Inspection on 18/04/05 for Dorset House

This inspection was carried out on 18th April 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

Dorset House 06/08/09

Dorset House 29/04/09

Dorset House 21/04/08

Dorset House 26/06/07

Dorset House 21/10/05

Dorset House 13/12/04

Dorset House 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Dorset House Blackfriars Avenue Droitwich Worcestershire WR9 8DR Lead Inspector Andrew Spearing-Brown FINAL - Unannounced 18 April 2005 09.10 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. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dorset House Address Blackfriers Avenue Droitwich Worcestershire WR9 8DR 01905 772710 01905 771476 dorset@agecare.org.uk Royal Surgical Aid Society 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) Mrs Pauline May Wilson CRH 42 Dementia - over 65 Old age Physical disability - over 65 42 42 42 Category(ies) of DE(E) registration, with number OP of places PD(E) Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no other conditions of registration other than those refered to on the previous page of this report. Date of last inspection 13 December 2004 Brief Description of the Service: Dorset House is a large attractive building, set in a beautiful garden on the outskirts of Droitwich. The older part of the building was built in 1928. There are currently 40 single rooms that measure at least 10 square metres, all of which have en-suite facilities. There is one double room at least 16 square metres in size with en-suite facilities; a single occupant currently uses this room. A new bedroom with en-suite facilities was recently created on the first floor. The result of this bedroom has not however altered the overall provision as a small room without en-suite was taken out of use as a resident’s room and is now an office. Two shaft lifts are available to enable people with mobility concerns to move easily between floors, a stair lift is also provided on a small flight of stairs on the first floor. A service is offered to a maximum of 42 people over the age of 65 years who may have needs associated with age and physical disabilities. The home is one of several care homes for older people run by Age Care, a charity formed in 1862 as the Royal Surgical Aid Society. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection carried out on the 18th April was an unannounced visit to Dorset House. This visit was the first to take place during the year 2005- 06. The inspection took place over a period of 6 hours. A partial tour of the premises took place and staff and care records were inspected. A representative sample of staff and residents were consulted. The registered manager was not on duty on the day of this visit having worked the weekend beforehand. What the service does well: What has improved since the last inspection? Significant improvement had taken place since the last inspection regarding the administration and recording of medication. One area where some further improvement is necessary was noted in order to achieve full compliance. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 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. Dorset House E52 S18648 Dorset House (2) V220045 180405.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 Dorset House E52 S18648 Dorset House (2) V220045 180405.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) 3. Standard 6 is not applicable to Dorset House. Additional work is required to ensure that all relevant information is available for staff to write an appropriate care plan for residents at the point of admission into the home. EVIDENCE: A copy of the Statement of Purpose was available within the reception area. Daily records and some other information were available to staff in relation to a newly admitted resident However no pre admission assessment was available; staff were confident that an assessment had taken place. Dorset House does not offer intermediate care. Dorset House E52 S18648 Dorset House (2) V220045 180405.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, 9 and 10 were all partially assessed on this occasion The process of providing care plans requires further attention, there is insufficient clarity documented regarding the needs of individuals. One further improvement is needed to fully safe guard residents when administering medication. EVIDENCE: Representative samples of care plans were viewed as part of this unannounced inspection. One in particular was viewed in greater detailed due to the range of care needs which became apparent upon initial reading. It was evident that a number of different persons were involved in formulating the care plan due the care needs as part of a multi disciplinary approach. However the actions to be taken by carers were not always clear. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 10 The home has made progress since the last inspection with regard to the arrangements for the safe storage and administration of medication. Those medication administration records seen were completed correctly accurately. One item, which needed to be destroyed after a period of twenty-eight days, was out of date. Since the last inspection the registered manager has changed to a different supplying pharmacist. Service users consulted confirmed that medical appointments such as GP consultations are carried out within their own bedrooms. From observations made as well as comments from residents it was evident that residents are treated with due regard to privacy, dignity and respect. A pay ‘phone is provided however this is located under the main staircase which becomes hot and stuffy when the door is closed. Dorset House E52 S18648 Dorset House (2) V220045 180405.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) 13, 15 Service users’ dietary needs are well catered for with a balanced and varied selection of food readily available that meets their individual preferences. EVIDENCE: Dorset House has ample of communal areas, which would provide a suitable space for service users to receive visitors in addition to the privacy of their own bedroom. It was evident from examining the visitors book that visits take place throughout the day. The inspector witnessed visitors been welcomed to the home. Dorset House encourages community inclusion, which was evidenced during this visit. All service users spoken to during this inspection were complimentary of the quality of food served to them and the choices made available to them. While joining service users for lunch these complimentary comments continued. Further evidence of residents’ satisfaction with the food provided was available via the results of a quality assurance questionnaire, which were displayed in the hallway. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 12 A copy of the week’s menu was on display at the entrance to the dining room. The menu was professionally set out and showed a good selection of nutritious meals. During the lunchtime routine waitress staff served meals while care staff and senior staff were able to offer service users assistance when needed in a caring and relaxed manner, as well as join service users for a meal. This provided an opportunity for service users to socialise with each other and with staff. Service users were able to serve themselves to vegetables the portions available were plentiful. Fruit as well as cheese and biscuits were available following the sweet. A residential drinks licence is held for the purchasing of a drink to have alongside a meal. Dorset House E52 S18648 Dorset House (2) V220045 180405.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 Residents consulted were confident that any complaints or concerns would be listened to. EVIDENCE: All of the service users spoken to said they felt safe in the home and that if they were unhappy with the care provided to them they knew whom to talk to and would be confident to do so. Residents spoke confidently of the manager and her ability to address any concerns, worries or complaints. Dorset House E52 S18648 Dorset House (2) V220045 180405.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, 20, 24, 26 Dorset House presents as a homely place to live, which is clean and comfortable. EVIDENCE: Dorset House was warm and clean on the day of the inspection. The communal areas of the home were well maintained; the drawing room has been re-carpeted and decorated since the last inspection. New curtains are in place within the morning room. Residents consulted confirmed that the home is kept clean and tidy Numerous pictures and other items such as plates ardour the walls, some of which show either Dorset House or Droitwich Spa. The drawing room contains a large picture as well as photograph albums of HRH The Duchess of Gloucester who is Patron to AgeCare. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 15 The corridor areas within the newer part of the building are bright and welcoming. The same areas within the original part of the home are in need of decorating as the current décor is looking dated and fatigued in its appearance. The extensive gardens consisting of lawned, patio and seating areas were well maintained. Future plans include a sensory garden and changes to the pond area. Dorset House has in the past won prizes within the Droitwich in Bloom competition. Lighting within the drawing room in particular was noted to be domestic and of a good quality. Bedroom number 31 had an unsuitable lock fitted to the door; its design could potentially lead to the resident locking themselves in their bedroom with the key in place thus prevent staff gaining access in cases of emergency. At the time of the previous inspection work was scheduled to complete the fitting of covers to radiators and pipe work. It was evident that the work upon radiators was complete. It is believed that all pipes delivering hot water are also now covered. The manager should ensure that this is the case. The laundry was in good order; walls are readily washable and the floor impermeable. Residents’ satisfaction with the cleanliness of the home and the laundry were displayed as part of the results from the quality assurance questionnaire. Dorset House E52 S18648 Dorset House (2) V220045 180405.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, 28, 29 The level of staffing at Dorset House is sufficient to meet the needs of residents. The procedures for obtaining suitable checks upon new employees are in need of improvment; not having these checks in place could leave residents at risk. EVIDENCE: The current staffing rota was not seen however the reported staffing level on the day of the inspection were consistent with previous inspections. A total of five (5) carers were on duty in addition to the senior. Other staff included kitchen staff, domestic staff, waitress staff, administrator and a maintenance person. Dorset House had no staff vacancies at the time of this inspection. Agency staff are not used in order to maintain continuity of care. A total of ten (10) members of staff have completed training to NVQ (National Vocational Qualification) level 2 while another one (1) member of staff has a level 3 qualification. This is a total of 50 of carers qualified, which is in line with the National Minimum Standards. In addition to the qualified staff a further six members of staff are working towards level 2 and one working towards a level 3 qualification. New member of staff confirmed that a Criminal Records Bureau check was obtained prior to him commencing work at Dorset House; this was verified by means of records seen. The administrator was aware of POVA first availability (Protection of Vulnerable Adults). Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 17 The file of another recently appointed employee was not satisfactory in that it was evident that induction commenced prior to the arrival of the reference from the previous employer and prior to obtaining either a POVA first or Criminal Records Bureau check. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 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 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) 35, 38 Staff safeguarded residents money by providing well documented records. A small number of shortfalls in relation to health and safety require further attention to fully meet the reuirements. EVIDENCE: The residents money, when checked, where in order. A recent internal audit concluded ‘ Everything found to be in order and well kept and records up to date.’ Fire records seen were satisfactory, records maintained of any shortfalls and action taken to remedy the problem. Some chairs currently within the morning room may not meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 19 Small kitchenettes are located at various locations around the home. Each contained a small domestic style fridge which contained milk to enable residents and their visitors to make hot drinks; suitable temperatures were in place. It was noted that the cupboard under the sink was not locked in one kitchenette; this cupboard contained cleaning liquid and blocks used within toilets. These items are potentially hazardous and must not be accessible to residents. Portable electrical appliances were not viewed on this occasion; the recently appointed maintenance operative was aware that suitable inspection / checking was necessary of these items and had already agreed to commence upon these checks in the near future. As a result these records will be viewed as part of the next inspection visit. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 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 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 x x x 2 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x 3 x x 2 Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 21 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 3 Regulation 14 (1) (a) Timescale for action The registered manager must immediate ensure that a pre admission and on assessment must be available for going staff to refer to. The registered manager must ensure that the residents care plan sets out in detail the action which needs to be taken by care staff to ensure that all aspects of need are met. (Previous timescale of 15/01/05 not met). 3. 8 17 (1) (a) The registered manager must ensure that nutritional screening is undertaken on admission and subsequently on a periodic basis. (Previous timescale of 15/01/05 not met). 4. 9 13 (2) The registered manager must ensure that items with a limited shelf life are dated onced opened and disguarded within the timescale identified by the manufacture. immediate and on going 30/06/05 30/06/05 Requirement 2. 7 15 Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 22 5. 20 23 (2) (b) The registered provider must 31/03/06 ensure that all areas of the home including corridors are kept well decorated. The registered provider must ensure that all bedroom doors without a suitable lock have one fitted. The lock must be of a standard recongised by the fire authority and have suitable overide facilities. In the meantime a risk assessment must be undertaken regarding the current situation. The registered manager must ensure that two written references are received before a candidate is offered a post and the commencement of employment. immediate and on going for risk assessmen t 31/07/05 for fitting locks immediate and on going 6. 24 12 (4) 13 (4) 7. 29 19 8. 37 4, 7, 9, 19 All records required by the regulations and listed in schedules 1, 2, 3 and 4 must be maintained and available for inspection, specifically those identified as needed in this report. (This standard was not fully assessed as part of this inspection.) 31/07/05 9. 38 13 (4) (a) The registered manager must ensure that all cleaning chemicals are stored securely at all times. (Previous timescale of immediate and on going was not met.) immediate and on going Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 23 10. 38 13 The registered manager must ensure that in the event of portable heaters having to be used that a risk assessment is drawn up and that suitable action such as securing to the wall takes place to prevent them falling or items being placed on top.(Previous timescale of immediate and on going was not met.) The registered manager must ensure that all electrical items are tested and safe to be used. (This standard was not fully assessed as part of this inspection.) immediate and on going 11. 38 13 30/06/05 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 10 22 Good Practice Recommendations The registered manager should consider alternatives to the present pay ‘phone facilities. The registered manager should consider the merits of providing pendant linked to the emergency call system for service users. Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 24 Commission for Social Care Inspection The Coach House John Comyn Drive Droitwich Road Worcester WR3 7NW 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 Dorset House E52 S18648 Dorset House (2) V220045 180405.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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