Inspection on 16/03/06 for Dulas Court

This inspection was carried out on 16th March 2006.

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

Dulas Court 14/03/07

Dulas Court 02/12/05

Dulas Court 22/02/05

Dulas Court 27/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Dulas Court Dulas Ewyas Harold Herefordshire HR2 0HL Lead Inspector Julian Mason Unannounced Inspection 16th March 2006 10:30 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 Dulas Court DS0000024704.V284813.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. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dulas Court Address Dulas Ewyas Harold Herefordshire HR2 0HL 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) 01981 240214 01981 240220 dulas.court@tiscali.co.uk Mr Phillip Raymond Keene Mrs Kathleen Barbara Keene Mrs Elizabeth Anne Blake Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability over 65 years of age of places (25) Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd December 2005 Brief Description of the Service: The Providers and Manager are registered in respect of Dulas Court to provide personal care to twenty-five older people whose needs arise from the ageing process or through physical disability. The Statement of Purpose produced by the Proprietors describes the primary aim thus: The purpose of this home is to provide continuous and holistic care for elderly people in a Christian environment, enabling and supporting them in their increasing frailty. The Home is located in a lovely rural setting and the house is situated in large grounds several acres of which are accessible to service users with mobility problems. One bedroom is dedicated to the provision of respite care. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, it started at 10.30am and finished late afternoon on the same day. One inspector visited the home and observed some of the events and routines of the day. The proprietor gave a tour of the building and the inspector met a number of people who were resident in the home. Two residents files were examined and a range of records were sampled. The inspector also met a number of staff and had discussions with the care manager, a team leader and a provider of an external service. Eleven “Key” National Minimum Standards were assessed and the progress on addressing the previous requirement and recommendations was also examined. This report should be read in conjunction with the previous inspection report because together the reports will cover the 22 “Key” Minimum Standards to be inspected in a 12-month period. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 6 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 Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 7 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 All residents have their needs comprehensively assessed before moving into the home. The home only accepts those people whose needs can be met by the service. EVIDENCE: An assessment process is undertaken for all perspective residents. This is carried out to ensure the home has the appropriate resources in place to meet individual needs. All assessments are carried out by the care manager who uses a comprehensive format to ensure all needs and risks are assessed. The home’s case files contained a range of information in relation to the care and support needs of each resident. This information is then used to develop an individual care plan for each resident, which is reviewed on a regular basis. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 8 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): 8&9 The administration of medication is being carried out to the required standard. Staff in the home promote and meet the health needs all residents in their care. EVIDENCE: Individual case files contained a range of information relating to the health and wellbeing of residents. The home’s care plan documentation detailed the actions and interventions needed to meet the continuing health needs of each resident. The plans are regularly reviewed and updated. Residents are registered with a range of local community health services that are appropriate to their needs. Systems are in place to ensure that all health appointments and arrangements are monitored and recorded. Staff in the home demonstrated a good awareness of preventative measures to take in relation to potential illnesses and infections. Health risks to residents are also assessed in relation to particular vulnerabilities that an individual may be susceptible to. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 9 The registered manager and staff have well-established relationships with a range of healthcare professionals. The home is able to access a range of advice and guidance that may be needed about matters of health and wellbeing. Arrangements are also made for healthcare professionals to visit the home to deliver specific training to the staff team. The home has appropriate arrangements and opportunities in place to promote exercise and physical activities. These arrangements are detailed in residents care plans and reflect the choices and abilities of individual residents. Dulas Court have policies and procedures in place for the administration of medication. Staff who have responsibility for the administration of medication have completed accredited training. The home uses a pre-printed administration of medication record sheet to ensure prescription and non-prescription drugs are recorded at the point of receipt, administration and disposal. The records demonstrated that the delivery and recording of the administration of medication is being carried out appropriately. The home’s Controlled Drugs Register also indicated that this aspect of practice is being carried out appropriately. The home had just undergone a medication audit, which was carried out by a pharmacist from the local PCT [Primary Care Trust]. The audit indicated that the home is meeting standards in most areas of the administration of medication. In the small number of areas that were identified for improvement the home is already in the process of remedial action. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 10 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): EVIDENCE: No standards were inspection in this section, [See previous inspection report 2 December 2005]. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 11 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 & 18 Systems and practices are in place to ensure residents are protected and safeguarded. EVIDENCE: The home has a complaints procedure in place that is accessible for everyone that lives, works and visits the home. There have been no recorded complaints made in the last 12-months. The complaints procedure also provides details of how to refer a complaint on to the Commission for Social Care Inspection. The home has a policy for the protection of vulnerable adults and holds a copy of Herefordshire’s Multi Agency Procedures for Protection of Vulnerable Adults. The documents give clear explanations and guidance in relation to issues of adult abuse and the reporting to appropriate agencies. Most staff have received protection of vulnerable adults training. The home’s whistle-blowing policy also explains how staff can raise concerns about adult protection issues to appropriate bodies outside of the home and organisational structure. Currently, the home has no adult protection issues or concerns. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: No standards were inspection in this section, [See previous inspection report 2 December 2005]. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 13 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, 29 & 30 The staff team at the home have the necessary skills and experience to ensure the residents needs are met. The vetting of staff is completed to the required standards to ensure residents are protected. Staff receive a good range of training appropriate to their learning needs and professional development. EVIDENCE: The home has an established staff team who have a varied range of skills and experiences. Dulas Court has an NVQ programme in place and the achievement of the appropriate qualifications within the staff team is progressing. A number of staff have achieved the appropriate NVQ qualification. The staff rota is planned in advance and ensures that there is an appropriate number staff onduty at any one time. Clear arrangements are in place to cover staff absences. The home does not use agency staff. The proprietors took an active role in the delivery of care and support to residents. Their involvement improved the home’s ability to respond to peak times of activity and offered more flexibility to the staffing arrangements. The home’s domestic routines are well managed; the environment was clean, hygienic and free from unpleasant smells. The recruitment and selection processes at the home follow an established procedure. Staff personnel files are appropriately stored and secured in the Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 14 manager’s office. A sample of personnel files for staff working at the home was made available to the inspector. The files demonstrated that appropriate checks are being undertaken in relation to an individual’s employment and the role to be undertaken. All new staff only start working at the home after all the necessary checks have been completed. The manager was able to provide a staff profile of all training events and development activities and that the staff team had attended. The profile demonstrated that a wide range of training and learning opportunities had been organised and delivered. The manager is in the process of developing individual staff learning and training profiles. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 15 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): 33 & 35 The home has started to consider ways of gathering information as part of the development of a formal quality assurance system. Systems are in place to ensure residents financial interests are safeguarded. EVIDENCE: The home does consult with residents and families about the day-to-day running of the home. Views and opinions are considered about care and support but the range and methods of consultation need to be expanded and included with in a wider quality assurance framework. The manager is aware of this shortfall and is in the process of developing monitoring and evaluation systems that will include resident surveys and stakeholder feedback. The manager will then use this information to assist with the production of an annual development plan for the home. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 16 Currently, all residents financial interests are managed by themselves, their families or advocates. All financial transactions relating to general expenses incurred by residents are appropriately recorded, audited and managed. Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 17 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 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 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 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No 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 OP33 Regulation 24 Requirement Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. Timescale for action 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN 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 Dulas Court DS0000024704.V284813.R01.S.doc Version 5.1 Page 20 - 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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