Inspection on 02/12/05 for Dulas Court

This inspection was carried out on 2nd December 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

Dulas Court 14/03/07

Dulas Court 16/03/06

Dulas Court 22/02/05

Dulas Court 27/07/04

Similar services:

Maple Lodge

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Bank House

Inspirations

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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 Dulas Court Dulas Ewyas Harold Herefordshire HR2 0HL Lead Inspector Sarah das Neves Pedro Unannounced Inspection 2nd December 2005 01:00 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.V270908.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. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 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.V270908.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 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.V270908.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. On the day of inspection 23 people were resident in the home. The inspection was unannounced and took place over one afternoon in December 2005 between 14.00 and 18.15. Not all of the core National Minimum Standards were reviewed so readers of this report are advised to read the reports of previous inspections carried out in July 2004 and February 2005 in order to gain a more complete picture of how Dulas Court meets the National Minimum Standards. The inspection confirmed that the home continues to be run and managed well. There was a comfortable relaxed atmosphere and service users were able to use all areas of the home as they wished. The inspector spoke privately at length with six of the residents and a visitor all of whom confirmed their complete satisfaction with the care that they received. They said that the home was “absolutely fabulous”, that the food was “exceptional” and that the staff “are so kind”. Other residents were seen during the inspection. The general view expressed was that they are lucky to have found the home and there are no complaints and no problems. The inspection confirmed that the home was clean and generally well maintained and that residents are able to bring their own belongings with them to personalise their rooms. Improvements have been started on service users files and other documentation. The home does not seek to admit service users with dementia illnesses and the majority are well able to express their preferences and views on the care they require. The home is professionally presented from the staff to the environment, this was a very satisfactory inspection which confirmed that Dulas Court continues to provide a caring and professional service to those living there. What the service does well: The residents in the home were well able to comment on their care and without exception they expressed their satisfaction with the care they receive. Staff were seen and heard treating residents politely and with respect, the atmosphere throughout the home was calm and relaxed. The home facilities are well above adequate providing comfortable accommodation with good quality furnishings and surroundings. The staff, owners and management were knowledgeable and approachable; the residents confirmed this. They were receptive to comments and suggestions and open in their responses. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 6 Residents have a choice of various day areas and sitting rooms with a large separate dining room. All areas of the home were fresh, clean and tidy. 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.V270908.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 Dulas Court DS0000024704.V270908.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): These standards were not fully inspected and so no comment is made. EVIDENCE: Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 All residents have a plan of care but the assessments seen were not fully completed. Intermediate Care is not offered. Service user contracts, the service user guide and statement of purpose were not examined during this inspection but were considered satisfactory at a previous inspection. The privacy and dignity of all residents is central to the ethos of the home. EVIDENCE: The manager informed that all resident documentation was under review and a considerable amount of work has been carried out on the care documentation. The files for two service users were read, both contained a new style care plan with relevant risk assessments for moving and handling and physical care. Monthly reviews were planned and had been completed in November. Space had been allocated to allow a resident to sign to indicate agreement with the plan but this had not been completed. Because of the work already in hand, the timescale for this standard will be extended and be reviewed at the next inspection. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 10 The home has a supply of pressure relieving equipment and a service user was on a pressure-relieving mattress. The bed rail risk assessment had not been signed by a representative or the resident. Residents confirmed that they were treated with dignity and respect at all times and staff were heard speaking to residents using their preferred form of address and seeking to ensure that their choice of activity was provided. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The home provides an active Christian community which is supportive of people as their dependency increases. Residents are able to see friends and relatives whenever they wish and contact with the local community is actively encouraged. Resident’s choice is actively promoted and central to the care provided. The evidence regarding the food is based on information provided by the residents. EVIDENCE: The home provides a programme of daily activities which includes regular Christian worship. The seasonal activity was reviewed and the programme includes visits to the home by local primary schools and choirs for concerts and pantomimes. On the day of inspection many of the residents attended a video showing. Regular activities include daily worship in the home, weekly shopping in the village and twice weekly whist drives. Residents informed the inspector that they could receive visitors whenever they wish; a visitor to the home confirmed this. Although the inspector did not see a meal being served, the comments about the standard of meals were that “The food is exceptional” and that staff serve food at the table, this allows residents to have as much or as little as they wish. The dining room was beautifully laid out for supper; residents sit in small social groups of their choice to dine. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 12 Dulas Court DS0000024704.V270908.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): No complaints have been received regarding this service, this standard was not assessed at this inspection. EVIDENCE: Dulas Court DS0000024704.V270908.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, 22, 23, 24, 25 and 26 The home provides an exceptionally high standard of accommodation with good quality furnishings, which are appropriate to the client group, age range and degree of disability. The atmosphere is quiet and relaxed. The extensive grounds are very well tended and easily accessed by the residents. Residents are encouraged to bring personal possessions with them. EVIDENCE: A tour of the premises was undertaken, shared bathrooms were inspected and six bedrooms were viewed. Public and utility areas were seen. Residents’ bedrooms were, without exception, very well personalised. All had been encouraged to bring in personal items, including furniture. A recently vacated room was being redecorated and the carpet renewed. The inspector was pleased to note that was no evidence of incontinence damage to the floorboards and no unpleasant smell in any part of the home. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 15 Where the home had provided furniture is was of a good quality and fit for purpose. Minor points regarding maintenance and storage in bathrooms were raised with the manager, in view of the high standards prevalent in the rest of the home; the inspector is confident that these matters will be assessed and receive appropriate attention, in view of this no requirement will made to correspond with the shortfalls observed. Equipment available for resident use such as hoists and wheelchairs were clean and tidy. It was noted that TPG had inspected and serviced a hoist on 3rd March 2005. All residents were wearing clean, tidy clothes and residents clothing seen in the laundry was well laundered and ironed. Dulas Court DS0000024704.V270908.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): These standards were not assessed at this inspection. EVIDENCE: Previous reports have shown satisfactory staffing standards. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 17 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, 32 and 38 The home is well managed and well run and true to it’s Christian ethos. Health and Safety issues were not considered in detail but those areas that were seen were generally satisfactory, however documentation regarding accident reporting and maintenance information should be reviewed. EVIDENCE: The Proprietors, Administrator and Care Manager all play an active role at the Home with considerable direct contact with staff, service users and relatives. All fire exits were clear of obstructions and the fire extinguishers had been serviced on the 1st of December 2005. Portable Electrical Appliances had been tested on 14th February 2005. The laundry was clean, tidy and hygienic with a recently installed system specifically to combat potential cross infection. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 18 The staff and resident accident records were reviewed. The recording system has recently been changed and requires further attention; for example, some entries included abbreviations that could be misinterpreted. • Staff records. The manager was advised to audit the accident records and follow up entries regarding staff injuries • Resident records. These should also be audited but it was noted that none of the entries required notification to CSCI under Regulation 37 and appropriate action had been taken in all cases. Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 4 3 3 3 4 4 4 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 X X X X X 2 Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. Timescale for action 02/02/06 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 2 Refer to Standard OP38 OP38 Good Practice Recommendations The manager should review and audit the accident records retained in the home The manager should ensure that all maintenance records are accurate and up to date Dulas Court DS0000024704.V270908.R01.S.doc Version 5.0 Page 21 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.V270908.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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