Inspection on 26/04/05 for Dulverton House

This inspection was carried out on 26th April 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

Dulverton House 27/06/08

Dulverton House 15/09/06

Dulverton House 24/11/05

Similar services:

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Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dulverton House 9 Granville Square Scarborough North Yorkshire YO11 2QZ Lead Inspector David Blackburn Unannounced 26 April 2005 9:00 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 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 J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dulverton House Address 9 Granville Square, Scarborough, North Yorkshire YO11 2QZ Telephone number Fax number Email 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 N/A Dr Khalid Hussain Javed and Dr Mussarat Javed Mrs Vanessa Teanby Care home only 22 Category(ies) of OP Old age (22), DE(E) Dementia over 65 (5) registration, with number of places Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 03/08/2004 Brief Description of the Service: Dulverton House is a large detached buidling situated in a residential area of the town. A former dweling 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 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 J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection on which this report is based was the first to be carried out in the inspection year April 2005 to March 2006. It was undertaken over 5.5 hours including preparation time. The focus was on a number of key standards together with any subject to requirements or recommendations at the last inspection. An inspection of some parts of the premises, including a number of bedrooms, was carried out. A number of policies, procedures and records were also examined. Discussions were held with the registered manager, four staff including two care staff, the cook and a domestic assistant, six residents and two visitors. What the service does well: What has improved since the last inspection? What they could do better: The registered providers and registered manager should continue to build on the achievements reached so far. Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 Page 6 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 J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 standard(s) 1, 3 and 6. Information published by the home together with the pre-admission assessment procedure were very good providing residents and prospective residents with a clear indication of the care, services and facilities on offer in the home and assuring them their needs would be met. EVIDENCE: The revised and updated Statement of Purpose and Service User Guide met current requirements. These documents were clear, precise and well presented. Information was available on services that were available to residents though not directly provided by staff in the home, for example advocacy. Copies of the documents were placed in the entrance hall and had been given to residents. Pre-admission assessment forms were supported by an assessment and initial care plan from the placing or funding agency where applicable. The information on file was comprehensive in nature giving a clear indication of the individual resident’s care needs. The registered manager stated that no form of intermediate care was offered. Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 9. The physical and health care needs of residents including medication were well recorded and acted upon by staff promoting good health. EVIDENCE: Four case files were examined. All had some form of assessment information either compiled by the registered manager for those privately funded or supplied by a care manager for those funded by a public body. In all instances the registered manager said she carried out her own assessment irrespective of the method of funding. Prospective residents and/or their families were asked to complete a “Getting to Know You” form. Risk assessments were available. Care plans were subject to regular recorded reviews. The Statement of Purpose made clear the fact that nursing care was not provided as a matter of course and short-term interventions would be arranged through the district nursing service. Health care needs of residents were recorded in their care plans. Specific needs, for example nutrition, pressure area and tissue viability care and the promotion of continence were noted. A record was kept of all referrals to health care agencies. One resident commented “My general health has improved since I came here. The doctor is very pleased with my progress.” Another said “I’m very well looked after. Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 Page 10 They always know what I need.” Relatives made similar positive comments. “They take good care of mum. I have no real worries about her.” Proper procedures were in place for the ordering, receipt, storage, administration, recording and return of medication. They were being followed. Staff handling medication had received the appropriate training. The procedures to be followed and the receipt of the required training were confirmed by staff. Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 standard(s) 15. The dietary needs of residents were well met with a varied menu of food being offered that satisfied their tastes and choices. EVIDENCE: The present menu had been based on the choices, preferences and wishes of residents. Choice was available at all meals. Residents said alternatives were always available. This was confirmed by observation in the kitchen of the food being prepared. Food was well presented and properly served. Tables were well set in the large dining room that offered residents and staff ease of movement and service. Apart from breakfast mealtimes were set. None of the residents expressed any concerns about this. Special diets and foods were readily available. Advice had been sought from visiting health professionals and the web site of a relevant organisation on specific dietary matters. One resident said “I need a special diet but that’s no problem.” Others made very favourable comments including “The food is always nice. There’s plenty of choice, you just ask.” “It’s better than I could do at home. I get very well fed.” Some residents made specific remarks related to the food including “The meat’s sometimes a bit tough.” “They don’t always get it right. But you can’t please everybody all the time. It’s usually very good.” Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 standard(s) 16. A satisfactory complaints procedure was in place that gave residents confidence that their concerns and worries would be listened to and acted upon. EVIDENCE: A complaints procedure was available. This showed how to complain, to whom and gave timescales for any response. Clear reference was made to the right to approach the regulatory authority at any time. Copies were in the Statement of Purpose and Service User Guide. All residents had been given a copy. Any complaints would be recorded. Residents were aware of how to raise their concerns. A number of comments were made “I’ve no complaints but if I had I would see Vanessa (registered manager).” I’d tell Vanessa, but everything is fine.” “There’s nothing to complain about. If there was I’d tell Vanessa. She’d soon sort it out.” Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 standard(s) 19 and 26. Environmental standards were very good providing residents with a homely, comfortable and safe place in which to live. EVIDENCE: The premises were in good structural order. Remedial work had been carried out to the exterior. Of the 20 bedrooms two could be occupied on a shared basis. Currently all were used as single rooms. Six rooms had an en-suite facility. Communal bathrooms and toilets were conveniently located on all floors accessed by residents. There was a passenger lift to all four floors. Equipment, crockery and cutlery, bed linen, towels and other furnishings were of a good quality and in a serviceable condition. A large garden with ramped access was provided with seating. The last reports from the Fire Officer and Environmental Health Officer were seen. All recommendations had been addressed and resolved. One resident said “I’m very happy with my room.” Those parts of the premises seen were warm, clean and free from offensive odours. Appropriate arrangements had been made for the proper laundering of bedding, linen and personal clothing. A visitor commented “It’s always clean and never smells.” Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 and 30. There was a competent and well-motivated staff team who had received the relevant induction and on-going training enabling them to give residents the appropriate, consistent care. EVIDENCE: 14 care staff were employed together with catering and domestic staff. Of the care staff over 50 had achieved a National Vocational Qualification to level 2 in care. The file of the last staff member to be appointed showed a detailed and relevant induction checklist. This was supplemented by attendance on the Working in Care Induction Standards programme (WICIS) for all new staff. This course met current agreed standards. On-going training was provided in the home and external locations. A training plan and matrix was seen showing courses undertaken and those planned. Some was role-specific for example Dementia Awareness for care staff and a Health and Safety course for domestic staff. The cook was to undertake a further catering course. Some training was more general in nature, for example fire safety and first aid. Discussion with staff confirmed attendance or planned attendance on such courses. Some certificates of attendance and/or successful completion were seen. The registered manager said the home was seeking the Investors in People award. Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 Page 15 The residents and visitors were complimentary in their comments about the registered manager and her staff team. “They’re all nice.” “You couldn’t wish for a better set of girls. They’re lovely.” “I feel happy to leave my relative in their care.” Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38. Proper attention was given to health and safety matters promoting a safe and secure environment in which residents could live. EVIDENCE: Relevant health and safety policies and procedures were in place. Observation throughout the inspection confirmed these were being followed. This led to the promotion and maintenance of a safe and secure environment for residents, visitors and staff. A number of satisfactory safety reports and certificates were seen relating to the premises. Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 3 Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 Page 18 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. Standard Regulation Requirement No requirements were made. 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. 1. Refer to Standard Good Practice Recommendations No recommendations were made. Dulverton House J53-J04 S62423 Dulverton House V223917 260405 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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