CARE HOMES FOR OLDER PEOPLE
Dulverton House 9 Granville Square Scarborough North Yorkshire YO11 2QZ Lead Inspector
David Blackburn Unannounced Inspection 24th November 2005 12:00 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 Dulverton House DS0000062423.V265875.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. Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Dulverton House Address 9 Granville Square Scarborough North Yorkshire YO11 2QZ 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) 01723 352227 01723 352227 Dr Khalid Hussain Javed Dr Mussarat Javed *** Post Vacant *** Care Home 22 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (22) of places Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users up to 22 (OP) and up to 5 (DE(E)) up to a maximum of 22 service users 26th April 2005 Date of last inspection Brief Description of the Service: Dulverton House is a large detached building situated in a residential area of the town. A former dwelling house and hotel, it has been adapted to provide accommodation for a maximum of 22 residents. Its location makes it convenient for access to local facilities and amenities and to the town centre. Public transport passes close by. The home is on four floors all served by a passenger lift. The lower ground floor has the office, kitchen, laundry and staff areas. The ground floor houses the communal rooms together with four bedrooms. The rest of the bedrooms are located on the upper two floors. Some bedrooms have an en-suite facility but there are ample communal bathrooms and toilets on each floor accessed by residents. There is a large well-kept garden provided with suitable seating. Ramped access is provided to this area. Dulverton House accommodates people admitted by virtue of old age and infirmity, some of whom may be suffering from dementia. The staff team provide personal care, a catering service, a laundry service and domestic and cleaning services. Staff cover is available throughout any 24 hour period. Leisure activities and recreational facilities are offered in the home and at external locations. Each resident is registered with a local medical practitioner who addresses their primary health care needs. Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection upon which this report is based was the second to be carried out in the inspection year April 2005 to March 2006. It was carried out over five hours including preparation time. The focus was on those key standards not assessed at the first inspection in April 2005 together with those that were the subject of a requirement or recommendation. An inspection of some parts of the premises including a small number of bedrooms was undertaken. Documents including policies and procedures were examined. Discussions were held with the acting manager, care and ancillary staff. A number of residents and visitors were spoken with and their comments are included in this report. What the service does well: What has improved since the last inspection?
Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 6 Staff continued to undertake training relevant to the resident group including courses on dementia awareness. The acting manager said that re-assessment of a number of residents’ needs had led to a discussion with the registered providers about increases in staffing levels. One visitor said she had noticed a steady deterioration in her relative but was very pleased with the way staff had responded and how the appropriate care continued to be given. A further number of staff had successfully completed a National Vocational Qualification in care to at least level 2. Some staff were now undertaking a management training course. The home had achieved the Investors in People award. There was firm evidence available of how the registered providers and staff were working towards the aims of the current business plan. 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. Dulverton House DS0000062423.V265875.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 Dulverton House DS0000062423.V265875.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): 0 None of these standards was assessed. EVIDENCE: Dulverton House DS0000062423.V265875.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): 10. Personal support was offered in such a way as to promote and protect residents’ privacy, dignity and independence. EVIDENCE: Residents spoke of the way care was offered. All were satisfied with the manner of delivery of care and the support they were given. They expressed no reservations about their care but rather were full of praise for the staff. Visitors said they had noticed that care was offered in an appropriate and proper manner. None of their relatives had expressed any concerns to them. Staff confirmed that induction and on-going training focused on the method of care delivery. The need to ensure residents’ dignity, privacy and independence were promoted and maintained was at the forefront of any service delivery. Staff were observed to approach and engage residents in an appropriate way. A number of residents had their own telephones. A public telephone was also available. Residents were seen to be well-dressed. They and their relatives said they were satisfied with the laundry service in the home.
Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 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): 12, 13 and 14. Residents were able to undertake a number of activities in the home and at external locations that greatly enhanced their life experiences. EVIDENCE: Residents confirmed they organised and arranged their day. They said there were few rules and regulations and that they felt free to make their own decisions about what to do and when. Although meal times were set this was welcomed by most residents. A diversional therapist was employed for three days each week. She brought into the home a variety and wealth of activities, pastimes and leisure pursuits. She was able to involve residents singularly and collectively and residents said they enjoyed these sessions. There was no compulsion to join in but the diversional therapist was skilled and had the ability to interest all residents in some or most of the activities. A number of residents undertook their own leisure pastimes in the privacy of their rooms including painting and reading. The home had made good links with a number of organisations in the community. Of particular note was the relationship with a local primary school. The residents were involved in crafts that enhanced the story books being used by the school. The schoolchildren had also invited the residents to school and entertained them.
Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 11 Good links had also been established with a local college. The residents had been invited to musical events that included refreshments. Information was available in the home about theatres, pantomimes and shopping trips. The acting manager said a number of residents took advantage of these events. Some were able to get out unaided while others required the support of relatives or staff. Most residents received visitors and a number were seen on the day of inspection. For those with little or no family contact a local church provided a befriending service and some residents had taken advantage of this. Residents were expected to handle their own affairs. They were encouraged to bring in personal items and a number of these were seen on the tour of the building. Personal items were recorded in each resident’s inventory. Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 12 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): 18. Staff had a very good knowledge and understanding of adult protection issues that protected residents from harm. EVIDENCE: The acting manager and staff confirmed that training on adult protection issues took place through induction, external training courses and National Vocational Qualification units. Policies were seen in the home on adult protection, whistle blowing, aggression and POVA. Staff had signed to say they had read and understood these policies. The acting manager had obtained a copy of the revised multi-agency agreement on adult protection and she and staff were able to discuss its’ suggestions and recommendations for dealing with allegations or suspicions of abuse. Staff in discussion appeared confident in the actions they would take should abuse take place. They were also able to discuss the various manifestations of abuse including some of the subtler forms. Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 13 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 and 26. The residents were provided with a comfortable and safe place in which to live. EVIDENCE: Overall the premises remained in a good condition internally and externally. Some small improvements had been made in terms of re-decoration. The general high standard was maintained through prompt attention to maintenance matters. A small number of bedrooms were seen together with some of the communal areas. All bedrooms were well personalised. The areas seen were clean, warm, tidy and odour free. Residents were complimentary towards the registered providers and staff for the continued high standards evident throughout the home. Good systems were in place for the laundering of bedding, linen, towels and personal clothing. Proper attention was given to infection control. Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 14 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 29. There was a motivated, well-trained and committed staff team offering a consistency of care to residents. Good recruitment and selection procedures ensured residents were protected from harm. EVIDENCE: There were fourteen care staff supported by the acting manager and catering and domestic staff. The staff rota showed a good deployment of staff throughout the 24 hour period. The acting manager said discussions had been held with the registered providers about improving staffing levels given the increasing needs of a number of residents. A diversional therapist was also employed on three days each week. Nine of the fourteen care staff had achieved a National Vocational Qualification to at least level 2. Two other staff were said to be working towards this award. The cook was undertaking a National Vocational Qualification in catering. The acting manager together with two senior care staff were involved in a course leading to a management qualification in health and community care. A thorough and sound recruitment and selection procedure was in place based on an employment control system devised by a Personnel Management Company. Job descriptions were available for all posts. Staff confirmed they received a contract and terms and conditions of employment. The acting manager said all staff had received a copy of the General Social Care Council’s Code of Practice.
Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 15 The files of the last two staff to be employed were examined. Each contained a completed application form, two written references, a POVA/First check and an enhanced disclosure from the Criminal Records Bureau (CRB). The acting manager said new staff were not employed on any care duties until the CRB disclosure had been received. Residents and visitors were complimentary in their comments about staff. Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 16 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, 35 and 38. The home was well managed, had a clear development plan and provided a safe and secure environment for those living there and those visiting. EVIDENCE: The registered manager resigned and left in August. The post had been advertised. In the interim the deputy manager had taken on the role of acting manager. She had a National Vocational Qualification in care to level 3 and was undertaking a management course. She promoted a good supportive management style leading to staff feeling valued and residents well cared for. Positive comments about her leadership were received from residents, visitors and staff. The registered providers had drawn up a business action plan for the current year. This detailed the aim to be achieved, the performance objectives required, the actions needed together with the nominated person and timescale. Some aims had been already achieved.
Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 17 Investors in People status had been granted in October and over 50 of the care staff had a National Vocational Qualification in care to at least level 2. There was an obvious commitment from the registered providers and staff to provide the best possible standards of care and services. The acting manager said a questionnaire was being devised to seek feedback on the home’s overall performance from residents, relatives and visiting professionals. This should be distributed as soon as possible. While residents were expected to handle their own affairs or make arrangements through a third party, the acting manager said she did hold a small amount of money for some residents. Records were kept and were seen. It was recommended that a more formal printed pro-forma be used to record this money. Proper attention continued to be given to matters of health and safety. Staff were aware of their responsibilities to maintain a safe, secure and hazard-free environment. A number of safety certificates and reports were seen. They were up-to-date and relevant. It was however noted that the record of tests of the fire detection system showed this happened on a monthly basis. The detection system must be tested weekly and recorded. While staff confirmed that a fire drill had been recently carried out this had not been recorded. Fire drills must be carried out at intervals prescribed by the Fire Service and recorded. Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 18 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 1 Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 19 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. 1 2 Standard OP38 OP38 Regulation 23(4) 17(1)(a) 4.14 23(4) 17(1)(a) 4.14 Requirement The fire detection system must be tested on a minimum of a weekly basis and recorded. Fire drills must be carried out at least every six months and recorded. Timescale for action 30/11/05 30/11/05 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 OP33 OP35 Good Practice Recommendations The registered providers should distribute a questionnaire to residents, relatives and visiting professionals to ascertain the overall performance of the home. The record of money held on a resident’s behalf should be recorded on a properly pre-printed form. Dulverton House DS0000062423.V265875.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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