Inspection on 23/06/05 for Dorothy House

This inspection was carried out on 23rd June 2005.

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 11/07/07

Dorothy House 15/01/07

Dorothy House 21/08/06

Dorothy House 19/10/05

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 Jayne Barnett-Middleton Unannounced 23 June 2005 09:00am - 2:00pm 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 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 J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dorothy House Address 186 Dodworth Road Barnsley South Yorkshire S70 6PD 01226 249535 01226 249535 None Mr Azar Younis Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant PC - Care home only 16 Category(ies) of OP - Old age (16) registration, with number of places Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 February 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 adequete 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 J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 09.00 a.m to 2.00 p.m. Five service users, three staff, the responsible individual and two relatives 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? Risk assessments had been completed for service users with particular attention to the prevention of falls. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 6 Staff personal files had been updated to include a photograph, however some work was still required to ensure that they contained a record of the employees full employment history. The registered provider was producing monthly reports as required by Regulation 27. 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 J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 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 J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 standard(s) 7,8 and 10. Service users individual needs were assessed and care plans had been completed for service users. There was no record to evidence that care plans had been completed with the involvement of the service user or that the service users had been consulted about their preferred funeral arrangements. Two Care plans required reviewing to ensure that the changing needs of the service user were reflected in their plan of care. Service users privacy and dignity was respected. EVIDENCE: Three Care plans set out in detail the action that was required by staff to ensure that all aspects of service users care needs were met. The Care plans had not been completed with the involvement of the service user; to give them the opportunity to agree with staff the help that they needed to live as independently as possible. Care plans did not evidence that the service user had been consulted about their preferred funeral arrangements, to ensure that any specific requests and spiritual needs could be respected. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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. The deputy manager confirmed that two service users were suffering from pressure sores. It was evident through discussions and detailed daily care notes that the appropriate care and treatment by healthcare professionals was being provided. However, the care plans checked did not detail that the service users were suffering from pressure sores or the specific care and treatment that was required. Service users said that their healthcare needs were met and confirmed that the staff would “contact my doctor when I need one”. One relative stated that the staff regularly “keep me up to date” in relation to their relatives cares. Service users were observed to be receiving personal care in a manner that respected their privacy and dignity. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 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: The daily routines within the home were flexible. Service users said that they could spend the day as they wished and described how they spent their day, “ I like reading and watching TV”. Several service users were observed to be spending time in the lounge whilst other’s had chosen to spend the day in the privacy of their bedroom. Service users said “I can get up and go to bed when I wish ” and “I can do as I like”. Service users were encouraged to maintain links with their family and friends. Service users said that their relatives could visit them at any time. One relative who visited their relative on a regular basis said, “We are always given a cup of tea and made to feel welcome”. The deputy manager said that regular entertainment was organised at ‘The Firs’ and service users confirmed that they were invited to attend. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 12 A good choice of menu was offered and special dietary needs were catered for. The cook said that she had recently reviewed the menus based on service users likes and dislikes. Service users said that they enjoyed their meals and described the food as “good” and “very nice”. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 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 and had “no grumbles” and that the staff were “approachable” There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The staff confirmed that they had received adult protection training Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 standard(s) 19,24 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 very clean and tidy, which promoted a comfortable and homely environment. The domestic staff said that they “worked very well together” in maintaining a good level of cleanliness. One service user said that the home was always clean “ they don’t give the dust time to settle”. The home was decorated in a comfortable and welcoming manner including homely touches of pictures and ornaments. Service users said that they liked the home “its very nice” and “I would recommend it”. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 15 There was a small-enclosed garden to the rear of the home, which did not appear to be used. One service user said that she would go outside more if comfortable seating were provided. Several bedrooms were checked and all were clean and well decorated. One bedroom carpet was beginning to show signs of wear and tear and was due for replacement within the near future. Service users had been encouraged to personalise their bedrooms with photographs and mementoes, which encouraged service users to retain their own identity. Service users said that they liked their bedrooms “its bright and airy”. Laundry facilities were sited away from food preparation areas 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. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30. Sufficient and experienced staff was provided that met the assessed needs of service users. Staff files required updating to ensure that they contained all of the required information. A training and development programme was in place. EVIDENCE: Service users and relatives spoke positively about the staff team and described them as “caring”, “good” and “very nice.” Staff rotas checked, demonstrated that the agreed staffing levels were being met to meet the individual needs of service users. A recruitment policy and procedure was in place that promoted the protection of service users. Three files checked did not contain the full employment history of the employee. The files checked did contain evidence that the employee had undertaken a criminal record bureau check. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. The staff confirmed that they had attended various training courses and had completed or were in the process of undertaking a N.V.Q level 2/3 in care. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38. The home was managed in the best interests of service users; positive comments were made about the service and the care that service users received. The health, safety and welfare of service users were promoted. 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. There was a relaxed and friendly atmosphere within the home. Service users spoke positively about the care that they received and stated that the management team were “approachable” and “they always try to help”. Service user and relatives questionnaires were available in the entrance of home, which gave them the opportunity to comment on all aspects of the care provided and to make suggestions on how the service could be developed. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 18 The responsible individual, Mr Younis, visited the home on a regular basis to check the standard of care provided and to inspect the premises. Records of these visits were forwarded to the C.S.C.I. A handyman was employed at the home and a routine programme of maintenance was in place. All areas throughout the home were well maintained which promoted a safe environment. Policies and procedures were in place and the staff had received training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 20 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 13 Requirement The incidence of pressure sores, treatment and outcome must be recorded in service users care plans. Care staff must review care plans in consultation with the service user (where practical) Service users preferences regarding funeral arrangements must be recorded on their care plan (Timescale of 1st April 2005 not met) Staff files must contain a record of the employee’s full employment history (Timescale of 30th April 2005 not met) N/A. Timescale for action 1st August 2005. 1st August 2005. 1st August 2005. 2. OP7 15 3. OP7 OP11 13 4. OP29 19 31st August 2005. 5. 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 OP19 Good Practice Recommendations The carpet in the identified bedroom should be replaced within the next six months. Comfortable seating should be provided in the garden. J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 21 Dorothy House 3. 4. OP28 OP38 A minimum of 50 of care staff should be trained to NVQ level 2 by 2005. The manager should achieve the managers award by 2005. Dorothy House J51 S18245 Dorothy House V234118 230605 UI Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffeild, S9 2LR 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. 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