Inspection on 24/11/05 for Dugdale House

This inspection was carried out on 24th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dugdale House 18/04/07

Dugdale House 26/04/06

Dugdale House 08/04/05

Dugdale House 21/10/04

Dugdale House 17/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Dugdale House 1 Santers Lane Potters Bar Hertfordshire EN6 2BZ Lead Inspector Yoke-Lan Jackson Unannounced Inspection 24th November 2005 16:30 Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 Dugdale House DS0000019329.V268965.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 Adults 18-65. 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. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dugdale House Address 1 Santers Lane Potters Bar Hertfordshire EN6 2BZ 01707 642541 01707 643653 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) Caretech Community Services Limited Care Home 8 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (2) of places Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th April 2005 Brief Description of the Service: Dugdale House, located near the town of Potters bar, is one of the care homes provided by CareTech Community Services Limited. The home provides full care services for eight service users with learning disability. The two storey detached house was converted into a care home in 1998. There is a front driveway and parking facilities. The ground floor comprises the office, lounge, dinning room, kitchen and two bedrooms with en-suite facilities. The other six bedrooms are on the first floor. These have no en-suite facilities. The toilet and bathroom facilities are nearby. The building itself is surrounded by spacious ground that is mainly laid to lawn with mature trees and shrubs. The patio and garden are accessible to wheelchair users. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted on 24 November 2005. The home manager and the deputy manager were present. There are seven service users and one vacancy. A tour of the premises was carried out. The service user’s care plan (within the support plan file) and other documents were examined. Staff performance and their interaction with the service users were observed and noted. The standard of service and care provided have been maintained. All the seven service users were unable to communicate verbally. However they appeared well cared for. One service user, admitted two days before this inspection, appeared very unsettled and she constantly required the attention of a staff member constantly on the day of the inspection. The home manager assured the inspector that there is a trial period of stay for the new admission. (Please see below for details of the inspection findings). What the service does well: What has improved since the last inspection? The home manager is currently going through the process of registration with the Commission for Social Care Inspection. A deputy manager has been appointed since the last inspection. The staffing level is now fully covered by permanent workers. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 the following standard(s): 2, 3, 5. Each service user has a statement of the terms and conditions with the home. There was a new admission two days before the inspection. A trial period of stay is arranged for her. EVIDENCE: Documents seen confirmed that the initial assessment and the decision to admit the new service user into the home was made by the provider, CareTech. The home manager has very little input in the admission process. The most recent admission was two days before the inspection. On the day of the inspection, the new service user appeared very agitated and very unsettled. A staff member has to attend to her constantly. Additional staff were deployed at times. The home manager assured the inspector that there is a trial period of stay and that a transfer will be arranged if the service user’s needs and aspirations cannot be met at Dugdale House. The home manager must ensure that the routine and welfare of the remaining six service users are not disrupted by the circumstances surrounding the new admission. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 the following standard(s): 6, 7, 8, 9, 10. Service users are given every opportunity to participate in all aspects of routine living in the home. Staff encourage them and give them support when necessary. Confidentiality is maintained in accordance with legislation. EVIDENCE: The majority of the service users have severe learning disability and their ability to communicate or to participate in the daily routine are limited. Their assessed and changing needs were reflected in the care plans examined. The support plan file and the care plan for the new service user are being formulated. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 the following standard(s): 11, 12, 13, 14, 15, 16, 17. Service users are treated with respect and dignity. They have regular contact with their relatives. Service users integrate into the community through outdoor activity programmes. The meals provided are balanced and nutritious. EVIDENCE: Arrangements are made for the service users (who have relatives) to visit them regularly. The weekly activity programme for each service user was displayed on the noticeboard. Each service user spends three days at the Day Care Centre of their choice. One service user attends the local college four days a week and participates in educational activities that she has selected. The members of staff take turns to prepare the food. Service users are encouraged to help. The dietician visits once a month to ensure that the menu provided is suitable for the respective service users. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 the following standard(s): 18, 19, 20. Service users receive the personal support and care in the way they prefer and require. Trained staff administer the medication in accordance with legislation. EVIDENCE: The home manager ensures that the health and behavioural concerns of any service user in the home are referred to the appropriate health care professional for immediate assessment. Proper records are kept in the Support Plan File. The care plan is updated accordingly following the assessment and review. The Medication Administration Charts were correctly completed and medicines were administered in accordance with legislation. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 the following standard(s): 22, 23. The Complaints Policy and Procedure are in place and they are available to the service users and others. The home manager ensures that service users are protected from abuse, neglect and self-harm. EVIDENCE: The home follows the Hertfordshire Adult Protection Procedure. Staff are aware of the Whistle Blowing Policy. The ‘Talking-Time’ sessions were documented, dated, signed and filed in the individual Support Plan file. Written risk assessments examined revealed that the individual service user is protected against self harm or neglect. There were no complaints received since the last inspection. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 the following standard(s): 24, 25, 26, 27, 29, 30. The home is well maintained and provides a safe and comfortable environment for the service users. EVIDENCE: The premises appeared clean and tidy. The lounge was recently refurbished with comfortable furniture. The carpets have been replaced with new ones. There is an on-going maintenance programme. The home keeps a daily record of the water temperature which is thermostatically controlled. The bedrooms examined were clean and tidy. One service user showed the inspector his bedroom. He seemed content and appeared well cared for. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 32, 34 and 35 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, 32, 33, 34, 35, 36. The home has an effective staff team. Staff have good knowledge of the needs and aspirations of the service users in their care. Service users are supported and protected by the home’s recruitment practices. The home is maintained by permanent staff. EVIDENCE: Staff interviewed confirmed that they are well supported by the manager. New staff are appropriately trained. The personal records examined were satisfactory and the recruitment process was in accordance with legislation. Since the last inspection, the home’s recruitment process has been successful and only permanent staff are now employed. In the past agency staff have made up for the shortfall in staff. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38, 40, 41, 42, 43. The administration and management of the home are consistently maintained. All records are kept and updated in accordance with legislation. EVIDENCE: The home manager ensures that the standard of care continue to improve and that good practice is maintained. She herself is going through the registration process with the Commission (CSCI). The home’s filing system provides easy access and is well maintained. The records are kept and handled in accordance with the Data Protection Act 1989. Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 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 2 3 x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dugdale House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 3 x DS0000019329.V268965.R01.S.doc Version 5.0 Page 17 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dugdale House DS0000019329.V268965.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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