home. Information is gathered about people before they move in to make sure that their needs can be met. EVIDENCE: There is a range of information available to people who currently live at the home as well as those who are thinking about moving into the home. This includes the statement of purpose and a resident guide, which are updated on a regular basis to make sure that the information is accurate and up to date. Copies of previous inspection reports are also available to any interested parties. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 10 Detailed information about people is gathered before they come to live at the home. This includes the local authority assessment documents as well as information from other healthcare professionals who may be involved. The staff at the home are very knowledgeable about the people living at the home and their specific needs. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Health and personal care needs are met. Care plans provide staff with details of the support people need to make sure that care needs are not overlooked. People living at the home are protected by safe medication practices. The staff respect the privacy and dignity of the people living at the home. EVIDENCE: The care of three people living at the home was looked at in detail and several other people were spoken with during the course of the day. Care and interaction between the people living at the home and the staff was observed. A senior member of staff has worked to adapt the standard local authority Lifestyle plans. She has developed a format which staff clearly understand Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 12 and seems to work well with a good standard of recording seen. There is an introductory needs assessment that provides a useful overview of the individual care needs of the person concerned. There is a ‘pen picture’ for each person that includes a personal history and where possible families are also involved in the gathering of information. The care plans then provide detail of what support the individual needs to make sure that their care needs are met. They provide good information and accurately reflected the care needs of the people living at the home. There was evidence of regular reviews that involved the person and their family and these were clearly documented. The care plans were subject to monthly review. These reviews should be developed to provide evidence that there has been an evaluation of the effectiveness of the care plan over the previous month. Daily records were detailed and gave a clear picture of the health and well being of the person living at the home. There were photographs in the records but these were too small for easy identification. One person with mental health problems had left the home and this photograph would not have been adequate to help in identification. This incident had not been notified to the CSCI. A range of risk assessments was carried out and included a nutritional risk assessment. One person had been identified as not being at risk even though they needed full assistance to eat and drink. Records should reflect the good practice by identifying this person ‘at risk’ and the measures that have been put in place which are effectively managing the risk. People said that they felt that staff knew how to look after them. One person who was visually impaired said that staff knew how to care for her and she felt well looked after. Staff approached people in an appropriate manner and showed respect for peoples’ privacy and dignity. All the staff involved in medication administration have had training to do so. The medication administration record (MAR) sheets were up to date with no gaps in recording. Staff are using codes when medication is omitted but on some occasions there was no explanation for the code used. There were clear photographs of each person on their MAR sheets. For one person who chose to self-administer some of their medication a risk assessment was seen in their individual file care file. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Overall, people who live at the home are able to exercise choice in their daily routines and their social expectations are met. People living at the home are provided with a varied and nutritious diet. EVIDENCE: Family and friends are welcomed at the home throughout the day and on the day of the visit several visitors were at the home. Visitors spoken with were satisfied with the care and spoke highly of the staff. One said that he was always kept informed of any changes in his mother condition and always told the outcome of any doctors’ visits. One person who had been admitted for respite was very settled and content at the home. There are no dedicated activities staff and with recent care staff shortages there has been a reduction in the number of activities offered. The most Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 14 recent newsletter explained that planned summer outings have had to be cancelled because of this. Staff try to organise at least one bingo evening each week and open the bar. These evenings are very popular. There is a strong commitment to the promotion of independence. One carer spoke of how people are encouraged to maintain some skills in the kitchenette areas, for example some people occasionally do a small amount of washing up and another was seen folding serviettes. People are able to exercise choice about their daily lives although one person said that staff shortages had had an impact on this very recently. The care manager was aware of this situation and said that it had been resolved. On the day of the visit a member of the local clergy was carrying out their regular visit to the home to give communion to those people who wanted to take part. The chef has been working at the home for two years. He is very knowledgeable about the likes and dislikes of the people at the home and of the needs of those with special dietary needs. He oversees the serving of meals and clearly enjoys the contact with the people living at the home. The lunchtime meal was leisurely with people eating at their own pace with help and support given where it was needed. People enjoyed their meals. Talking to the people at the home and some of the staff before lunch it seemed that no one knew what was for lunch and menus were not displayed. It was suggested that menus should be available and staff should be aware of what is to be served. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. There is a clear complaints procedure available to people at the home. The people who live at the home feel confident that any concerns would be taken seriously. Staff have received training in adult protection and people living at the home can be assured that they are safe. EVIDENCE: There is a clear complaints procedure in place and copies of this and other information on how to complain is displayed in the home. People were not necessarily aware of the complaints procedure but felt confident that they could talk to staff about any concerns and that they would be taken seriously. All those spoken with felt safe and well cared for at the home. There have not been any complaints since the last inspection visit. All the staff have had training with regard to adult protection and have regular update. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Overall, people live in a safe and well maintained environment. EVIDENCE: There is an ongoing programme of redecoration and refurbishment at the home. Since the last inspection the entrance area has been redecorated and provides a comfortable sitting area. Refurbishment has been carried out in bathrooms to a high standard. There are two new fully assisted shower rooms and three new assisted baths have been provided. In addition a new call bell system was installed in June of last year. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 17 The laundry facilities were clean, tidy and well organised. There is a dedicated laundry person who was on holiday at the time of the visit. Sluice washing facilities are provided. West Yorkshire Fire Service (WYFS) carried out a fire safety inspection in April of this year. Issues were raised in connection with the in house fire risk assessment and fire plan, in that it was not detailed enough, and staff training. The local authority property services are working on their response to WYFS. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Overall the number and skill mix of staff is sufficient to meet the care needs of the people living at the home. Staff are well trained and competent to meet the needs of the people living at the home. EVIDENCE: Duty rotas indicated that overall there were sufficient staff available to meet the care needs of the residents on day duty. The care staff are also supported by a team of ancillary staff carrying out domestic, laundry and catering duties with a handyman also providing day-to-day support for the staff team. There is a core group of staff who have worked at the home for a number of years. The stability of the staff team means there is continuity and familiarity for the residents. There are two care staff rostered for the night shift to provide care for up to 35 people overnight. The layout of the building combined with the numbers of people living at the home suggests that this may not be enough staff to make sure that people are properly supervised overnight and their care needs met. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 19 Of the small sample of accident records looked at the majority occurred at night. The night staffing levels should be reviewed taking into account the dependency levels, the number of accidents and the layout of the building and the provision of additional care staff at night should be considered. There has been good progress in staff achievement of National Vocational Qualifications (NVQ) in care at the home. Currently 66 of the care staff have achieved NVQ level 2 in care. Further staff are about to start the training and a small number have NVQ in care at level 3. All the care officers are NVQ assessors. New staff undergo an induction programme and all staff have formal supervision sessions and appraisal where training needs are identified. There is also a variety of other training in such topics as dementia and care of the dying available to staff as well as statutory training. Recruitment is carried out centrally and records held at the home are photocopies. There was evidence that the required checks are carried out before staff commence work at the home. The photographs on staff files were too small for clear identification. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The home is well managed. The interests of the people who live there are seen as very important to the manager and her staff and are safeguarded at all times. EVIDENCE: The manager has completed the Registered Managers Award (RMA) and has achieved NVQ level 4 in care. On the day of the visit she was attending training about changes in legislation regarding mental capacity. The manager holds regular meetings for all the different designations of staff and notes are kept of the discussions. There was an active residents Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 21 committee allowing the people living at the home to put their views forward. However, it seems that recent staff shortages have affected the regularity of these meetings and notes available at the home indicated the most recent meeting was held in September 2006. A regular newsletter is produced for relatives, friends and carers to keep them in touch with events at the home. The most recent is dated May - July 2007. There is an established system of quality assurance at the home. This takes the form of a comprehensive annual audit. The audit involves seeking a range of views from interested parties including the people who live at the home, visitors, advocacy services and visiting professionals. The results of this consultation are collated and an action plan is produced to address any identified shortfalls and planned improvements to the service and facilities. The annual plan is divided into two monthly sections and progress is monitored. Records are kept of any accidents involving people living at the home. Reports looked at for April, May and June showed that the vast majority of accident occurring to people living at the home happened during the night. The manager needs to work with the provider to try to identify any trends or issues that could be addressed in an attempt to reduce the number of accidents. A review of the number of night staff should from part of this to make sure the safety and well being of the people at the home is not being compromised. The examination of records indicated that perhaps not all incidents and accidents were being notified to the CSCI as required under Regulation 37 of the Care Homes Regulations 2001. Guidance was left with the care officer in charge so that staff can be clear about the requirements. Detailed financial records were seen that included money paid in, paid out and the remaining balance. Receipts are kept of all transactions. There are weekly in house checks and the home is also subject to external audit. Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 23 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. 1 Refer to Standard OP7 Good Practice Recommendations The manager should work with the staff to develop detailed evaluation of care plans. This will mean that the people at the home and the staff will be clear about whether a care plan has been effective. The manager should make sure that the night staff have taken part in a fire drill as part of their fire training. The numbers of care staff on night duty should be reviewed taking in to account the dependency of the people living at the home and the layout of the home. This is to make sure that the safety and well being of staff and the people at the home is not compromised. The manager should make sure that staff are aware what incidents at the home need to be notified to the CSCI to ensure compliance with Regulation 37 of the Care Homes Regulations 2001. 2 3 OP19 OP27 4 OP33 Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dolphin Manor DS0000033250.V326078.R01.S.doc Version 5.2 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. 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!