Inspection on 02/05/07 for Dorcas House

This inspection was carried out on 2nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Dorcas House 03/06/08

Dorcas House 06/11/07

Dorcas House 21/11/06

Dorcas House 23/05/06

Dorcas House 26/10/05

Dorcas House 19/05/05

Dorcas House 08/09/04

Dorcas House 25/05/04

Dorcas House 24/11/03

Dorcas House 15/07/03

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

CARE HOMES FOR OLDER PEOPLE Dorcas House 56 Fountain Road Edgbaston Birmingham West Midlands B17 8NJ Lead Inspector Kulwant Ghuman Key Unannounced Inspection 2nd May 2007 09:00 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 Dorcas House DS0000016840.V335334.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. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dorcas House Address 56 Fountain Road Edgbaston Birmingham West Midlands B17 8NJ 0121 429 4643 F/P 0121 429 4643 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Kate Danquah Mr Pan Danquah Mrs Kate Danquah Care Home 11 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (11) of places Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That four named persons under 65 years of age at the time of admission can continue to be accommodated and cared for in this Home. The home must demonstrate through comprehensive care planning and regular reviews carried out by Social Services that it is able to meet all the needs of each individual. The home must not in future admit any other persons under the age of 65 years. 21st November 2006 3. Date of last inspection Brief Description of the Service: Dorcas House is an adapted domestic property that accommodates 11 people who are users of mental health services. The home has three floors with accommodation for residents on two of these. The third floor is for staff use. One lounge has a door out onto the rear garden and contains a large screen television and comfortable seating. Communal space is also provided in the form of a lounge/diner. Residents were seen to sit here to eat, to play games at a dining table and to watch television. The home has both single and shared bedrooms situated on the ground and first floor. A stair lift is available for service users to access the upper floor. There are shower, toilet and bathing facilities on both floors but none of these provide an assisted bathing facility. Laundry facilities are provided at the neighbouring house owned by the Danquah family. At the front of the home is a steep drive on which three cars can be parked. The side gate to the property permits further parking for up to three vehicles. At the rear of the home is a garden. The current fees at the home are £330 to £380 a week. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced, key inspection over one day during May 2007. During the inspection the inspectors toured the building, sampled the care files of two of the people who lived at the home in depth and two were briefly examined. The inspectors sampled various health and safety records, the files of two new members of staff, the training record of another member of staff and spoke to 5 of the 11 people who lived in the home. What the service does well: What has improved since the last inspection? Since the last inspection improvements had been made to the care plans for the people living in the home. The management of medicines in the home had improved and one person living in the home was able to manage some of their medicines independently. There had been a few improvements to the physical environment including the fitting of some doors to the shower on the ground floor preventing the whole floor from becoming wet and posing a risk to the people living in the home. The garden had been made safer and was tidy. Some bedroom furniture had been replaced and one bedroom seen had been repainted. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 6 Staff recruitment procedures had improved to ensure that only suitable people were employed at the home. Fire training had taken place for the staff. The insurance cover for the home had been renewed. 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. The summary of this inspection report can be made available in other formats on request. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 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 Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People thinking about moving into the home were provided with some information about the home and were enabled to visit the home prior to moving in. The registered manager was not ensuring that a decision to admit people to the home was based on all the available information about the individuals. EVIDENCE: Evidence was available that people who lived in the home had received a service user guide and a copy of the complaints leaflet as a copy was seen in one of the bedrooms. This ensured that people who lived in the home were aware of the services provided by the home. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 9 The range of fees being charged at the home were not indicated in the service user guide so people considering whether they wanted to move into the home were not able to compare prices with other homes they may have considered. Contracts were available on the files sampled but because they had not been signed by the either of the parties it could not be determined whether the conditions of residence had been discussed with the individuals living in the home. The files of two people recently admitted to the home were sampled during the inspection. One of the files showed that the individual had been in the home for four days before the assessment was undertaken. Some of the assessment sheets had not been completed for example the manual handling risk assessment and the nutritional assessment. During discussions with people who lived at the home one said that he had visited the home a couple of times before moving in and an assessment was carried out whilst he was there. The second file showed that several areas of assessment had been undertaken and some of them had been the day before the person was admitted to the home. The assessments fed into an initial care plan that contained many generic statements where the name of the person being admitted was slotted in even when they were not appropriate. For example, one of the care plans for eating and drinking assessed that there were no difficulties identified in eating independently and the person had a good appetite however, the potential problems identified were that there could be weight loss and dehydration due to appetite and reluctance to eat and drink. Where detail was required this was not provided for example, where the person required a diabetic diet the action to be taken stated ‘ensure he has an appropriate diet’. The registered manager had not ensured that all the available information had been collected about people who were considering moving into the home. Two people had moved into the home from another home. No information had been obtained from the previous home or the social workers prior to admission to the home. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans were of variable quality and some risk assessments were not in place. This could leave the people living at the home at a potential risk of not having their personal and health care needs met in a person centred way. The management of medicines in the home was generally good ensuring that the people living at the home received their medicines as prescribed. EVIDENCE: The files of two people who had recently moved into the home were sampled. There were care plans in place for both individuals. There were 18 care plans for each person covering areas such as smoking, family contact, breathing and circulation, personal hygiene, falls and mental health. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 11 The care plans were an improvement on previous ones and there was some good information available in them. For example, for one person the care plan identified that the individual did not have any teeth or dentures but mouth wash needed to be offered twice a day and the gums checked regularly. There were also some statements that were unclear and not person centred, for example, the care plan also stated that ‘edible meals to be offered’. It was not clear whether this referred to the quality of the cooking or to the presentation of the meal eg soft meals. In another care plan it identified that the individual had decided not to continue with some of their medication. As a consequence there could be some ‘adverse behaviours’ but there was no indication of what these may be. In general there was a lack of information about the individuals’ mental health status and identification of indicators of relapse. For another person living at the home there was inconsistency in the records identifying the number of units of insulin to be drawn up by the staff. The registered manager was very well aware of the amounts of insulin that were required but the records had not been updated and this could put the person at a potential risk of not receiving the correct amount of medication. One of the people living at the home had been identified as being at risk of developing pressure sores however there was no corresponding plan to manage this risk. The daily records for one of the people living in the home indicated that they could be aggressive and would wander into other peoples’ bedrooms. There was no plan in place to manage this behaviour placing the staff and people who live in the home at risk of being subjected to this behaviour. The home used a weekly monitored dosage system for the administration of medicines. There were very few boxed medicines in place. The records audited were all acceptable and there was only one minor discrepancy where it was likely that the staff had given one tablet of the painkiller instead of 2 as this was dependent on what the person requiring the medication wanted. There were no controlled medicines in use at the time of inspection. The controlled medicines register was in good order. Four staff had undertaken safe handling of medicines training. There was a self-medication policy in place. The care plan of one person living at the home indicated that they were to manage their own medicines. No risk assessment was in place for this to assess the person’s ability to manage their medicines, management of storage in the bedroom and compliance checks. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 12 Privacy curtains were in place and locks were available on the bedroom doors. One resident stated that she did not have a key to the bedroom and that items had been stolen from her. The inspectors accepted that these comments were regularly repeated about other professionals including specialist doctors and was a part of the mental health condition. Furniture and soft furnishings were not always age appropriate and appropriately ironed and matched suggesting that the people living in the home were not given the dignity and respect required for people in need of care. Dorcas House DS0000016840.V335334.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activity levels had improved in the home but further improvements were needed so that all the people living in the home had fulfilled lives. The people living in the home appeared to be satisfied with the meals they were receiving and their dietary needs were being met. EVIDENCE: There had been an improvement in the level of activities being provided at the home. The registered manager stated that activities had improved at the home and these included snooker, games, going out for walks and drawing. She said that the people living in the home appeared to be happier but some did not want to get involved. There were activity reports in place starting from 12.3.07. The inspectors saw the activity records for three of the people living at the home. Some individuals were able to go the local shops unescorted and some went out with Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 14 the staff. The registered manager needed to ensure that all the people living in the home who wished to go out were given the opportunity to do so. Friends and relatives could visit the home to see the people living at the home. Staff were encouraged to assist the people living at the home to choose the clothes they wore and to be assisted with personal care in the way in which they wanted. It was noted by the inspectors that one of the people who had moved into the home was unable to go out of the home because the front door was locked. The individual did not have a key to be able to get back into the home. The manager needed to discuss the issue of keys being available to those who had the capability to go out and return to the home alone. All the people living at the home that were seen or spoken with appeared to be happy and content. One person who had recently moved to the home stated that it was quiet and that the food at the home was not that different to where they had come from and that it was ‘bad but not too bad’. The individual said that he ‘liked a fry up in the morning’ and that ‘he had had bacon and toast that morning’. Also in the daily records it was recorded that on getting up for a cup of tea in the morning he had stated that ‘the other place did not give them a cup of tea in the morning’. Other people spoken to said they enjoyed their food. There was a four-week rolling menu in place and these were varied and choices were available. The menus included dishes such as chilli con carne. There were records of food eaten by the people who lived at the home. There were good supplies of fresh fruit and vegetables available ensuring that the people who lived at the home were provided with a varied and nutritious diet. The manager stated that new menus had been introduced with 2 or 3 choices daily. The meals were written up on the board in the dining room to enable the people living at the home to know what meals were available during the day. Some staff had undertaken nutritional training. At the time of inspectors arrival one staff member was seen to be assisting one person to eat breakfast. The member of staff was appropriately seated to assist the person. Dorcas House DS0000016840.V335334.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of protection needed to be improved to ensure that the people living in the home were safe from abuse. EVIDENCE: No complaints had been received about the service at the home and none had been lodged with the CSCI since the last key inspection. The people living at the home had received a copy of the home’s complaint procedure. The inspectors were told that a copy of the multi-agency guidelines on adult protection were available in the home. The home had policies on adult protection and whistle blowing. Training in adult protection had not been arranged although this had been raised at the last inspection. There remained some ongoing issues regarding the management of some of the financial records being held by the home for the people living there. Dorcas House DS0000016840.V335334.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): 19,20,22,23,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical environment was suitable for those who had good mobility and provided a basic standard of comfort for the people living in the home. EVIDENCE: The home continued to provide a basic standard of comfort and was suitable for people with a good degree of mobility. Some improvements had been made to the physical environment including, the replacement of some bedroom furniture and the re-decorating of some bedrooms. This issue had been raised at the last inspection and the environment still needed to be updated and refurbished so that the people Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 17 living in the home were provided with a comfortable and homely place to live. For example, many of the carpets in the home were old and needed to be replaced as part of a refurbishment programme. The windows were doubleglazed but in several of them the sealing had been broken so that the glass was misty and restricted the vision for people looking out of the windows. Furnishings and fabrics in the home did not show that the environment was being updated with the people who lived in the home in mind or that they had been consulted on the changes. For example, at the last inspection it was noted that the privacy curtains, were very creased and several window curtains had hooks missing. At this inspection the privacy curtain had been replaced with curtains that had cartoon-type pictures of pears, bananas and rabbits on them. The window curtains in this room were of different lengths, creased and the linings were longer than the curtain material itself. Communal space was satisfactory with a lounge with some easy chairs and a lounge/dining room where the people living in the home were able to watch television. The garden area had been made safer for people who wanted to sit out side and on the day of the inspection the garage door of the adjoining house had been closed. The grassed area was on a higher level to the paved are and accessible to people with good mobility but in the long term the registered person needed to look as making the whole of the garden accessible to the people who lived in the home. During the day of the inspection one of the people living in the home spent the majority of the day sitting in the garden. There was a walk-in shower on the ground floor that all the people who lived in the home could use and a bath on the first floor that was suitable for people with full mobility. Other adaptations in the home included a stair lift that people living in the home could use to access the first floor and an emergency call system was available. Zimmer frames were available for those needing them to assist their mobility. It was noted during the inspection that there was no light bulb in the toilet on the first floor or in the area just outside the toilet and bathroom. The light bulb in the passage way on the first floor was also very small and did not provide a good level of light for people who may have deteriorating sight or who may not be fully awake during the night and could put them at risk of falling. There were no odours in the home and the home was generally clean. Dorcas House DS0000016840.V335334.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were variable during the day and would not always support the people who live in the home to live individualised lifestyles. Recruitment practices were good and ensured that only suitable individuals were employed in the home. EVIDENCE: Staff at the home undertook a multi-task role including cleaning and cooking. The morning shift was staggered with two staff on duty between 8am and 10am before the third member of staff came on duty. During the afternoon staffing levels again fell from three to two between 2pm and 3pm. Between 8pm and 9pm the staffing levels fell to one member of staff. During the day there needed to be a minimum of two staff on duty and this was maintained at most times of the day. This staffing structure would mean that anyone living at the home who wanted to go out would be restricted to between 10am and 2pm when there were three staff in the home if they needed someone to go out with them. At other times of the day a member of staff escorting someone on a trip out of the home would leave only one lone member of staff on duty. This would leave the individual member of staff in Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 19 difficulties if there was an emergency in the home where they needed assistance. The proprietor was identified as being on duty from 8am to 6pm, and then as a sleeping in member of staff however, on the day of the inspector he was absent from the home for long periods of time. This was the same as at the last inspection. Two staff files were sampled during the inspection. The recruitment procedures were found to be satisfactory with the appropriate checks in place. The induction training undertaken by one new member of staff was not in line with the Skills for Care guidelines so it was not clear if the individual had the appropriate knowledge and skills before being left to care for the people who lived in the home. Some staff had undertaken first aid, food hygiene and fire fighting equipment training within the past twelve months with certificates available. The inspectors were told that other training including administration of medicines, health and safety and infection control had been undertaken but the certificates had not been received. Moving and handling and adult protection training had not yet been arranged. It was difficult to determine the levels of NVQ level 2, or equivalent, training undertaken by staff as there was no staff training matrix that showed which staff had undertaken what training. It could not therefore be determined whether the people living in the home were being cared for by appropriately trained staff. Dorcas House DS0000016840.V335334.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered manager had been in post for several years and was of good character however, the people living in the home were not always safeguarded. EVIDENCE: The manager was qualified and had several years experience of managing the home. The manager had introduced some new care plans that included some good information however, there were some areas of the care planning documents Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 21 that were not being completed in a way that meant ensured staff knew the needs of the people living in the home and how they were to help them. The manager needed to ensure that the views of the people living in the home were taken into account in all areas of the home including decor, furnishings, food and activities, risks they wished to take in life and how they wanted their care needs to be met. The inspectors were shown some sample questionnaires for staff, people living in the home and visiting professionals however none had been completed. There had been some ongoing issues at the home regarding the management of the monies for some of the people living at the home, in particular the record keeping. Some improvements had been made at the home over the past few weeks however further requirements were needed. There were some examples of receipts not being available for expenditures that had taken place on behalf of the people living at the home. One persons personal allowance could not be audited because one of the statements from the building society were not available. The manager was not always carrying out her duties to safeguard the people living at the home as shown by one persons records that showed that they were paying £23.00 for having their toe nails cut. One person in receipt of benefits did not always get their money put into their accounts in a timely manner. During the inspection one cheque for £66.84 was found that had not been banked, one was not able to be located and the inspectors were informed that another uncashed cheque had been returned to the Department of Works and Pensions as it had not been cashed within the timescales and as a result the individual had lost out on the money. The manager must ensure that the individual is reimbursed the equivalent of two months benefits. Other examples where the people living in the home had not been safeguarded were the fact that the patio doors from the lounge into the garden could not be opened. The manager was aware of this but the matter had not been rectified. The doors were identified as a fire exit point and needed to be kept in order to ensure that the people living in the home and the staff working at the home could use it to exit in an emergency situation. One of the people living in the home was identified by the inspectors of increasing the risk of fire in the home as a black plastic bag had been put on the back of a television. The manager, and staff, had not identified this as a potential risk and no discussions had taken place with the individual about removing the bag, ensuring that the bedroom door remained closed, ways in which the television could be kept cool or ways in which staff could monitor the situation or how early methods of detection of raised temperatures could be used. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 22 The equipment in the home had been serviced and all fire tests had been carried out appropriately. The inspectors were informed that the minibus was not currently in use because the MOT needed to be updated. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 23 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 2 2 2 X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 2 X 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 X 2 1 Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1)(b) Requirement Assessments carried out by the placing authority must be obtained before the person moves into the home. This will ensure that the home is aware of all the needs of the person moving into the home and they can be planned for. 2. OP7 15(1) The care plans of the people living in the home must clearly show all the needs of each person and how the staff are to meet the identified needs. Care plans must include strategies for dealing with difficult and challenging behaviour. This will ensure that the needs of the people living in the home are met in a consistent way by the staff. (Previous timescale of 01/08/05, 01/01/06, 01/08/06 and 01/02/07 not met.) Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 25 Timescale for action 01/07/07 01/07/07 3. OP7 15(2)(b) Care plans must be regularly updated. This will ensure that the changing needs of people who live in the home are met. 01/07/07 4. OP7 13(4)(c) Risk assessments for the people living at the home must be holistic and identify how the risks are to be managed. This will ensure people living at the home will be protected from risk. (Previous timescale of 01/08/05, 01/12/05, 14/08/06 and 01/02/07 not met.). 01/07/07 5. OP9 13(2) Staff must record the number of tablets given where there is a choice. Risk assessments and compliance checks must be carried out where people living in the home look after their own medicines. This will ensure that the people living in the home get their medicines as prescribed and according to their wishes. 01/07/07 6. OP10 12(4) Furnishings and fittings must be suited to the age, culture and gender of the people living in the home. This will ensure that the people living in the home will feel that they are respected as individuals. All staff must be able to identify and act upon incidents of actual or suspected abuse appropriately. DS0000016840.V335334.R01.S.doc 01/07/07 7. OP18 13(6) 01/08/07 Dorcas House Version 5.2 Page 26 This will ensure that people living in the home are not at from harm and abuse. (Previous timescales of 01/08/06 and 01/03/07 not met.) At least one member of staff on each shift must have first aid training. All staff must receive training in manual handling. This will ensure that the people living in the home are safe. A system should be implemented to take the views of those living in the home into account. This will ensure the that people living in the home will receive person centred care. (Previous timescales of 31/12/04. 01/09/05, 01/03/06, 01/10/06 and 01/04/07 not met.) A system must be implemented to ensure that the financial interests of the people living in the home are safeguarded. This will ensure that the people living in the home are safeguarded from financial losses. (Previous timescale of 01/08/06 and 01/01/07 not met.) 11. OP38 23(4)(b) People living, working or visiting the home must be able to exit the home via the identified fire exit doors. This will ensure that everyone can safely exit the home in the event of an emergency. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 27 8. OP30 13(4) 01/09/07 9. OP33 24 01/08/07 10. OP35 17(2) Sch 4(9) 13(6) 01/07/07 01/06/07 12. OP38 (13)(4)(c) People living in the home must be made aware of any potential risks and steps taken to minimise them. This will ensure that people living in the home will know the risks and take the appropriate steps to keep safe as far as possible. 01/06/07 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 OP1 Good Practice Recommendations There must be information available for people who may move into the home that includes the range of fees charged by the home. This will ensure that people moving into the home have information that will enable them to make an informed choice about whether to move into the home. Contracts and the terms of conditions of residence at the home must be discussed with the people who live in the home at the time they move into the home. This will ensure that people moving into the home are aware of the terms and conditions of moving into the home. The personal, health and social care needs of people moving into the home must be fully assessed before they move into the home. This will ensure that people moving into the home will be sure that their needs can be met by the home. Previous care plans should be archived when an up to date one has been written. This will ensure that staff know which care plan to follow and the needs of the people living in the home are met appropriately. Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 28 2 OP2 3 OP3 4 OP7 5 OP19 The furnishings and decor throughout the home must be updated. This will ensure that people who live in the home are provided with an environment that is homely, comfortable and inviting. The people living in the home should have windows that they can see out of clearly. This will enable them to be able to see the surrounding area with ease and be a part of the community. The garden area should provide an accessible and safe space to all the people living in the home regardless of physical, sensory or cognitive impairments. This will mean that all the people living in the home will have access to safe and pleasant outdoor space in which to sit and walk. All communal areas should have lighting that is sufficiently bright. This will ensure that people who live in the home can move around the home and use the facilities safely irrespective of sensory and cognitive impairments. There must be sufficient numbers of staff on duty to enable the people living in the home to carry out activities they wish to undertake. This will ensure that the people living in the home will be have a fulfilled and satisfied social life. At least 50 of the care staff are qualified to NVQ level 2 or equivalent. This will ensure that the people living in the home are cared for by staff with the appropriate knowledge and skills. New staff should undertake induction training in line with Skills for Care. This will ensure that the people living in the home are assured that only people who have the appropriate skills and knowledge are caring for them. 6 OP19 7 OP20 8 OP20 9 OP27 10 OP28 11 OP30 Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Dorcas House DS0000016840.V335334.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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