Inspection on 01/05/07 for Dorley House

This inspection was carried out on 1st May 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

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Dorley House 19/20 Bedfordwell Road Eastbourne East Sussex BN21 2BG Lead Inspector Gwyneth Bryant Key Unannounced Inspection 1st 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 Dorley House DS0000067684.V337780.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. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dorley House Address 19/20 Bedfordwell Road Eastbourne East Sussex BN21 2BG 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) 01323 729545 01323 648893 dorley @stmichaelscare.com St Michaels Care Homes Limited Mrs Norma Wood Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is thirty three (33) Service users must be older people aged sixty-five (65) years or over on admission. N/A Date of last inspection Brief Description of the Service: Dorley House is a large detached three-storey house with large secluded rear gardens close to Eastbourne town centre with all its amenities and approximately two miles from the seafront and promenade. All floors are accessible via the provision of a passenger lift and stair lifts, however there are also some internal steps so those accommodated in these areas need to be mobile. The home has a dining room and two lounges, one of which is located on the top floor. There are twenty-five single rooms and four doubles, of which twelve single rooms have en-suite toilet facilities. All rooms have at least a wash hand basin. Grab and hand rails are provided throughout the home. There are communal bathrooms on each floor except the attic floor and bath hoists are provided in all bathrooms. As part of the pre-admission process people are provided with an information pack that includes a copy of the service users guide, the statement of purpose and a brochure. Copies of inspection reports are made available if requested. Fees charged as from 1 April 2007 range from £375 to £495, which includes toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit and took place over six hours and its purpose was to check compliance with both key standards and other minimum standards. There were twenty people in residence on the day of which five were spoken with. Discussion also took place with two carers, one visitor, the registered provider and the acting manager. Following the site visit 3 relatives were contacted by phone and their views incorporated in this report. A tour of the premises was carried out and a range of documentation was viewed including care plans, personnel and medication records. All of the people spoken with spoke highly of the care given and the kindness of staff and food was another area singled out for special mention as being very good. The Registered Provider makes monthly visits and the subsequent reports available in the home for inspection. The reader should note that there has been a recent change in ownership although the manager has remained the same. During the site visit the manager provided copies of surveys sent to relatives and people living in the home as part of the quality monitoring process and comments included: ‘I think I’m spoiled’. ‘too much to eat’. ‘I am very satisfied here’. ‘staff are all kind and considerate, trying to keep residents happy’. ‘we are so pleased to see my aunt looking so much better and happier’. ‘I really am very happy with everything and the staff are so kind and helpful’. Comments from relatives and those living in the home provided via CSCI survey included: ‘There are always activities in which service users are encouraged to participate’ ‘ I visit regularly but staff always inform me of any changes’ ‘caring manager & staff- always made to feel welcome when we visit. It is always clean and excellent food and entertainment provided. ‘My mother has improved since being there, very good team, its nice to know she is safe and cared about’. ‘I would like to say how much I love the way you look after us’. ‘Meals are very good’. ‘I thinks its tip top. All staff love the people’. ‘I’m very happy with service and attention’. ‘Happy with care & support. If not happy I would speak to …(staff names given)’. ‘I feel at home and comfortable’. The food is good, if you don’t like something it is rectified. ‘I feel well looked after’. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 6 ‘I am very satisfied with the care, the food and the help I get’. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dorley House DS0000067684.V337780.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 Dorley House DS0000067684.V337780.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): 3 and 4. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are carried out at the time of admission to ensure the home can meet the needs of people living in the home. EVIDENCE: Pre-admission sheets for the last three people to be admitted to the home were viewed and found to be satisfactory. Discussion with the manager found that as part of the admission process all people who wish to move into Dorley House are offered a visit and to stay for a meal to enable them to meet staff and others who live in the home. Relatives spoken with confirmed they have a contract and were given information on the services provided. A copy of the service users guide is in each individual’s bedroom as a point of reference. Intermediate care is not provided. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 9 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 outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care planning systems ensure that the health, medical and personal needs of those living in the home are identified and planned for in a consistent and comprehensive manner. EVIDENCE: Five care plans were viewed and it was evident that pre-admission assessments are used to inform the care planning process. Care planning documents included information on meeting service users’ healthcare needs such as dental, hearing and eyesight checks and also provided clear direction to staff as to how service users daily care needs are to be met. Risk assessments had been carried out and they clearly identified the hazards and included sufficient detail for the management of risks. Some comments in the daily notes were of a general nature. This was discussed with the manager who agreed to ensure that in future staff record the actual care given. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 10 Some people living in the home hold and administer their own medication and satisfactory risk assessments have been carried out to ensure they are not at risk. There are policies and procedures on respecting service users dignity and privacy and all service users are offered keys to their bedrooms and staff were seen to knock on doors before entering. Medication is stored and handled appropriately but some signatures in the medication administration chart had been overwritten, suggesting that medication had been signed for prior to administration. These charts need to be accurate and up to date as it is important to show whether or not medication has been administered. People living in the home said that the ‘girls’ are lovely and they are all very kind and that they felt all looked after. One lady commented ‘he’s such a lovely man – he does all kinds of little things for you that show he cares’. Other comments included: ‘its lovely here- the food is marvellous – lots of choice and plenty of it’. Comments from CSCI survey included: ‘Staff are patient & kind and act upon any problems promptly’ ‘Every effort is made to support service users and make a happy atmosphere’. ‘All staff are kind and understanding’ A harmonious atmosphere is always sought’ ‘Medical problems are always dealt with promptly’ Surveys provided by the home showed that generally those living in the home were satisfied with all aspects of care although one said they felt that staff are not always available when needed. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 11 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): People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle of people living in the home matches their expectations in respect of activities, choice and meals. EVIDENCE: The home has an open house policy and visitors are encouraged to visit at times to suit them. Visitors and relatives spoken with confirmed that the staff are always very welcoming and that they are offered refreshments. Activities provided include card games, aromatherapy, word games, musical entertainment, and outings to shops and local attractions. On the day of the site visit music and games were provided by an outside agency. People spoken with said how much they enjoyed the activities and were looking forward to the summer outings. In addition the manager has arranged for people in the home to visit another care home to enable them to widen their social circle. Comments in the surveys provided by the home included; ‘good social events available even though many residents do not feel able to participate’. ‘I appreciate the kindness and welcome always given to me when I visit’. ‘we always have a warm welcome and to date have no adverse comments about the care of residents’. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 12 ‘Comments are always listened to and visitors are always welcomed’ Generally the surveys indicated that those living in Dorley House were happy with activities provided and the food. Some people are able to go out independently to the town and surrounding areas. Monthly religious services are provided in the home and arrangements are made for who wish to follow their own religion. Menus provided by the home show that meals are well balanced, nutritious and varied. Alternatives are offered at each meal times, snacks, drinks are provided throughout the day. People spoken with on the day all said that the food was good. Comments from those spoken with included: ‘the food is very good, no complaints about anything’ ‘you cant fault the food’. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 13 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 outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure with evidence that those living in the home feel that their views are listened to and acted upon. People living in the home are further protected by satisfactory adult protection systems. EVIDENCE: The home has policies and procedures on complaints and no complaints have been received by the CSCI. The home has received two internal complaints in the last six months and these were recorded with actions taken and outcomes. They were of a nature that should have been reported to the CSCI. This was discussed with the manager who agreed to ensure this is rectified should there be further incidents. People spoken with said they would be happy to speak to staff or the manager should they have any concerns. The home has policies and procedures on adult protection and staff are expected to be familiar with this document. Most staff have been trained in Protection of Vulnerable Adults and the home has a rolling training programme to ensure all staff receive this training and updates provided for existing staff. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 14 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 adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are provided with a homely, comfortable and pleasing environment. Those living in the home would benefit if all staff followed infection control procedures. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and décor is good. Individual bedrooms were attractively decorated and it was evident that many of the people living in the home had taken the opportunity to personalise their rooms with pictures and ornaments. The home has an on-going maintenance and refurbishment programme and now all bedroom doors have been fitted with locks and the occupant provided with a key. The laundry room was clean and tidy however, one member of staff was observed to continue to wear gloves and apron in communal areas after delivering personal care. This practice puts all persons in the home at risk of Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 15 cross infection. This was discussed with the manager who explained it was a new member of staff who has yet to receive formal infection control training. She agreed to provide basic training in the interim. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 16 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 good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff with appropriate skills to meet the needs of those people living in the home and the recruitment practice is also sufficiently robust to safeguard those living in the home. EVIDENCE: Staff rotas showed there were four carers on duty in the morning and three in the afternoon. There are two waking staff on duty at night and domestics and cooks also employed. Recruitment records were viewed and it was found that all staff had provided the required information prior to appointment. One person had not provided a reference from their last employer as they were from abroad. This was discussed with the manager who agreed to look into possibility of contacting employers who are based abroad. The manager is in the process of developing a comprehensive induction programme that meets the common induction standards and it is recommended that this be implemented as soon as possible. Staff spoken with said they had a short induction period and that they felt supported by the manager and provider. The provider has implemented a programme of NVQ 2 training for all staff and by June 2007 all care staff should have achieved at least a level 2 NVQ in Care. One comment from an individual living in the home was ‘An extra person would be helpful at night’. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 17 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, 32, 33, 35 and 38. People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home and staff benefit from clear leadership and direction and most aspects health, safety and welfare are protected and promoted. EVIDENCE: The manager has a qualification in management and has just begun her NVQ 4 in care ensuring that she has up to date knowledge and skills appropriate for her role. She consults with both those living in the home and staff via regular meetings. Minutes of these meetings were available and demonstrate that those living in the home are listened to and their suggestions acted upon. Staff and relatives confirmed that she is open and approachable and both staff and relatives were seen to consult with her throughout the site visit. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 18 Some gaps in staff training in respect of fire safety and Protection of Vulnerable Adults but there is training planned in the near future and basic training will be provided by the manager in the interim. Some work has started in respect of fire risk assessments by the registered provider. This needs to be further developed into a comprehensive fire safety risk assessment of the premises and be carried out by a suitably qualified person. The manager holds some monies on behalf of some people living in the home and all transactions are recorded and receipts obtained as necessary. Records were available to demonstrate that regular checks are made to ensure that all electrical and gas systems and appliances are safe and maintained in good working order. There is a range of health and safety checks including fire drills, call bells and checks on water delivery temperatures. Fire safety equipment is regularly serviced and most staff have been trained in fire safety procedures. Staff spoken with confirmed that fire safety is included in the induction process. Accident records were viewed and found to be accurate and maintained in line with the Health and Safety Executive guidance. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 19 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 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 2 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 3 3 X 3 X X 2 Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 13 (2) Requirement That administered medication is properly recorded as required under Regulation 17 (1) (a) Schedule 3 (k) That staff are trained to work in ways that minimise the risk of cross infection. That a system is devised to inform the CSCI of any adverse events affecting service users. That a fire safety risk assessment for the premises is carried out. Timescale for action 01/06/07 2 3 4 OP26 OP38 OP38 13 (3) 37 (1) (e) (g) 23 (4) (a) (c) 01/06/07 01/06/07 01/08/07 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 2 Refer to Standard OP29 OP30 Good Practice Recommendations That consideration be given to obtaining employers references from those employers based outside the UK. That the proposed staff induction programme be finalised and implemented. Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Dorley House DS0000067684.V337780.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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