Inspection on 23/05/06 for Dorcas House

This inspection was carried out on 23rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 02/05/07

Dorcas House 21/11/06

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 Unannounced Inspection 23rd May 2006 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.V289401.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V289401.R01.S.doc Version 5.1 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.V289401.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. 26th October 2005 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 area that requires some attention so that residents can enjoy it in fair weather. The current fees at the home are £381.94 a week. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out be two inspectors on 23rd May 2006 however one inspector returned on 30th May 2006 to sample records that were not accessible due to the proprietors not being available. During the inspection eight of the residents were spoken to, care files were sampled and some health and safety documents were inspected. A tour of the home was also carried out. Eight residents completed the questionnaire sent out the home. They indicated that they were happy at the home, liked the staff and liked the food. Two completed surveys were returned by relatives and one visiting professional to the home, which were generally positive. What the service does well: What has improved since the last inspection? What they could do better: The home needed to improve the information available to residents in the service user guide and contracts of residence to enable them to make informed choices about the home. The assessment, care planning and risk assessment process needed to be improved so that only suitable people were admitted to the home and once in the home that their needs could be safely met in the home. These processes needed to cover all aspects of care and provide plans for meeting each aspect identified. Care plans and risk assessments needed to be regularly reviewed Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 6 and updated and involve the residents or their representatives in formulating them. There needed to be individualised plans for meeting the social needs of the residents and their involvement in the day-to-day operation of the home could be improved. There needed to be increased interactions between the staff and residents. The quality of the food provided and the crockery being used was poor leading to a reduced quality of the eating experience. Residents needed to be encouraged to be involved in the development of menus for the home. The majority of decor, furniture and floor coverings in the home needed to be improved and a refurbishment programme determined for the home. The garden area needed to be made safe for the residents to use and the garage next door made inaccessible to the residents to prevent any accidents occurring. Infection control within the home needed to be improved with the removal of tablets of soap and nail brushes from communal areas, the purchase of a large, lidded bin for the storage of clinical waste and the replacement of wall tiles in the laundry. A higher priority needed to be given to the training of staff to ensure that they had undertaken all mandatory training and 50 of the staff were trained to NVQ level 2. The recruitment records for some staff needed to be improved and there needed to be sufficient numbers of staff on duty to meet the needs of the resident group. Management of the home needed to develop the systems for collecting information regarding the quality of the service provided in the home. The records for the management of residents’ monies needed to be improved as a matter of urgency. All hazardous chemicals needed to be kept locked away at all times, lights kept in working order, carpets made safe and the water system tested for the prevention of Legionella. 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. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 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.V289401.R01.S.doc Version 5.1 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): 1, 2, 3, 4, 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The information available to residents needed to be amended further to ensure that they have all the necessary information to make informed choices. The contracts need to be updated and residents or their relatives made aware of what the terms and conditions of residence are. The assessment process must ensure that only residents whose needs can be met by the home are admitted so that they are not moved around unnecessarily. EVIDENCE: There was information available in the home that included the service user guide and statement of purpose. There was no indication of the range of fees for the residents and the concerns and the complaints section needed to be amended so that it gave details of whom any complainant could contact to make a complaint, other than the staff on duty, how they could be contacted and the details of the Commission for Social Care Inspection (CSCI). Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 9 There were contracts on the files sampled however some of the conditions were not being fulfilled, for example, a monthly visit from the GP to see the residents; other conditions indicated an institutionalised approach rather than an individualised person centred approach, for example, all medicines, cigarettes and alcohol must be handed in on admission rather than on the basis of a risk assessment. The contracts had not been signed by the residents, did not identify the room to be occupied and were not dated. Some of the surveys completed by the residents and their representatives stated that they did not have a contract; the majority stated that they were able to visit the home before admission to the home. Examination of care documents indicated that one resident had been admitted to the home during January 2006 but there was no evidence of any details of needs having been assessed by the home or the assessments carried out by the placing authority. The individual was not suited to the home and moved to nursing care within a fortnight. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 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): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans and risk assessments needed to be updated and strategies put in place to cover all risks identified to ensure that residents’ needs were being met. The documentation for the identification and follow up on health care needs needed to be improved so that health care could be more easily tracked and residents assured that their needs were being met. EVIDENCE: All the residents had care plans in place that covered areas such as their medical needs, personal care needs, mobility and eating skills. The care plans were not holistic and in some cases did not clearly identify what mental health conditions were affecting the residents and how their mental health needs were to be met. There was no clear documentation of who was responsible for checking blood sugar levels, when they were checked and what actions needed to be taken when the levels were outside the identified norms for the individual residents. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 11 Some of the residents’ needs had changed, for example, smoking, but this had not been updated in the care plans that still identified the individual as smoking outside the home. Another resident continued to isolate herself or herself in the bedroom but there were no updated details on how the staff were to encourage the resident to leave the bedroom, as the identified plans had not achieved the desired outcome. The care plans did not identify specific needs regarding cultural and religion for the residents and how these were to be met. There were risk assessments in place but there were no strategies in place to indicate how these risks were to be managed, for example, when residents were at risk of developing pressure ulcers and how staff would assist residents off the floor following a fall. There were some details of visiting health care professionals including the dentist, CPN’s and GP but these did not clearly identify the reason for the visit or the outcome. There were on-going difficulties with the district nurses visiting the home to undertake blood sugar monitoring and as some residents were unable or unwilling to go out this aspect of their health monitoring was not being fulfilled. The home used a monitored dosage system that was made up by the pharmacist. Most of the medicines were in the cassettes and a new supply had been received two days earlier. Audits of some of the medicines did not tally as amounts brought forward from the previous supply had not been acknowledged on the Medicines Administration Record (MAR). Some medicines that needed to be transcribed onto the MAR chart had not been recorded and therefore auditing was not possible. There were no controlled medicines in the home. Bedroom doors had appropriate locks fitted however, one resident who had been given a key to the door had been given the wrong key and the resident was therefore unable to lock the bedroom when they left it. There were some privacy screens in place in the bedrooms. The door to the bathroom on the first floor did not close fully and therefore could not be locked. Privacy and dignity for the residents could not be guaranteed. Poor practice was observed in the home when chiropodists entered the home and set up in the dining area. The expectation needed to be that residents were either taken into their bedrooms to have their chiropody needs met or the quiet lounge used if residents were not using it. One resident was seen in the bedroom by the chiropodist and this practice should be promoted for all residents. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 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): 12, 13, 14, 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The majority of residents spent most of their time sitting in the lounges. There was little interaction between the staff and residents leading to a lack of stimulation. The meals provided were repetitive, the food quality was poor, their appeared to be no choices and the crockery was of poor quality resulting in a lack of choice for the residents. EVIDENCE: One of the residents attended a day centre two days a week and some residents played dominoes and cards in the dining room. There were no other activities in the home and the residents were seen to sit in the lounge/ dining room, the quiet lounge or return to their bedrooms. One relative stated that the residents had been out for a picnic to Wales but due to the distance they had little time to spend out of the minibus before returning to the home. The manager needed to ensure that activities were suitable for the resident group. Residents were not involved in the running of the home, for example, by setting tables, cleaning bedrooms or undertaking everyday tasks such as Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 13 laundry. Staff needed to encourage residents to be involved in the day-to-day running of the home where possible. There were some residents meetings but they appeared to be repetitive. There were no restrictions on the residents’ movements in the home. No meaningful interactions were observed between the staff and residents except when medication and meals were given. The staff were seen to be very task orientated. There was nothing to indicate that contact with residents’ families was discouraged but there was no evidence to suggest that any contact with the local community was encouraged. At the time of the inspection the manager was on leave and the proprietor was at work. The staff were finding it difficult to maintain the levels of food in the home. The quality of food in the home was found to be poor with potatoes that were sprouting and spongy, there were four very old bananas in the kitchen. The quality of the meals being provided to the residents was poor and repetitive as indicated by the menus, there were no expressed choices and there were no separate identified foods for diabetics. The crockery being used in the home was mismatched and of poor quality with chipped edges. The majority of residents said they were happy with the meals provided and assistance was provided when required with eating. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 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, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The policies and procedures in respect of complaints and adult protection needed to be improved to ensure that the rights of residents were upheld and that they were safeguarded from harm. EVIDENCE: There was a complaints procedure in place but it needed to be amended so that it was easily understood by the residents and their relatives and included details of how a complaint could be made directly to the owners or the CSCI. One complaint had been lodged with the CSCI since the last inspection regarding the manager’s attitude, medication procedures and lack of contact with the complainant by the home. The issues regarding medication procedures and lack of contact were not upheld but on the balance of probability it was felt that the manager could have spoken to the complainant in a manner that could have caused her complaint. The home needed to ensure that there were documented details of what actions needed to be taken in the event of any residents becoming unwell, particularly where there was no next of kin. The adult protection policy was generally acceptable, however, a concise procedure was needed for staff to follow in the event of or suspicion of abuse. There were no multi-agency guidelines available. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 15 Improvements in the records of checks made on staff employed in the home and the records of the monies handled on behalf of residents would ensure that they were further safeguarded from abuse. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 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, 24, 25, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The physical environment was suitable for residents who had good mobility. There were some basic adaptations in the home including a walk-in shower but the bath was not assisted and not suitable for those with limited mobility. A basic standard of comfort was provided by the furniture and decor of in the home. EVIDENCE: The home was safe and provided a basic standard of comfort. It was accessible in all areas to those with a good degree of mobility. There needed to be a refurbishment programme for the home to ensure that furniture and carpets were replaced on an on-going basis. The communal areas provided a choice of seating in a quiet lounge or the lounge/dining room. The garden area needed to be made safe by relaying the slabs and reducing the steepness of the slope up to the grassed area. The Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 17 garage to the adjoining home (also owned by the proprietors) needed to be kept locked and inaccessible to the residents as it could pose risks to any residents in the garden area on their own. There was a shower room on the ground floor that had a tray that had to be stepped up into. The water from the shower would wet the surrounding area and make it slippery for the residents. Some form of barrier needed to be fitted around the shower to stop the floor becoming wet. The bath on the first floor was not adapted but had a seat laid across it. The door to the bathroom did not close. The carpet tiles in the bathroom were stained and needed to be replaced. There were no en-suite facilities in the home but all bedrooms had a wash hand basin available to the residents. The toilet by the kitchen needed to be decorated, a shade put on the light and made more homely. Residents had access to zimmer frames and stair lifts made the first floor accessible. There was a nurse call system in all areas of the home however, when the inspectors raised the alarm on one occasion when the staff were in the lounge/dining room they did not respond but did respond when a member of staff was in the kitchen. At the time of the inspector’s return to finish the inspection she was told that a new panel had been installed to ensure that the alarm could be heard in all areas of the home. There were no hoists available in the home. The bedrooms appeared to meet the needs of the residents but some of the furniture was old and needed to be replaced, for example, dressing tables and bed bases, some carpets were lifting and could pose a tripping risk, some curtains were fraying, were very creased or had shrunk during washing. Some bedrooms needed redecorating. There was central heating throughout the home and all radiators were covered except in the shower room. The hot water temperature was regulated at the appropriate temperatures. There were several light bulbs not working in the quiet lounge, one of the lights in the lounge/dining room did not work and the diffuser was broken, the light in the toilet in the first floor toilet and outside the toilet and bathroom did not work. The home was generally clean but some areas needed attention paying to them including toilets and bathrooms. There was one bedroom where odour control was an issue. Bars of soap needed to be removed from communal areas and liquid soap needed to be provided in all of these areas. There was a nailbrush in the toilet by the kitchen. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 18 The manager needed to ensure that there was a bin large enough to store all incontinence waste until it was collected. Bags must not be left on the floor, as they would attract vermin. The kitchen was found to be clean. There was a small area of flooring by the sink where the tiles had been removed and a bare cement floor was exposed that would be difficult to keep clean. Laundry was carried out in the property adjoining the home. There were several wall tiles missing in the laundry and the toilet where the wash hand basin was site. Some COSHH items were not locked away. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Staffing levels enabled the home to meet the basic day-to-day needs of the residents. Some of the staff files did not evidence that all the recruitment checks had been undertaken to ensure that the residents were safeguarded. Staff training needed to be given a higher priority to ensure that all the residents’ needs were adequately met. EVIDENCE: On the day of the inspection staffing levels were low. There were two carers on duty whilst the manager was on leave. These staff undertook the cleaning, laundry and cooking. There were nine residents in the home at the time of the inspection. Staff were seen to be busy and there was little time for interactions with the residents. During the night there was one sleep-in staff member and one waking night staff. Staffing levels needed to be closely monitored and additional staff employed to ensure that residents were enabled to have meaningful lives. During the first day of the inspection the responsible individual was working elsewhere but the rota indicated that he was due to be on waking night duty. This was not acceptable as no individual could work a 24-hour shift and ensure the safety of residents who may require assistance during the night. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 20 One member of staff identified as working a shift during the week of the inspection had not been seen by staff at the home and it was later determined that she was a bank member of staff and could be asked to work a shift. The staffing roster needed to be a true reflection of the staff on duty. One staff file did not evidence a CRB or reference checks and another had not had a CRB undertaken at Dorcas House. Two of the files did not evidence that the individuals had a right to work in the country. None of the care staff had achieved NVQ Level 2 training although some were undertaking it. Staff were due to undertake first aid training on 2.6.06. Some of the staff had undertaken food hygiene training and manual handling training within the past 18 months but some staff had not had the mandatory training. All staff should receive three days paid training a year and this needed to include mandatory training in fire safety, food hygiene, infection control, moving and handling, and, first aid. It would be advisable that staff also have training in the specific needs of the residents including continence management, dementia and mental health awareness. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 21 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, 33, 35, 36, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The manager had been in post for several years and had completed the Registered Managers Award. The manager needed to develop ways in which the service being provided in the home could be monitored and improved. Record keeping in the home needed to be improved. Some issues of health and safety were raised with the home. EVIDENCE: The manager had been at the home for several years and had undertaken the Registered managers Award. Relatives spoken with indicated that there were generally good relationships with the manager and the families although on occasions the communication regarding the care needed and provided to the residents could be improved. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 22 They stated that the residents were happy at the home, that they had missed the manager when she was not there but that residents would benefit from more socialising and trips out. The staff team did not reflect the ethnic backgrounds of the resident group and this was mainly due to the fact several family members were involved in supporting the running of the home. The manager needed to take into consideration the staff make-up when recruiting staff to the home in order to reflect the background of the resident group as far as possible. There was evidence that some staff supervisions, residents and staff meetings were being undertaken, however, these were found to be repetitive and not very informative. The home had not yet developed any systems for monitoring the service provided in the home. The records for residents personal allowances managed by the home were poor. There was no easy way in which the records could be audited as there were no clear records of the amounts of monies the residents’ were receiving, where the income was coming from and there were no running balances that could be checked. There were receipts available in envelopes but these had not been put into any order and the inspector could not check the expenditures against the receipts. The home must provide records that can be easily audited showing what monies have been received, when they were received, what the money had been spent on and how much money was available to the resident. Receipts needed to be numbered so that they could be cross-referenced. There needed to be an individual record for each resident. This issue will be followed up through the inspection process. There needed to be a policy in place for the handling of residents’ monies that showed how the money was to be managed and how the residents would be safeguarded from abuse. Where residents were not receiving their personal allowance this needed to be pursued with the relevant departments. There was evidence in the home that the equipment including gas equipment, electrical installations, stair lifts, fire alarms and emergency lighting were being maintained on a regular basis. The only issues of health and safety raised were the locking away of the COSHH items in the laundry, some lights not working, some carpets lifting, strategies being in place where risks had been identified for residents and the Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 23 call system being audible to staff in all areas of the home. The details of the MOT and insurance for the mini-bus were not available for inspection. The testing of water for Legionella was not evidenced during the inspection. Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 24 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 1 1 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 2 2 2 3 2 2 1 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 1 2 2 Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4 5(1) Requirement Amendments must be made to the service user guide and statement of purpose. (Previous timescale of 30/11/04 and 01/12/05 not met.) All residents must be given a contract or statement of terms and conditions of residence. The contracts must be up to date, identify the room to be occupied and include appropriate information including complaints procedure. Conditions that are misleading and indicate an institutionalised approach must be removed. No resident must be admitted to the home without the home having received assessment documents from the placing authority and a documented assessment undertaken by the home to ensure that their needs can be met at the home. The residents care plans must be developed to clearly show the needs of each person and how DS0000016840.V289401.R01.S.doc Timescale for action 01/08/06 2. OP2 5(1) 01/08/06 3. OP3 14(1) 01/07/06 4. OP7 15(1) 01/08/06 Dorcas House Version 5.1 Page 26 the staff are to meet the identified needs. Care plans must include strategies for dealing with difficult and challenging behaviour. Care plans must be regularly updated. (Previous timescale of 01/08/05 and 01/01/06 partially met.) Risk assessments must be holistic and identify how risks are to be managed. (Previous timescale of 01/08/05 and 01/12/05 not met.) The manager must ensure that arrangements are made to ensure that all residents’ medical needs are met appropriately. The home must write a policy for the safe handling of medicines within the home. (Previous timescale given 01/08/05 and 01/12/05. Not assessed for compliance at this inspection.) A copy of this policy must be forwarded to the CSCI. All medicines carried forward from one month to the next must be recorded so that an audit can be carried out. All medicines in use in the home must be recorded on the MAR charts. The registered manager must ensure that there are adequate and suitable locks on all toilets and bathrooms. (Previous timescale of 01/08/05 and 01/12/05 not met.) 5. OP7 13(4)(c) 14/07/06 6. OP8 13(1)(b) 01/08/06 7. OP9 13(2) 14/07/06 8. OP10 12(4)(a) 01/07/06 Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 27 9. OP12 16(2)(n) 10. OP15 12(1)(a) 11. OP15 12(1)(a) Residents must receive health care support in private. The registered manager must consult residents about their social interests and make arrangements to engage in local, social and community activities. (Previous timescale of 01/08/05 and 01/12/05 not met.) The registered manager must ensure that food stocks are maintained at suitable levels at all times. (Previous timescale of 01/07/05 and 01/12/05 not met.) The registered manager must ensure that systems are in place to make residents aware of what meals are available. (Previous timescale given 01/07/05 and 01/12/05.) Instructions must be available for staff regarding meeting the needs of residents who needed a diabetic diet. The registered manager must ensure that the meals are varied, wholesome and nutritious. The registered manager must ensure that the crockery is not chipped and mismatched. The registered manager must ensure that an appropriate complaints procedure is available to residents. (Previous timescale given 01/07/05 and 01/12/05 not met.) The registered person must ensure that a procedure of actions to be taken in the event of an allegation or suspicion of abuse is available for staff. There must be a copy of the multi-agency guidelines 01/08/06 01/07/06 01/07/06 12. OP15 16(2)(i) 01/07/06 13 14. OP15 OP16 16(2)(g) 22(1) 01/07/06 01/08/06 15. OP18 13(6) 01/08/06 Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 28 16. OP19 13(4)(b) available. The registered person must ensure that the garden area is made safe for the use of residents. (Previous timescales of 01/07/05 and 01/12/05 not met.) The garage of the adjoining property must be kept locked so that it is not accessible to residents who use the garden. The registered manager needed to take actions to ensure that the residents were not at risk of slipping when using the shower. The floor tiles in the bathroom on the first floor must be replaced. The toilet by the kitchen must be decorated and made more homely. The registered manager must ensure that the furniture and curtains in residents’ bedrooms are of a suitable standard. (Previous timescale of 01/12/05 not met. A plan of how the furniture is to be replaced must be forwarded to the CSCI.) Residents’ bedrooms needed to be redecorated. (An action plan of how this is to be achieved must be forwarded to the CSCI.) The registered manager must ensure that all lights in the home are maintained in working order. (Previous timescale of 01/12/05 not met.) The missing tiles from the walls in the laundry must be replaced. (Previous timescale of 01/12/05 not met.) All tablets of soap and nail brushes must be removed from communal washing and bathing facilities and replaced with liquid DS0000016840.V289401.R01.S.doc 01/07/06 17. OP21 13(4)(c) 01/08/06 18. 19. 20. OP21 OP21 OP24 16(2)(c) 23(2)(d) 16(2)(c) 01/08/06 01/09/06 01/07/06 21. OP25 23(2)(p) 01/07/06 22. OP26 13(3) 01/08/06 23. OP26 13(3) 01/07/06 Dorcas House Version 5.1 Page 29 soap. There needed to be a lidded bin large enough to store soiled continence waste until it was removed by the contractors. The flooring in the kitchen must be impervious and easily kept clean. Adequate numbers of staff must be on duty to meet the needs of the residents. (Previous timescale of 01/12/05 not met.) The staffing roster must be a true reflection of the staff on duty and hours worked. At least 50 of the care staff must be trained to NVQ level 2 or equivalent. All records required by Sch 2 of the Care Homes Regulations must be in place for all staff. Staff must undertake training appropriate to meet the needs of the resident group. (Previous timescales of 01/09/05 and 01/02/06 not met.) 24. OP27 18(1)(a) 01/07/06 25. 26. 27. OP27 OP28 OP29 17(2) Sch 4(7) 18(1)(a) 19 Sch 2 18(1)(c) (i) 01/07/06 01/10/06 01/08/06 28. OP30 01/09/06 29. OP33 24 30. OP35 12(2) Sch4(9) There must evidence available for inspection that all staff have recently undertaken mandatory training. (Previous timescale of 01/02/06 not met.) The home must develop a quality 01/10/06 assurance tool, which takes into account the views of service users. (Previous timescales of 31/12/04, 01/09/05 and 01/03/06 not met.) The manager must have access 01/08/06 to residents’ monies and records at all times. (Previous timescale of 01/12/05 DS0000016840.V289401.R01.S.doc Version 5.1 Page 30 Dorcas House not met.) Suitable and accurate records showing the income for residents, when it was received and where from, what it was spent on and the amounts remaining need to be prepared. Receipts must be available for all expenditures and numbered for auditing purposes. A policy for the handling of residents’ monies must be in place and ensure that residents are protected from abuse. A copy of this document must be forwarded to the CSCI. The accident procedure must be amended to include the actions staff must take in the event of an accident in the home. (Previous timescale given 01/07/05. Compliance not checked at this visit.) The registered person must ensure that there are risk assessments in place for the premises, fire, staff and food. (Previous timescale given 01/08/05. Compliance not checked at this visit.) Evidence that the minibus has a valid MOT and insurance certificate must be forwarded to the CSCI. The radiator in the shower room must be covered. All items covered by the COSHH regulations must be locked away at all times. The registered manager must ensure that testing for Legionella is carried out regularly. (Previous timescale of 01/08/05 and 01/12/05 not met.) DS0000016840.V289401.R01.S.doc 31. OP37 17(2) Sch4(17) 01/08/06 32. OP38 13(4) 01/08/06 33. OP38 23(2)(c) 14/07/06 34. 35. 36. OP38 OP38 OP38 13(4)(c) 13(4)(c) 13(3) 14/08/06 14/07/06 01/09/06 Dorcas House Version 5.1 Page 31 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 OP28 Good Practice Recommendations 50 of all care staff employed by the home must possess NVQ level 2 or equivalent by 2005. (not assessed at this inspection.) The names of staff should be included in the records of fire training and fire drills. 2. OP38 Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Dorcas House DS0000016840.V289401.R01.S.doc Version 5.1 Page 33 - 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. 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