CARE HOMES FOR OLDER PEOPLE
Dorothy House 186 Dodworth Road Barnsley South Yorkshire S70 6PD Lead Inspector
Jayne Barnett-Middleton Unannounced Inspection 19th October 2005 09:30 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.V254942.R01.S.doc Version 5.0 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.V254942.R01.S.doc Version 5.0 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 01226 249535 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.V254942.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd June 2005 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. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 09.30 am to 2.30 pm. On the day the majority of service users had gone out for a pub lunch followed by a mystery tour. Four service users, five staff, the manager and one relative were spoken to. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection?
Care plans had been reviewed to evidence that the service user had been involved in their plan of care and that they had been consulted about their preferred funeral arrangements. However, further work was needed to ensure that they met the required standard. A trainer had been employed to ensure that the staff was provided with regular training, to meet the assessed care needs of service users. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 6 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. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 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 Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 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 and 3. Prospective service users and their relatives were provided with the information that they needed to enable them to make an informed decision about moving into the home. Service users were not admitted to the home without their needs being assessed. EVIDENCE: A Statement of Purpose and Service Users Guide were available, these provided service users and their relatives with the information that they needed to make an informed choice about living at the home. A full needs assessment was carried out for all service users prior to their admission, which confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. The home does not provide an intermediate care service.
Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Care plans and risk assessments required more detail to ensure that they met the required standard. Healthcare records required more detail; to ensure that the healthcare needs of service users could be monitored. A policy and procedure was in place to ensure that staff adhered to safe practices regarding medication and the protection of service users. EVIDENCE: Three Care plans were checked. Two set out in detail the action that was required by staff to ensure that all aspects of service users care needs were met. One care plan had only been partially completed and did not clearly identify the specific needs of the service user. One Care plan had not been reviewed on a regular basis to reflect the changing care needs of the service user. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 10 Records of healthcare visits were maintained and these evidenced that other healthcare professionals, e.g. general practitioner, chiropodist and optician, were visiting service users on a regular basis. Two service users suffering from diabetes confirmed that they received the appropriate care. However, the care records checked did not detail the treatment that the service users were receiving to ensure that their condition could be monitored. Risk assessments had been completed which identified the individual risks that were presented to service users on a daily basis and the action required to reduce the risk, which enabled service users to live as independently as possible. The risk assessments in the care plans checked had not been reviewed regularly to reflect the changing needs of the service user. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of service users. The recording and storage of medication was checked on a sample basis. One service users prescribed medication was checked and the amount in stock was more than the record stated had been administered. The senior care confirmed that no service users self-administered their own medication. However, there was no record to demonstrate that service users had been given the opportunity to continue to administer their own medication, to maintain their independence. Staff had received medication training, which promoted the safe administration of medication. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. The daily routines within the home were flexible and promoted service user choice. Service users were encouraged to maintain contact with their family, friends and the local community as they wished. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: There was a relaxed atmosphere within the home. Service users were observed to be following their preferred routines. Several service users were sitting in the lounges socialising with other service users whilst others had chosen to spend time in the privacy of their bedroom. Service users said that the routines within the home were flexible and said that their friends and relatives were welcome to visit them at any reasonable time. A good programme of activities was provided which included bingo, pea and pie suppers and professional monthly entertainment. Regular entertainment was organised at ‘The Firs’ and service users confirmed that they were invited to attend. On the day, the majority of service users had gone out for a pub lunch followed by a mystery tour. Several service users confirmed that they were looking forward to their day out.
Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 12 A good choice of menu was offered and special dietary needs were catered for. Menus were reviewed on a regular basis based on service users likes and dislikes. The cook had a good knowledge of service users dietary requirements. Service users said that they enjoyed their meals and described the food as “very good”. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure and all staff had received adult protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Service users stated that they were satisfied with the care provided. They confirmed that if they did have any problems about their care, they were confident that the staff team would listen and resolve any concerns that they may have. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The staff had received adult protection training to promote the protection of service users and was able to demonstrate how they would protect service users from harm. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24 and 26. The home was clean, comfortable and well maintained. Service users were provided with an environment that was safe, accessible and homely. EVIDENCE: The home is an extended bungalow in the same grounds as its sister home, The Firs. The home was well maintained and pleasantly decorated. All furnishings were clean and presented a homely environment. The grounds were tidy, well maintained and safely accessible to service users. Several bedrooms were checked and all were clean and pleasantly decorated. All the rooms had been personalised by the service user with small items of furniture, photographs and mementoes, which encouraged service users to retain their own identity. One service user said that they enjoyed spending time in their bedroom to “read and watch TV”. A previous recommendation to replace one bedroom carpet, which was due for replacement, had not been carried out.
Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 15 All areas throughout the home were clean and tidy and a good level of cleanliness was maintained. One service user commented that the home was “always very clean”. Laundry facilities were sited away from food preparation and service users areas, to ensure that any soiled linen was not carried through areas where food was prepared and did not intrude on service users. Staff confirmed that they had attended Infection Control training, to promote a hygienic environment to control the risk of infection. There was a small-enclosed garden to the rear of the home. Service users said that they had spent time in the garden during the summer months. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. A training and development programme was in place. Staff received regular training, which enabled them to meet the needs of service users. The home operated a recruitment procedure. Staff files did not contain all of the required information. EVIDENCE: All service users spoke positively about the staff team and described them as “good” and “I get on well with them all”. Staff rotas checked, demonstrated that the agreed staffing levels were being met to meet the individual needs of service users. There were no care staff vacancies, which promoted a consistent quality of care to service users. Over 50 of the staff team held a level 2 or 3 National Vocational Qualification in Care, which developed the skills and competence of staff, to enable them to meet the changing needs of service users. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Care plan and accountability training had recently been held at the home. The manager confirmed that she was in the process of implementing a training matrix to clearly demonstrate the training that staff had attended and to identify any individual training requirements. Staff confirmed that they received a good range of training appropriate to their role.
Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 17 A recruitment policy and procedure was in place that promoted the protection of service users. Staff files checked did not contain a full employment history of the employee. One file checked did not contain a recent photograph of the employee. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 18 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 and 38. Service users and staff benefited from the ethos, leadership and management approach. The homes policies and procedures promoted the health, safety and welfare of service users and staff. One service users finances that were checked. There was no written record or receipts for transactions made on behalf of one service user. Night required regular drills to ensure that they were fully conversant with the action that they needed to take in the event of a fire. EVIDENCE: The manager of the sister home ‘The Firs’ is currently overseeing the home. The owner’s intention is to register The Firs and Dorothy House as one registered home with one manager. The manager was undertaking a level 4 National Vocational Qualification in management and care. The staff commented that they “worked well together” and that the deputy manager was “very good”.
Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 19 There was a relaxed and friendly atmosphere within the home. Service users spoke positively about the care that they received. Service users were observed to be receiving personal care in a manner that respected their privacy and dignity. Interactions between staff and service users appeared respectful and caring. Service users were encouraged to manage their own finances, which enabled them to maintain their independence. Arrangements were in place for service users who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. Two service users finances were checked. One record checked was well maintained and safeguarded the financial interests of the service user. However, there were no written records or receipts for transactions made on behalf of one service user. Fire drills were being conducted on a regular basis. Records demonstrated that not all staff, in particular the night staff, had received regular drills to ensure that they were fully conversant with the action that they needed to take in the event of a fire. The staff had received training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 20 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 x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 2 Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15 Requirement Care staff must review care plans in consultation with the service user (where practical) Timescale of 1st August 2005 not met. Care plans must detail the specific care needs of the service user. Risk assessments must be reviewed at least monthly. Healthcare records must detail the specific treatment offered ensure that their healthcare needs can be monitored. Accurate records of medication administered to service users must be maintained. Service users must be given the opportunity, within a risk management framework, to continue to administer their own medication. The carpet in bedroom 10 must be replaced. Staffs’ personal files must contain a record of the employee’s full employment history. Any gaps in employment must be accounted for and
DS0000018245.V254942.R01.S.doc Timescale for action 30/11/05 2 3 4 OP7 OP7 OP8 15 12,13,15 12 30/11/05 30/11/05 30/11/05 5 6 OP9 OP9 13 12,13 20/11/05 30/11/05 7 8 OP19 OP29 13,23 19 01/12/05 30/11/05 Dorothy House Version 5.0 Page 22 9 OP29 19 10 OP35 17 11 OP38 13,23 recorded. Timescale of 31st August 2005 not met. Staffs’ personal files must contain a recent photograph of the employee. Timescale of 1st August 2005 not met. Written records and receipts of all transactions made on behalf of service users must be maintained. All staff, including night staff, must receive regular fire drills. 01/12/05 30/11/05 15/11/05 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 OP19 OP38 Good Practice Recommendations Comfortable seating should be provided in the garden. The manager should achieve the managers’ award by 2005. Dorothy House DS0000018245.V254942.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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