Inspection on 04/05/05 for Dorriemay House

This inspection was carried out on 4th May 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

Dorriemay House 15/04/08

Dorriemay House 30/04/07

Dorriemay House 27/04/06

Dorriemay House 07/11/05

Dorriemay House 11/01/05

Dorriemay House 20/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Dorriemay House 23-27 Eaton Road Margate Kent CT9 1XB Lead Inspector Clair Brown Unannounced 10:30 am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dorriemay House Address 23-27 Eaton Road,Margate Kent, CT9 1XB 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) 01843 292616 Mr David Barrie Mirsky Care Home 25 (LD) Category(ies) of Learning Disability registration, with number of places Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11.01.05 Brief Description of the Service: Dorriemay House provides residential care to up to 25 people who require varying degrees of assistance as a result of their learning disabilities. The Home comprises three adjoining terraced properties, with a paved garden area, situated close to the sea front in a residential area of Margate. The Home is within a short distance of amenities such as rail and bus services, shops and churches, a library and a concert hall. Staffing comprises of the registered provider, a head of care, care staff and ancillary staff. The premises lack access for people with impaired mobility. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Homes unannounced inspection, which was conducted with the registered person and the head of care and lasted 3 ½ hours. The main focus of the inspection was to observe the progress being made to met requirements and recommendations made following the last inspection. Also concerns had been raised by social service regarding the meeting of one service users needs. A quick tour of the premises was conducted to give the inspector an overview of the layout and general condition of the building. 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. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These outcomes were not inspected on this occassion, but will be at the next inspection. EVIDENCE: Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 The care plan system provides staff with the information they need to meet service users needs, but some confidential information is held inappropriately. Service users wishes and choices are acknowledged and supported. EVIDENCE: Two service users care plans were case tracked, these were recently reviewed and included details of the how to meet the individual care needs of the service users. The service user signed the care plans. The are records kept where information about all of the service users and their personal care provided is held in one file, such as the person hygiene records. The registered provider and head of care were able to verbally demonstrate how the Home supports service users to make choices and decisions, especially when relating to maintaining contact with relatives and friends. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These outcomes were not inspected on this occassion , but will be at the next inspection. EVIDENCE: Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Service users health needs are being met. EVIDENCE: Two service users care plans were read, daily records provided evidence of accessing health care and the meeting of healthcare needs. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The Homes complaint procedure is not adequate and is not fully implemented by staff. Staff are not confident in using adult protection procedures. EVIDENCE: The complaints records book was blank, with no entries made by visitors, service users and staff. During discussion with the head of care it was stated that minor concerns/complaints are not formerly recorded and it became apparent that staff are not aware of the need to follow the complaints procedure. There are confidentiality issues when using a communal book for people to record concerns that is held in a communal area. There were concerns raised by another agency about the appearance / personal hygiene of a service user, these were raised directly with the Home by care management but no record of this contact was made. The registered person raised concerns about a service users behaviour and the possible cause. There was a reluctance to inform the appropriate authorities of these concerns. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,30 The Home was free from offensive odours and clean. The Home is a comfortable environment, which would benefit from some refurbishment but is maintained to an acceptable standard. EVIDENCE: The Home is a large building made up of three terraced town houses, which have basements floors and three further floors. The Home has a paved garden with planted boarders. The Home was seen to be maintained although there were some areas of the Home that need some attention, such as some patches of damp in a bedroom and passageway. The Home was seen to be clean, however infection control procedures were not inspected. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 The recruitment procedures implemented do not ensure the safety and welfare of the service user. The staffs working rotas do not ensure safe working practices of the care staff. EVIDENCE: The most recently employed care staff file was assessed. The carer was employed before CRB and POVA was applied for and before written references were obtained. The carer started work the day after they were interviewed, without any of the required checks. Applications for CRB and references were made after employment had started. The duty rota showed that one carer regularly worked a 19 hour day which starts at 08.00 to 17.00hrs and then returns at 22.00 hrs to work a full waking night shift, being the only waking night carer, the other carer on duty is a sleep shift. The waking carer is required to take on the responsibilities of administering medication and is in-charge of the Home. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These outcomes were not inspected on this occassion, but will be at the next inspection. EVIDENCE: Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 2 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dorriemay House Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 17 yes Are there any outstanding requirements from the last inspection? 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 34 Regulation 17 schedule 2 Requirement Timescale for action 13.05.05 2. 33 3. 17, 23 4. 22 5. 6 The registered person must operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of Service Users. All new staff must not work unsupervised until XXX 13, 16, The registered person must 17,18, 23 ensure safe working practices relating to staff working hours schedule 4 and comply with current legislation. 12, 17,20, For a two signature procedure to 23, be used for the recording of svhedule service users financial records. 4 17, 22 All concerns and complaints schedule must be acknowledged and 4 recorded and the complaints procedure adhered to. 12,13,15, All individual confidential 17 information to be recorded in the individual service users file. 13.05.05 30.05.05 30.05.05 30.05.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 18 No. 1. 2. 3. Refer to Standard 17, 23 22 37,38 Good Practice Recommendations To review the format used for recording service users finances to provide clear records of the accounts. to review the Homes complaints procedure. To obtain copies of the national minimumstandards and regulations. Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dorriemay House H56-H05 S23391 Dorriemay House V225224 090505 Stage 4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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