Inspection on 21/10/05 for Dorset House

This inspection was carried out on 21st October 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 18/04/05

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 Spa Worcestershire WR9 8DR Lead Inspector Andrew Spearing-Brown Unannounced Inspection 21st October 2005 15:30 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 Dorset House DS0000018648.V260805.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. Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dorset House Address Blackfriars Avenue Droitwich Spa Worcestershire WR9 8DR 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) 01905 772710 01905 771476 dorset@agecare.org.uk Royal Surgical Aid Society Pauline May Wilson Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42), of places Physical disability over 65 years of age (42) Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th April 2005 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 residents 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 DS0000018648.V260805.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by an inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The visit lasted three hours from late afternoon to early evening. The last inspection at Dorset House took place during April 2005 making this inspection the second statutory visit during the 2005 – 06 inspection year. Part of this inspection was to assess the progress made in relation to the requirements from the previous inspection. At the time of this inspection the registered manager was on duty. Some time ago the CSCI were informed that the registered manager had tendered her resignation in order to explore a new venture. Acting up arrangement will be in place from November until a new manager is recruited. Once AgeCare appointed a manager it will be necessary for that person to apply to the CSCI to become registered. Due to the time of this inspection (around supper time) consultation with residents on this occasion was minimal. Some parts of the home were seen. and staff areas. These were primarily communal rooms The care records of a small sample of residents were viewed. Other documents seen included medication records, fire records, and some staff records. What the service does well: Communal areas at Dorset House are homely and welcoming. The grounds are well maintained, neat and tidy and continue to win awards as part of Droitwich in Bloom competitions. Community links continue to be maintained, visitors are welcomed. A range of activities take place within the home. Staffing training including mandatory and National Vocational Qualification (NVQ) is taken seriously. Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 6 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dorset House DS0000018648.V260805.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 Dorset House DS0000018648.V260805.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): 3. Standard 6 is not applicable to Dorset House Pre assessments are carried out in sufficient detail to demonstrate that the home is able to meet care needs prior to their admission and to provide an initial care plan. Information is available to potential residents and their representatives about the services offered at the home. EVIDENCE: Neither the Statement of Purpose nor Service Users Guide was viewed on this occasion. A copy of the Service Users Guide was noted to be in the entrance hall of the home. The registered manager is leaving Dorset House at the end of the month; therefore a new manager will need to be appointed and apply to be registered with the CSCI. As a result both the above documents will need to be amended to take the change of manager into account. These documents will be re assessed as part of a future inspection. The pre admission assessment and initial care plan regarding a recently admitted respite resident contained basic but sufficient information for carers to met identified care needs. This care plan would need to be developed Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 9 further in the event of the individual resident receiving additional respite stays in the future. Intermediate care is not offered at Dorset House and the home has no plans to provide such as service. Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 10 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 and 9 Care plans have improved however more attention is needed in relation to nutritional screening to ensure residents’ wellbeing is fully protected. Further improvement is needed to fully safeguard residents when administering medication. EVIDENCE: Individual plans of care are available. Representative samples of care plans were viewed as part of this unannounced inspection. One of the care plans seen related to a recently admitted residents while the other related to a resident whose care needs had changed significantly over the past few months. Since the last inspection significant improvements were noted around care plans. Care plans are now held on computer, which are situated in the up stairs office. Hard copies (paper copies) of care plans were held on individual files. The care plans seen gave suitable information in order for staff to collectively meet care needs. The registered manager needs to ensure that when care needs change frequently the care plan is up dated as necessary. Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 11 Although some evidence of likes and dislikes regarding diet were on file improvement in is needed to ensure that nutritional screening takes place. This screening needs to take place prior to admission and on a periodic basis in line with changing care needs. Dorset House uses the Monitored Dosage System (MDS) supplied by a high street pharmacist for the storage and administering of prescribed medication. All medication was held securely with the drug trolley chained to the wall. The Medication Administration Record (MAR) sheets were examined and showed some areas of good practice. The MAR sheets showed that medication is booked into the home accordingly and the section to record any known allergies was completed. In addition two members of staff signed to show any handwritten amendments. The manager was strongly advised to obtain confirmation of any verbal instructions to change medication by requesting a fax. The supplying pharmacist last visited the home during September 2005 and left a report, which did not highlight any undue concerns. The MAR sheet relating to two residents showed that they were recently on a course of antibiotics. These sheets were incorrect in that the number of signatures was in excess to the number of drugs prescribed. In addition one had a signature, which was then recorded as ‘signed in error’. The term ‘signed in error’ was noted on a number of occasions, this could indicate that staff are signing the MAR sheets prior to administering medication or not following the organisations own policies and procedures. A dedicated fridge is provided for medication requiring such storage. Appropriate temperature records need to be maintained for this piece of equipment. A logbook for the recording of these temperatures was found to have a number of gaps within it. During August 2005 a period whereby the temperature was not recorded for 10 days was noted. Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 12 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 and 13 Activities within the home provide stimulation and interest for people living in the home. 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 is evident from the visitors’ book that visits take place throughout the day. The inspector witnessed staff interacting well with a visitor. Dorset House encourages community inclusion, which was evidenced during this visit. A range of activities are arranged for residents to partake in. These activities can be evidenced via notices on display of forthcoming events around the home. Laminated notices are put up on the day of the activity with smaller ones placed on dining tables to ensure that residents are informed of these events. Dorset House DS0000018648.V260805.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 17 Procedures are in place to ensure that residents’ civil rights are protected. Complaints are listened to and taken seriously. EVIDENCE: The complaints log was viewed. Since the last inspection the home has received one formal complaint. A letter from the complainant as well as the registered managers response was seen which concluded that some elements of the complaint were up held while others were not up held. The Commission for Social Care Inspection has received no complaints in relation to this home. The registered manager confirmed that a number of residents used postal votes while others voted at a nearby polling station at the time of the last general election. A copy of a booklet recently issued by the County Council entitled ‘ Reporting abuse or mistreatment of vulnerable adults – guidance for staff ’ was displayed on a notice board near to the morning room as well as within the care office. Dorset House DS0000018648.V260805.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, 21, 25 and 26 The appearance of the home and the grounds continues to create a comfortable and homely environment for residents EVIDENCE: Dorset House was warm and clean on the day of the inspection. The communal areas of the home were well maintained comfortable and attractive. A display case in the entrance hall contained an autumn scene. 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. The corridor areas within the newer part of the building are bright and contain pleasant sitting areas. The same areas within the original part of the home remain in need of decorating, as the current décor is looking dated and Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 15 fatigued in its appearance. This work is scheduled to take place during the new financial year, which commenced on the 1st September 2005. The home was noted to be clean and tidy with no offensive odours. The laundry is appropriately sited and contained suitable equipment. Liquid soap and paper towels were in place at wash hand basins throughout the home in line with infection control procedures. The grounds are well maintained. Some raised flowerbeds are due to be built in the coming months. During the recent summer months Dorset House won the best communal garden category and came second in the hanging basket and window box category. Dorset House DS0000018648.V260805.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 and 28 A commitment to National Vocational Qualification (NVQ) training is evident to provide staff with the necessary skills and knowledge to promote good practice. Procedures for the recruitment of staff are not sufficiently robust to ensure the protection of residents. EVIDENCE: The current staffing rota was not seen however the registered manager confirmed that staffing levels remain consistent with previous inspections. Due to some staff shortages agency staff were used recently. A senior carer is due to leave Dorset House in November. Recruitment can be problematic therefore recruitment takes place overseas. A total of ten (11) 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. In addition one (1) care is awaiting final verification regarding her NVQ level 2. 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 number of staff are working towards their level 2 qualification. Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 17 The file of a recently appointed employee was not satisfactory in that it was evident that employment commenced prior to the arrival of at least one reference as well as confirmation of a POVA first or Criminal Records Bureau check taking place. This was a requirement following the last inspection and therefore found to be unmet during this inspection. The registered manager must ensure that suitable documentation and checks are in place prior to employment commencing to reduce the potential of residents being placed at risk. Dorset House DS0000018648.V260805.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 and 38 The registered manager seeks feedback from residents to develop a quality service. Some health and safety matters were identified that could potentially place residents and others at risk. EVIDENCE: The registered manager has tendered her resignation and is due to leave Dorset House at the end of October to take up a new venture. While a new manager is recruited acting up arrangements are taking place. Once a new manager designate is appointed an application must be made to the CSCI for registration. No resident’s money was checked as part of this inspection. The previous inspection reported upon an internal audit, which concluded that: ‘ Everything found to be in order and well kept and records up to date.’ Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 19 The required certificate of public liability insurance was on display. A resent survey was carried out seeking the views of residents. At the time of this inspection the registered manager had started to collate the results. The forms returned were however viewed as part of the visit. It was noted that the majority of response were ‘ good’ with a small number stating either ‘ excellent’ or ‘ average’. Once collated the results of this survey should be forwarded to the Worcester office of the CSCI. A small number of chairs currently within the morning room and within the library area may not meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). The registered manager stated that these are due to be replaced in the future. Fire records seen were satisfactory, records maintained of any shortfalls and action taken to remedy the problem. A recent report from a fire officer confirmed this stating ‘ the premise and the fire risk assessment were found to be satisfactory’. The self-closure on one fire door was checked and found to be in order. The annual inspection of fire extinguishers by a contractor is due at some point before the end of this month. Records regarding water temperatures and the testing of portable electrical equipment were briefly viewed and found to be in order. A random sample of electrical items were also viewed and found to have appropriate ‘stickers’ on them indicating that the item was checked at some time during the previous 12 months. Small kitchenettes are located at various locations around the home. Each contained a small domestic style fridge that contained milk to enable residents and their visitors to make hot drinks; one fridge was checked and found to be clean and in suitable order. Cupboards within these areas contain cleaning matters; these were suitably secure. Two passenger shaft lifts are provided to ensure that residents have access to all areas of the home. Due to the location of the beam on one of these lifts a risk assessment is needed regarding the possibility of the doors closing on to a resident and failing to open automatically. No servicing certificates were sought on this occasion. A label on a hoist demonstrated that it was last serviced in May 2005 and that the next service is due in November 2005. This level of servicing is in line with the Lifting Operations and Lifting Equipment Regulations 1998. Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 20 The maintenance officers have a room on the lower ground floor that contained a range of DIY items. This floor level is primarily used by staff and therefore infrequently used by any residents, however the door to the room containing such items should be secure. The registered manager undertook to ensure that this is done. Mandatory training has taken place for the vast majority of staff in relation to moving and handling, first aid, fire safety, infection control, health and safety and basic food hygiene. Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 2 3 3 X X X 3 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 3 X 3 X X X X 2 Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 22 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 OP8 Regulation 17 (1) (a) Requirement The registered manager must ensure that nutritional screening is undertaken on admission and subsequently on a periodic basis. (Previous timescale of 30/06/05 not met – a new time scale is given.) 2. OP9 13 (2) The registered manager must ensure that medication administration records are completed adequately at the time of administration. 21/10/05 Timescale for action 30/11/05 3. OP9 13 (2) The registered manager must ensure that a record is maintained of the temperature within the fridge used for medication requiring such a facility. 21/10/05 Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 23 4. OP19 23 (2) (b) The registered provider must 30/06/06 ensure that all areas of the home including corridors are kept well decorated. (The previous time scale of 31/03/06 is extended to provide additional time to met this requirement) 5. OP29 19 The registered manager must ensure that two written references are received before a candidate is offered a post and the commencement of employment. (The previous time scale of immediate and on going not met – this requirement must be met with immediate effect following this inspection) 21/10/05 6. OP38 13 The registered provider must ensure that furniture, which may not meet the required fire safety standard, is replaced. The registered manager must ensure that a suitable risk assessment is undertaken in relation to the location of the sensor beam on the passenger lift and that appropriate action is taken. 31/12/05 7. OP38 13 30/11/05 Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 24 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. Refer to Standard OP9 Good Practice Recommendations The registered manager should obtain written confirmation (such as via a fax) of any changes or amendments to residents prescribed medication. The registered manager should consider alternatives to the present pay phone facilities. (This recommendation remains) 3. OP22 The registered manager should consider the merits of providing pendant linked to the emergency call system for service users. (The provision of a new emergency call system will provide similar facilities – the system is expected to be fitted prior to 31/12/05) 2. OP10 Dorset House DS0000018648.V260805.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, 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 DS0000018648.V260805.R01.S.doc Version 5.0 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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