CARE HOMES FOR OLDER PEOPLE
Dothan House 458 Upper Brentwood Road Gidea Park Romford Essex RM2 6JB Lead Inspector
Ms Rhona Crosse Unannounced Inspection 24th February 2006 09:40 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 Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 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. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Dothan House Address 458 Upper Brentwood Road Gidea Park Romford Essex RM2 6JB 01708 761647 01708 761647 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) Genesis Residential Homes Limited Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th October 2005 Brief Description of the Service: Dothan House is a property that has been converted over time to accommodate 19 older people. The home provides 24 hour care. The home is situated in a residential area of Gidea Park, parking is to the rear of the property. There are single and shared bedrooms. Nine of the bedrooms have en-suite facilities. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection therefore the home did not know the inspector was coming. The inspector arrived at 9.40am. The acting manager assisted with the inspection. The proprietor arrived at the home later in the morning. The home was appropriately staffed. The home was well heated (it was a very cold day). This inspection was to check compliance with the previous requirements made at the unannounced inspection carried out on 19.10.06. Also to inspect the remaining ‘core’ standards which were: the admission process, medication practice, recruitment and selection of staff, service users finances, the management of the home and the homes quality assurance system. This information was gained from the inspection of documents and discussion with the manager, staff, service users and relatives visiting the home at the time of the inspection. What the service does well:
The service has improved since the manager took up his post. He is well liked by the service users and relatives. The inspector was met by the cook, she was appropriately dressed for her role, being very neat and tidy and had a spotless white tabard covering her clothing. Service users spoke with the inspector stating that they were happy with the service the home provides. “ You can do what you like and get up when you want”. “I like the food here but sometimes you don’t get a choice, I expect if you asked they would give you something else, but I don’t ask.” “I like fish and chips, it’s fish and chips today it’s Friday”. “The staff are kind and take time to help us”. Relatives visiting the home at the time of the inspection stated to the inspector that they were happy with the home and the care provided. “We are always made welcome and offered a cup of tea or coffee”. “The cook always makes a point of welcoming us and offering us refreshments”. “Mum occasionally asks to go home but has responded well to being here, she has improved since she has been living here”. “Any things we raise are dealt with, I have no complaints, other family members visit Mum and if they had concerns they would tell us, we are all happy with the care”. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 6 Entertainers were booked to visit the home on the afternoon of the inspection and service uses were looking forward to this event. An inspection of money held in safekeeping was made. All entries were correct with corresponding receipts/records from Chiropodist, hairdresser and Aroma therapist held on file. The acting manager stated that family members are able to check any expenditure made by the home on behalf of their relative. What has improved since the last inspection? What they could do better:
It was a requirement made at the last inspection in October 2005 that the hallway from room 3 through to the ‘blue’ corridor is decorated. This requirement has not been met within the timescale given at the last inspection. A further timescale will be set, however the home must comply with the new timescale given. For 2 staff newly employed there were documents that were not held on file. The home must ensure that prior to new staff working in the home that the documentation required by legislation is provided by staff and held in staff files. It was a requirement that the cook undertake a food & hygiene course. Although this was undertaken the score to pass the course was one point below that required to receive a certificate. The cook has therefore to take this course again. The home must put forward the cook to retake this training as a
Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 7 matter of urgency and provide any support as necessary for her to achieve this certificate (despite this the cook has been observed by the inspector at 2 unannounced inspections to work within the food hygiene standards). It was a requirement at the last inspection that one staff member who had not yet received training in the protection of vulnerable adults should be put forward for this course. It is a regulation that all staff have to attend this training. A new timescale for compliance will be given for this to be achieved. Any new staff employed who have not had this training must also be put forward for this course. The home must carryout a quality assurance survey and when the information has been returned to the home from relatives, friends and health professionals an analysis of the information must be made. This analysis must form part of the Service Users Guide. This should be taking place annually. 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. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 8 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 Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 9 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 This standard is met. This ensures that the home can meet the needs of any prospective service users before any admission takes place. EVIDENCE: At the last inspection although the manager stated that he carried out a pre admission assessment, there was no written evidence to support this. At this unannounced inspection the file of the most recent services user admitted to the home was inspected the file held a written assessment carried out by the home. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 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): 9 This standard was met. Good medication practice ensures that service users received the appropriate medication at the prescribed times and that their health and wellbeing is addressed. EVIDENCE: The home has policies and procedures for the administration and recording of medication. Staff who are designated to administer medication have undertaken training to enable them to do this safely. The manager stated that he checks the medication into the home when it is delivered monthly ensuring that all is correct before the new months medication is used. An audit of medication was carried out. All medication was appropriately signed for when administered. If medication was not given then the correct ‘code’ was used to identify why the medication was not given. A random selection of medication that was not held in a monitored dosage system was
Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 11 counted. The amount of medication held corresponded correctly with the medication administration records. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 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): These core standards were met at the last inspection, therefore they were not checked at this inspection. These standards will be inspected at further inspections. EVIDENCE: Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 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): These core standards were met at the last inspection, therefore they were not checked at this inspection. These standards will be inspected at further inspections. EVIDENCE: Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 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 The standards 20, 21, 22, 23, 24, 25 and 26 were met at the last inspection and were therefore not checked at this inspection. These standards will be inspected at further inspections. Standard 19 relates to the building in general. The home have not complied with the requirement to decorate the hallway from bedroom 3 down to the ‘blue’ corridor, within the timescale set at the last inspection. The lack of compliance with requirements has implications for the well being of service users. EVIDENCE: It was a requirement at the last inspection of 19 October 2005 that the hallway from bedroom 3 down to the ‘blue’ corridor be decorated. This has not been achieved. A further timescale will be given for this work to be completed, however compliance with this timescale must take place. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 15 The laundry room was having some refurbishment work undertaken at the time of the inspection, with pipe work being boxed in and new shelving put in place. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 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): 28 and 29 Standard 28 was met. This ensures continuity of care and provides staff with a good knowledge base to provide appropriate care. Standard 29 was not met as some documents required by legislation were not held for 2 new staff. The lack of supporting documents for staff selection purposes does not protect vulnerable service uses. EVIDENCE: Staffing levels (care staff) were appropriate at the time of the unannounced inspection and the cook and maintenance man were also at the home. A member of the domestic staff had rung in sick earlier in the morning prior to the manager arriving at the home. This post was therefore not covered that morning due to short notice. The home has 50 of it’s current staff trained to NVQ level 2. One staff member holds an NVQ level 3 qualification. All new staff undertake a TOPPS induction which is undertaken over a 6 month period. When an inspection of the most recent staff employed was made it was observed that some documentation required by the Regulations had not been provided. For staff number 1 there was no current photograph or copy of a passport (if held). For staff number 2 there was not copy of a birth certificate or a copy of the staff member’s passport (if held). The home must ensure that all documentation required is provided prior to staff commencing duties.
Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 17 Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 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 35 The manager is not yet registered with the Commission therefore standard 31 is not met. However he has made good progress with the changes he has implemented in the home. The home needs to carryout a quality assurance survey to establish if the ongoing operation of the home is continuing to meet the needs of service users. EVIDENCE: The home has to ensure that as part of the ongoing operation of the home that a quality assurance system is in place. Therefore a questionnaire must be sent out to all service users, relatives, friends and health professionals that visit the home. Once the information is returned, the home should carry out an analysis of the information. This analysis should then become part of the information provided to service users as part of the Service Users Guide.
Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 19 The manager undertakes training to keep abreast of the needs of service users and increase his skills and knowledge. The last training undertaken was the Registered Managers Award and Dementia training to become a ‘trainer’ this will enable the manager to train the staff group in dementia care. The homes insurance policy is current. Service users money held in safekeeping and used on their behalf for purchases or services from the Chiropodist, Hairdresser and Aroma-therapist were found to be in order. All entries were recorded and receipts were kept to evidence any expenditure. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x x Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23(2)(d) Requirement The hallway (from room 3 down to the blue corridor) requires the woodwork and the walls decorating (this is an outstanding requirement from the last inspection). Timescale for action 30/05/06 2. OP29 7,9,19Sch d2,1-9 18(1)(c) (i) 3. OP30 Copies of passport, birth 15/03/06 certificate and recent photograph must be held for the 2 new staff identified to the manager. Food hygiene training must be 30/03/06 provided for the current cook and a certificate achieved (this is an outstanding requirement from the last inspection). The one staff who has not 30/05/06 attended protection of vulnerable adult training must do so (this is an outstanding requirement from the last inspection). Also new staff employed who do not have this training must also attend this course. The manager’s application for registration must be sent to the
DS0000027859.V284350.R01.S.doc 4. OP30 13(6) 5. OP31 9(1) 15/03/06 Dothan House Version 5.1 Page 22 Commission (this is an outstanding requirement from the last inspection). 6. OP33 24(1)(b) A quality assurance survey must be completed and the analysis of the information must added to the Service Users Guide (annually). 30/04/06 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 OP38 Good Practice Recommendations The manager must monitor the accident forms more closely. Dothan House DS0000027859.V284350.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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