Inspection on 11/07/07 for Dorothy House

This inspection was carried out on 11th July 2007.

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

Dorothy House 17/11/08

Dorothy House 16/01/08

Dorothy House 15/01/07

Dorothy House 21/08/06

Dorothy House 19/10/05

Dorothy House 23/06/05

Dorothy House 22/02/05

Dorothy House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dorothy House 186 Dodworth Road Barnsley South Yorkshire S70 6PD Lead Inspector Christine Rolt Key Unannounced Inspection 11th July 2007 09:45 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 Dorothy House DS0000018245.V345113.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. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dorothy House Address 186 Dodworth Road Barnsley South Yorkshire S70 6PD 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) 01226 249535 F/P 01226 249535 none None Mr Azar Younis Vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th January 2007 Brief Description of the Service: Dorothy House is situated on the main road from the M1 motorway to Barnsley town centre. The home is an extended bungalow that stands well back from the main road at the top of a driveway. The home shares the grounds with its sister home, The Firs. The gardens are landscaped and there is adequate car parking space. There are no stairs or steps either approaching or within the home therefore it is accessible to persons using walking frames or wheelchairs. The home has small bedrooms to the front of the property and larger bedrooms to the rear of the property. There is a communal lounge/dining room and a small quiet lounge. There is a small patio area leading from the lounge/dining room. This has been a ‘no smoking’ home since February 2007. The weekly fee was £327.50. Hairdressing, newspapers, toiletries, chiropody, dry cleaning and taxis were not included in the weekly fee and were charged separately. The acting manager supplied this information in the pre-inspection questionnaire received on 7th March 2007. The statement of purpose, service user guide and CSCI inspection report were available in the home. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9.45 am to 6.30 pm h on 11t July 2007. The majority of residents were seen throughout the day. Two residents were tracked throughout the inspection. Questionnaires were sent to the home; five for residents, of which three were completed and returned, five for staff of which two were completed and returned and five for health professionals of which none were completed and returned. A visitor was asked for their comments about the service provided. During the site visit, Mr. Younis, the registered provider, visited the home to meet the inspector and explain his future plans for Dorothy House. Care practices were observed, a sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the acting manager, members of staff, residents, the visitor and the registered provider for their assistance and cooperation. What the service does well: What has improved since the last inspection? This home had improved since the previous inspection. The home now had a statement of purpose, which was available for visitors to see. The service users guide had been updated and copies were available in all residents’ bedrooms. Residents care plans have improved and included physical, health, social and emotional needs but can be further improved (See next section). Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 6 The home was in the process of being redecorated and refurbished and repairs had been carried out. A new adapted bath had been fitted; therefore residents had the choice of a bath or a shower. Residents and relatives had been asked for their views about the home and action had been taken to address any issues. The owner visited the home every week. knew him. He knew the residents and they All systems and equipment had been serviced and maintained and the manager carried out regular health and safety checks to ensure that the home was a safe environment. Administration within the home had improved. The owner produced monthly reports of his findings and submitted these to the CSCI. The acting manager was informing CSCI of any incident that affected the wellbeing of residents. What they could do better: The residents’ assessments provided detailed information of residents’ needs but this information was not always included in their plans of care. When residents’ needs changed, staff were aware of the changes because the home is small, however, the changes were not always reflected in the residents’ plans of care. Accidents were recorded but the monitoring of the residents involved was not always recorded. The accident procedure did not include a procedure for dealing with head injuries. The acting manager had some supernumerary hours for managerial tasks but also worked with staff on shift for part of the time. However, her managerial role meant that she could be called away, e.g. visits by prospective residents and health care professionals, leaving only one member of staff to meet residents’ needs. The necessity of ensuring that there were sufficient staff at all times to meet residents’ needs was discussed with the owner. The acting manager had not applied for registration with the Commission for Social Care Inspection. The system for accounting and auditing residents’ personal allowances needed improving to ensure that there were no errors. The acting manager needs to determine which members of staff have not undertaken mandatory health and safety training (e.g. emergency first aid, fire awareness, moving and handling, infection control and basic food hygiene) and then provide opportunities for training to ensure that staff have the skills and knowledge to increase competency. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. 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. This home does not provide intermediate care. Prospective residents had the information needed to make an informed choice about the home. Residents’ assessments provided a good range of information of their needs and wishes but there was no written verification that the home could meet their needs. EVIDENCE: The home had a statement of purpose that covered the criteria as required by regulation. Residents had copies of the service user guide. Copies of the statement of purpose, service user guide and last inspection report were available for prospective residents. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 10 The home assessed prospective residents to ensure that they could meet the residents’ needs. Two assessments were checked. These contained detailed information of each resident’s needs and wishes and additions were made as residents’ needs changed. However, the assessments were not signed or dated. Also prospective residents were not informed in writing that the home could meet their needs. This was discussed with the acting manager who was advised to discuss the means of doing this with the registered provider. A resident’s comments were that this home suited her because “It is small with only 10/12 residents…”. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents were treated with respect, but their care needs were not fully reflected in their care plans. Medication procedures were generally sufficient to ensure that residents were protected but could improve. EVIDENCE: Residents’ looked well cared for and residents said that they were happy. Two care plans were checked in detail. The care plans had generally improved since the last inspection but some relevant information on the assessments had not been transferred onto the plans of care. Some of this information of needs and how this was to be met was stated on the residents’ assessments and some was within the daily recording. In one instance, a resident’s health had dramatically deteriorated but the care plan had not been reviewed and updated to provide all the information of how the resident’s needs had changed Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 12 and how staff were to meet those needs. However, because this is a small home all staff were aware of this. The necessity for reviewing and updating care plans as residents’ needs changed was discussed with the acting manager. Daily records provided information of how staff had met residents’ physical, health, emotional and social needs. Files contained a range of risk assessments that provided information about residents’ needs. However, the Nutritional Risk Assessments being used had insufficient information to determine what the scores meant and when interventions might be necessary. One care plan contained information that the resident had bed rails fitted but there was no risk assessment to ensure that the resident was not being put at risk by use of these bed rails. Information on visits by health care professionals e.g. GPs, district nurses and opticians provided good information. A visitor said that the resident received visits by their GP, the dentist and the chiropodist and they were satisfied with the care given. Accidents were recorded but there was no consistent monitoring system in place i.e. to raise awareness of injuries that were not apparent at the time of an accident. The home now had an accident policy and procedure but the procedure did not provide instructions for dealing with head injuries. A resident who had sustained a cut to their head had not been referred for medical treatment. The need to ensure that all head injuries are referred for medical intervention, and that staff are aware of this, was discussed with the acting manager. Many of the documents on the residents’ files were not dated or signed. The acting manager said that none of the current residents was capable of managing their own medication because of their deteriorating physical and mental health. Observations of residents confirmed this. Residents’ medication contained some minor discrepancies e.g. discontinued medication not returned to the pharmacist, handwritten entries on MAR sheets not containing dosage. It was strongly recommended that handwritten entries be countersigned to ensure information had been copied accurately onto the MAR sheet. The home did not hold any controlled drugs for any resident. Medication required refrigeration was kept in the home’s domestic refrigerator. home’s medication store was being used as a general storage area. acting manager was instructed to clear out this cupboard and ensure that medication was stored. that The The only Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 13 All of the above was discussed with the acting manager during the site visit and she was advised to carry out audits as part of her quality assurance monitoring system. After the inspection, the acting manager contacted the CSCI to inform that the medication cupboard had been cleared and the discontinued medication had been returned to the pharmacy. The purchase of a medication refrigerator was recommended to the owner and the acting manager. The CSCI was now being notified of issues relating to residents’ wellbeing as required by Regulation 37 of the Care Homes Regulations. Residents were observed to be treated with respect and dignity and residents confirmed this. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Not all residents found the lifestyle matched their expectations and preferences. Meals were good and available at times convenient to residents. EVIDENCE: At the time of this site visit, a member of staff had organised a game of snakes and ladders. The giant board game was in the middle of the floor, which enabled all residents to take part if they wished to do so. This activity was advertised on the notice board. The home did not have a programme of activities. One resident chose to stay in her bedroom and read a book. Another resident was attending a weekly function in the community. The patio area contained flower filled hanging baskets and large flowerpots and the staff said that a resident who was interest in gardening had helped with these. Care plans contained information of activities that residents had participated in. The acting manager said that local schoolchildren visited the home to chat to residents and were also organising a concert for the residents. A hairdresser and a trained manicurist also visited the home. Residents also Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 15 had the opportunity to join in activities at the sister home The Firs, situated in the same grounds. Money raised from a Summer Fayre was being used to take residents on a boat trip. One resident considered that there were usually activities arranged whilst two considered that activities were only sometimes arranged. One resident commented “I would like more stimulation – there are very few activities and no arranged outings – there is nothing for those who have no family support. I would like more outings and activities”. The inspector spoke to the registered owner and discussed staffing issues (see section Staffing) and also asked the owner to consider the feasibility of residents being taken out individually in the local community and he said that he would consider this. Families and friends could visit at any time. One visitor was seen during the site visit. Residents had choices e.g. getting up and going to bed, use of bedroom and attending functions in the local community. Since the last inspection, a new adapted bath had been fitted which meant that residents now had a choice of a bath or a shower. Residents’ choices, likes and dislikes were contained in their care plans. Meals on offer were displayed on the menu board. The visitor said that the food was fine and that the home catered for residents’ needs. The visitor’s personal observations were that if the resident did not want either of the options available then they had been given something that they liked. On the day of the site visit, a late lunch was provided for a resident who had been out. Plans were in place for all meals to be cooked in the kitchen at the sister home The Firs. The owner had purchased hot trolleys to transport meals across to Dorothy House. The kitchen at Dorothy House was to continue to provide refreshments and snacks for residents. A residents’ meeting had been held to inform residents of the proposed changes and minutes of this meeting were seen during the site visit. The visitor confirmed that relatives and visitors had also been notified. There were no objections. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and visitors considered that their complaints would be listened to and acted upon. Residents were protected from abuse. EVIDENCE: The home had a complaints procedure and copies were also included in the service user guides that residents had in their bedrooms. There were no complaints and residents considered that if they had a complaint the manager would deal it with. There were no allegations of abuse. A member of staff demonstrated that she was aware of what actions constituted abuse and said that she had received training. The acting manager said that with the exception of a new employee all staff had undertaken adult protection training. The home had the Barnsley Multi-agency Adult Protection Policy and Procedures and also its own adult protection policy and procedure. The acting manager was advised to produce her own step-by-step procedures that included local contact details to ensure that staff in charge knew what to do if there was an allegation of abuse. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 17 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 quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was clean and hygienic and maintenance work was ongoing. EVIDENCE: Residents and the visitor considered that the home was fresh and clean. There were no offensive odours during the site visit. All residents’ private and communal spaces were checked during this site visit. The home was in the process of redecoration and refurbishment. One corridor had been redecorated and another was in the process of being redecorated. New brighter lighting had been fitted on corridors. Some bedrooms had been redecorated and others were in the process of, or awaiting redecoration. One resident who had recently had her bedroom redecorated Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 18 said that she had been able to choose the colour and was happy with this. Another resident said that she was satisfied with her bedroom and her visitor said that the bedroom was now much better. The acting manager said that lounges and the dining room would also be redecorated and new furniture was to be purchased. The owner said that he would be purchasing new carpets. A new adapted bath had been fitted. The damaged furniture and fitments had been repaired or discarded and headboards had been fitted to all beds. Since the last inspection beds had been moved from against the walls to enable staff to access both sides of the beds when assisting residents. Mobility aids and equipment, i.e. wall bars, raised toilet seats, support rails, were fitted throughout the home. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty did not always meet residents’ needs. Residents were protected by the home’s recruitment procedures and staff were competent to do their jobs. EVIDENCE: At the time of this inspection there were nine residents. There were two staff on duty at all times, but according to the staffing rotas, the acting manager was included in these numbers. When residents were asked about staff availability, two said that staff were usually available and one said that staff were sometimes available. When residents were asked whether staff listened and acted on what they said, one resident commented, “When they have the time, but sometimes they are harassed”. The inspector raised her concerns about how residents’ needs could be met if the acting manager was in discussion with health care professionals or prospective residents and their families, leaving only one carer to meet residents’ needs. The acting manager had some supernumerary hours but the timing of these must be reviewed to ensure that residents’ needs are met and that they are not put at risk because of lack of staffing. This was discussed with the owner who said that he would review the situation. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 20 The pre-inspection questionnaire provided information that the ratio of staff who had attained NVQ Level 2 or above in care was above the minimum ratio of 50 . The acting manager also confirmed that two members of staff were undertaking NVQ Level 2, another member of staff was preparing to start this qualification and another member of staff was undertaking NVQ Level 3 in care. The promotion of skills training e.g. dementia care, sensory needs, continence awareness, tissue viability and palliative care, to enhance training already undertaken, was discussed with the acting manager. A member of staff was interviewed and she demonstrated her awareness of residents’ needs. Two staff files were checked. Criminal Records Bureau disclosures were available. The acting manager said that all staff had undertaken Criminal Records Bureau disclosures. Other relevant documentation was included. The acting manager said that all staff were interviewed prior to appointment but files did not contain this information. As a measure of good practice the acting manager was advised to include interview documentation. This should record any specific points that needed discussion e.g. discrepancies or issues noted in the candidate’s application form, references or CRB disclosure. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. This home did not have a registered manager. The home had commenced a quality assurance system to ensure that the home was run in the best interests of residents but this needed to be extended and accounting procedures to safeguard residents’ finances must improve. The health, safety and welfare of residents were partially promoted. EVIDENCE: This home has not had a registered manager for several years. The current acting manager has been in post since September 2006 and was undertaking the Managers Award. The home has shown progress since her appointment. Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 22 The need for her to apply to become the registered manager was discussed with both her and the registered owner. Since the last inspection the home had commenced a quality assurance system that included residents’ meetings and questionnaires for residents, relatives and staff. Minutes of the residents’ meeting and the completed questionnaires were seen during the site visit. The acting manager said that comments received had resulted in action being taken to improve the service. Environmental risk assessments for health and safety were carried out regularly. The acting manager was informed that her quality assurance system needed to be extended and was advised of how to do this e.g. care plans, medication, accidents, staff files and staff training, and audits of the environment e.g. furnishings, furniture, decoration. These monitoring systems would ensure that any problems were highlighted and could be rectified at the earliest opportunity. The registered owner now produced written reports of his visits to the home as required by regulation. The acting manager now notified the CSCI of incidents that affected residents’ wellbeing as required by Regulation 37 of the Care Homes Regulations. The home now had a fully operational facsimile machine. Money held on behalf of residents was stored safely. The personal allowances held for two residents were checked against the records and in one case the money did not tally with the records. The acting manager was told to obtain proof i.e. receipts, for money spent on behalf of residents. The registered owner was advised to audit residents’ personal allowances during his visits to the home. The pre-inspection questionnaire provided information that plans were in place for staff to attend several mandatory health and safety training courses, i.e. adult protection, fire awareness, medication, basic food hygiene, first aid and infection control, throughout the year. During the site visit, the acting manager was asked about this training and said that these had been arranged and then cancelled by the registered manager of the sister home, The Firs. The acting manager was told that all staff must undertake mandatory health and safety training including moving and handling to ensure that staff were competent to do their jobs, thereby ensuring the health and welfare of residents. Servicing and maintenance of systems and equipment within the home had been carried out and certificates were available and were checked during this site visit. Dorothy House DS0000018245.V345113.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Dorothy House DS0000018245.V345113.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 Requirement Prospective residents must be informed in writing, prior to admission, that the home can meet all their needs. (Previous timescale 12/03/07 not met) All relevant information of residents’ needs must be transferred from their assessments on to their plans of care with details of how these needs are to be met. When residents’ needs change, their care plans must be reviewed and updated with details of how these needs are to be met. Risk assessments must provide sufficient information to enable staff to understand what they mean and at what stage staff need to take action (i.e. Nutritional Risk Assessment) Where bed rails are fitted, risk assessments must be carried out to ensure that residents are not put at greater risk by their use. The Accident Procedure must be amended to include the DS0000018245.V345113.R01.S.doc Timescale for action 05/09/07 2 OP7 13, 15 05/09/07 3 OP7 13, 15 05/09/07 4 OP7 13 05/09/07 5 OP7 13 05/09/07 6 OP8 13 05/09/07 Dorothy House Version 5.2 Page 25 7 OP8 13 8 9 10 OP7 OP19 OP27 15, 17 16,23 18 11 12 OP31 OP33 9 24 13 OP35 13 14 OP38 13 and 23 procedure for dealing with head injuries and all staff made aware of this procedure. Residents who have had accidents must be monitored and a record kept to ensure the no injuries were sustained that were not apparent at the time of the accident. All documents, particularly those in residents’ files, must be signed and dated The rolling programme of redecoration and refurbishment must continue Sufficient numbers of care staff must be available at all times to ensure that residents’ needs can be met. The acting manager must apply to the CSCI for registration The system for evaluating the quality of the service must be extended (e.g. audits of care plans and reviews, staff files, supervision and training, medication and accidents, and environmental checks) to ensure that residents receive a good quality service. Accounting and auditing procedures for residents’ finances must improve to ensure that residents’ finances are safeguarded. (Previous timescale 29/01/07 not met) Staff must undertake mandatory health and safety training and must demonstrate competence to ensure that residents are in safe hands at all times. (Previous timescales of 30/10/06 and 12/03/07 not met) 05/09/07 05/09/07 04/10/07 05/09/07 05/09/07 05/09/07 05/09/07 05/09/07 Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 26 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 3 4 Refer to Standard OP9 OP9 OP12 OP18 Good Practice Recommendations It is strongly recommended that all handwritten entries on Medication Administration Record sheets be countersigned to ensure that the information has been copied correctly. Consideration should be given to the purchase of a medication refrigerator. Residents should be given the opportunity for individual outings in the community. The provision of a step-by-step Adult Protection Procedure that includes local contact details would ensure that staff left in charge of home knew what to do if there was an allegation of abuse. Staff should be given the opportunity to receive training that will enhance their care skills e.g. tissue viability, continence, sensory awareness, palliative care. It is strongly recommended that the registered provider carry out regular audits of residents’ personal allowances and other financial issues during his visits to the home. 5 6 OP27 OP35 Dorothy House DS0000018245.V345113.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. 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