Inspection on 26/01/06 for Dunley Hall

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dunley Hall 18/01/07

Dunley Hall 09/08/05

Dunley Hall 21/02/05

Dunley Hall 10/08/04

Dunley Hall 25/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Dunley Hall Dunley Hall Dunley Nr Stourport-on-Severn Worcestershire DY13 0TX Lead Inspector N Andrews Unannounced Inspection 2:25 26 and 30 January 2006 th th 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 Dunley Hall DS0000055364.V281254.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. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dunley Hall Address Dunley Hall Dunley Nr Stourport-on-Severn Worcestershire DY13 0TX 01299 822040 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) Mrs Monica Arjan McGlynn Trading as Minster Grange Residential Home Ms Elizabeth Joy Flood Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (19) Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: There were no conditions of registration other than those referred to on the previous page of this report. Date of last inspection 9th August 2005 Brief Description of the Service: Dunley Hall is a large, adapted residence occupying a secluded position near to the centre of the village of Dunley. The home stands in its own attractive grounds at the end of a drive that provides shared access to other residents who live nearby. The home is accessible to people who use wheelchairs. There are car-parking facilities at the front of the premises. The service users are accommodated on the ground and first floor in 13 single bedrooms and three double bedrooms. Eight of the single bedrooms and all three double bedrooms have an en suite facility. The home provides two lounges and a separate dining room. The home also has a passenger lift. The home is registered to provide a residential i.e. personal, care service for a maximum of 19 people over the age of 65 years, who may also have a physical disability and/or a dementia illness. At the time of the inspection 18 service users were in residence and 1 service user was in hospital. The main purpose of the home is to provide a high standard of care in a secure and happy environment for people who are unable or who do not wish to live alone. The homes stated aims are to provide all service users with a life that is as normal as possible, given their health and needs, in homely surroundings and with care which will enable them to live as independently as possible with privacy, dignity and with the opportunity to make their own choices. It is the intention of the registered provider to provide a large extension to the premises that will increase the number of service users for which the home is registered. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection that took place over two half days. The service users’ records, staff records and other relevant policies and procedures were inspected. A tour of part of the premises was also made. Individual discussions were held with four service users and two members of staff. Time was also spent with the registered manager assessing the progress made by the home in implementing the requirements and recommendations arising from previous inspections. The service users were observed to be clean, well dressed and well-presented. The comments made by the service users about the care that they received were mainly very positive. One service user stated, ‘The care is excellent. The staff are kind and always polite. I don’t feel out of it. If I don’t understand something I will ask and they will come and tell me’. Another service user said, ‘The staff are kind but they don’t have enough time to talk to you. Some staff hurry you a bit too much’. Another service user made a similar comment and said, ‘Some staff are excellent but some don’t have time to talk to you’. One service user stated, ‘Staff are hard to get. Things have been a bit difficult staff wise’. One service user confirmed that the staff respected their privacy and always knocked the door before entering their bedroom. Another service user also confirmed that the staff treated her with respect. She said, ‘The staff are always well intentioned and conscientious about what they do’. All of the comments made by the service users about the standard of food were positive. One service user said, ‘The food is very good. It’s cooked nicely and presented nicely and there is sufficient variety’. Another service user said, ‘The food is good and they are willing to change it if necessary’. Another service user said, ‘The food is satisfactory, well cooked and presented’. Three service users confirmed that they felt confident about raising any concerns or making a complaint if necessary. They also felt confident that any issue of concern thus raised would be dealt with quickly and appropriately. The two members of staff with whom discussions were held also spoke positively about the home and their work. One of the staff said, ‘It’s one of the nicest places I’ve worked’. Both members of staff said that the staff worked well together and that there was a friendly atmosphere in the home. They also confirmed that there was a positive relationship between the staff and the service users. Both members of staff also stated that the registered manager was approachable and supportive. They both felt confident about discussing any concerns that may arise in connection with their work with the registered manager and receiving an appropriate response. They both felt that the home provided good training opportunities and that the service users were well looked after. However, both members of staff also wished that they had more time to spend in individual discussion with the service users. They also said that they would like to see more activities and entertainment provided for the Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 6 service users. One member of staff said that she had discussed the possibility of introducing a regular newsletter with details about events in the home etc with the registered manager. During this inspection the home was inspected against twelve of the National Minimum Standards. Nine of the twelve Standards were met, two were nearly met and one Standard was not met. However, it was disappointing to note that, since the previous inspection, the number of requirements and recommendations had increased from 13 to 19 and from 8 to 14 respectively. The registered manager stated that this was partly due to the lack of time available to devote to addressing some of the issues. She said that the lack of time had been caused by the staffing difficulties that the home had experienced. What the service does well: What has improved since the last inspection? What they could do better: Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 7 Greater vigilance was needed in order to eliminate errors in record keeping e.g. the administration of medication and service users’ financial records. There was scope for improving the range of social and recreational activities. A more speedy response should be given to addressing the physical aspects of the home e.g. the provision of paper towel dispensers and window opening restrictors. The staff recruitment procedures must become more robust in order to ensure the safety of the service users and systems must be introduced to monitor the quality of the service provided. The registered manager acknowledged that improvements to the administrative aspects of the home needed to be made. 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. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 8 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 Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 9 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 There was evidence to show that the care needs of the service users were assessed by the home prior to admission and that the needs that had been identified were being met. EVIDENCE: The registered manager stated that, in most cases, she carried out the assessments of prospective service users in their own home or hospital, as appropriate. It was also confirmed that approximately 50 of the current service users had undergone a Community Care Assessment. However, all of the service users had been assessed by the home using the home’s assessment form. A copy of the form used by the home for assessing the care needs of prospective service users was made available for inspection. The assessment form covered all of the aspects of care listed in Standard 3.3. However, it was noted that the amount of space provided in parts of the form for recording the information obtained was limited. The registered manager should consider revising the layout of the assessment form in order to ensure that it contains sufficient space to record all of the relevant details. It was confirmed that all of the service users had a care plan that had been developed from the assessments. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 10 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, 9 and 10 The home was taking appropriate action to improve the service users’ care plans. The home worked well with other agencies to ensure that the service users’ healthcare needs were being met. The service users felt that their privacy and dignity were respected. Greater vigilance was needed in maintaining the records relating to the administration of medication. EVIDENCE: The home’s response to the requirement that was made in regard to Standard 7 as a result of the previous inspection was assessed. The requirement was that the care plans must contain clear, specific details that describe the way in which the service users’ needs would be met. A copy of the care plan form used by the home was made available for inspection and the completed care plans in respect of a small number of service users were also inspected. The care plans had improved since the previous inspection in both layout and content. The care plans that were inspected were clear, simple to understand and contained details of the action that needed to be taken by the staff to ensure that all aspects of the service users’ needs were met. The requirement was, therefore, regarded as having been implemented. However, the work to ensure that all of the service users’ care plans were produced in the same format had not been completed. It was stated that there were still eight care plans that needed to be developed using the new format. A discussion was Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 11 held with one of the deputy managers about the care plans and the new forms that the home intended to introduce to show that the care plans were being reviewed at least once a month. It was pleasing to note that the deputy manager with whom this matter was discussed had a good understanding of the way in which to proceed and the work that needed to be completed in order to demonstrate how the home would meet this Standard. The registered manager stated that the home was well supported by the district nurses. The staff referred their concerns about the service users healthcare needs to the district nurse and they visited and carried out their assessments accordingly. The district nurse was leading a staff training session on the day of the inspection on continence management. Pressure relieving equipment i.e. cushions and mattresses, was provided where necessary. The registered manager confirmed that the staff were aware of which service users were likely to develop pressure sores. The care of two service users was being monitored and reviewed by the district nurses at the present time. The registered manager stated that the district nurses carried out risk assessments on the service users’ tissue viability. Some of the service users engaged in physical exercises that were lead by Mobility Plus every two weeks. The registered manager stated that there were sufficient numbers of staff to ensure that the service users had appropriate exercise e.g. escorting them on short walks. It was also confirmed that a risk assessment had been carried out and recorded on all of the service users in respect of falls, that nutritional screening was carried out at the time of admission and that the service users’ weight was recorded every month. A chiropodist visited every six weeks. An NHS chiropody service was provided for one service user once a quarter. An NHS dentist visited the home as and when required. One service user visited a local dentist. The service users had their eyesight tested by a visiting optician every twelve months. One service user visited a local optician. The ears of several service users were monitored by the district nurse for ear wax. A hearing aid specialist visited the home once a year to carry out checks on the service users’ hearing aids. The home had a satisfactory policy and procedure for the administration of medication. The registered manager stated that none of the current service users self medicated. The two deputy managers were responsible for monitoring the Medication Administration Record (MAR) charts. The MAR charts were checked and were found to be satisfactory. Two service users were in receipt of Controlled Drugs. The Controlled Drug register was also checked and it was noted that, since the 11 November 2005, the signature of a second member of staff involved in the administration of the medication had not been recorded in five separate instances. It was also noted that the list of the names and signatures of the staff members that were involved in the administration of medication was not up to date. A Notice of Immediate Requirement was given to the registered manager at the conclusion of the inspection in regard to both of these issues. The home had a medication trolley that was secure and satisfactory for the safekeeping of medication. The Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 12 arrangements for the safekeeping of Controlled Drugs were also satisfactory. The date of opening for eye drops and creams etc were recorded on the outside of the respective containers. Eye drops were kept in a separate container in the fridge. The registered manager acknowledged that this was unsatisfactory and stated that the home was in the process of obtaining a new dedicated fridge for the purpose of storing medication that required cold storage. The registered manager stated that the home enjoyed a positive relationship with the local pharmacist who visited the home twice a year to check the administration of medication procedures and to offer appropriate advice. The registered manager also confirmed that only senior members of staff were involved in the administration of medication and that they had all undertaken suitable, relevant accredited training to enable them to do this. The registered manager stated that the staff were made aware of the importance of ensuring that the service users’ privacy and dignity were respected at all times through induction training and NVQ training. The registered manager said that the home adhered to the good care practice guidelines outlined in Standard 10.1. The service users with whom discussions were held confirmed that they were treated with respect by the staff. It was stated that the district nurses telephoned the home in advance to notify the staff that they were on their way to visit the service users. This allowed the staff sufficient time to ensure that the service users were ready to be seen by the district nurse in private. The registered manager also said that she ensured that the staff were not left in a vulnerable position in regard to personal care giving. The home provided a mobile handset in order to ensure that the service users were able to make and receive telephone calls in private. In addition, five service users had a telephone in their own rooms. The registered manager said that the home kept a small supply of clothing for use in a ‘dire emergency’. It was also stated that sometimes the staff provided the service users with items of clothing. However, under normal circumstances, the service users always wore their own clothes. It was confirmed that the staff always used the terms of address preferred by the service users and that examinations and treatment were always provided in private. The home had three double bedrooms. The registered manager stated that one of the double bedrooms had fixed screening. The registered manager also said that two service users who shared one of the other two double bedrooms did not wish to have any screening and that it would be detrimental to their wellbeing if it were provided. However, fixed screening must be provided in the third double bedroom i.e. bedroom 2, to ensure the service users’ privacy and dignity. The home’s response to the recommendation that was made in regard to Standard 11 as a result of the previous inspection was assessed. The recommendation was that the process of discussing and recording the service users’ wishes concerning terminal care and the arrangements after death should be completed. The registered manager said that the process had not been completed. Therefore, the recommendation had not been implemented Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 13 and still stands. It was stated that it was intended to introduce a new form that would enable this recommendation to be implemented. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 14 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 Different social and recreational activities were provided for the service users. However, the frequency and range of the activities needed to be increased. The service users were helped to maintain contact with their relatives and friends and visitors were welcomed and encouraged. The service users were helped to exercise choice and control over their own lives. EVIDENCE: The registered manager confirmed that the service users were provided with a range of social and recreational activities. These included manicures each week, daily newspapers, hairdressing twice a week, music, videos, Bingo, ‘Let’s Talk’, television, exercises to music every two weeks, a mobile library and occasionally outside entertainers. The local vicar visited the home once a month to hold a Communion service. In addition, birthdays and seasonal and special occasions were celebrated. The home had recently held two open days to celebrate Christmas. The home had had two separate visits from the Brownies pack prior to Christmas. The ‘Sunshine Girls’ clothing company had visited the home twice. It was intended to make arrangements for a similar visit to take place every three months. A visit to Webb’s Garden Centre in Bromsgrove was planned for later in the year for four service users. It was stated that service users were taken out individually wherever possible. The registered manager stated that a record used to be kept of the activities that had taken place with the dates and the names of the service users that had participated. However, the practice had lapsed. The mealtimes were flexible. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 15 There was a choice of food. The service users could choose to eat their meals in their own rooms if they so wished. The registered manager stated that four service users ate all their meals in their own rooms by choice. The service users were able to enjoy social relationships with other service users and with their families and friends outside the home. Three sets of friendships had developed within the service user group involving seven of the service users. Another service user received visits from a member of the same religious denomination. Music is played to one service user with a dementia illness and another service user received regular visits from her husband. The home encouraged all of the relatives to visit. One service user had a ‘day and night’ calendar. The service users are told individually about the activities arranged by the home and, in addition, posters are displayed to advertise special events. Both the members of staff that were spoken to during the inspection felt that the range and frequency of the social and leisure activities provided could be enhanced. The service users were able to have visitors at any reasonable time and visitors were encouraged to maintain contact with the service users and to have meals with them if they wished. The service users were able to receive their visitors in private. The registered manager said that the service users’ right to choose whom they saw or did not see was respected. The home’s service users’ guide stated, ‘We actively encourage relatives, friends and representatives of service users to be involved in the pre assessment, admission and in the planning of their (the service users’) care’. The registered manager stated that the home encouraged all of the service users to retain a small amount of money on their person in order to encourage a sense of independence. The home also held varying amounts of money handed over for safekeeping in respect of 14 service users. The money was used to pay for the service users’ personal expenses e.g. hairdressing. The registered manager was aware that the relatives of two service users had Power of Attorney. The service users’ guide included details of the address and telephone number of the Wyre Forest Advocacy Service. The registered manager stated that the advocacy service was involved in supporting one service user at the present time. It was also stated that another service user had recently been offered the service but had refused. The service users were entitled to bring personal possessions with them when they were admitted to the home including small items of furniture. The service users’ bedrooms contained evidence to show that this practice was maintained. The registered manager confirmed that the service users’ right to have access to the records held about them by the home was upheld. The service users’ guide contained information outlining the home’s policy on this issue. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 16 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): N/A It was not possible to form a judgement as none of the Standards in this section of the report were fully assessed. EVIDENCE: The home’s response to the recommendation that was made in regard to Standard 18 as a result of the previous inspection was assessed. The recommendation was that staff who may be unsuitable to work with vulnerable adults should be referred for consideration for inclusion on the Protection of Vulnerable Adults register. The registered manager stated that appropriate advice had been sought in regard to this issue and it had not been considered necessary to make a referral in this instance. The recommendation was regarded as having been implemented. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 17 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): 26 The service users lived in a clean and pleasant environment. EVIDENCE: The home’s response to the two requirements and one recommendation that were made in regard to Standard 21 as a result of the previous inspection was assessed. The first requirement was that the items stored in the bathroom on the first floor must be removed and the bathroom refurbished and used appropriately for its intended use. The requirement had not been implemented and still stands. The registered manager stated that the requirement was part of the consideration that was taking place for the overall provision that will exist for the proposed development of the home. The second requirement was that liquid soap and paper towel dispensers must be provided near to the wash hand facilities in all of the communal toilets and bathrooms. The registered manager stated that liquid soap dispensers had been provided in all of the communal toilets and bathrooms. It was also stated that paper towel dispensers had been purchased but had not yet been installed. The requirement, therefore, had not been fully implemented. A Notice of Immediate Requirement was given to the registered manager in respect of this issue at the conclusion of the inspection. The recommendation was that all Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 18 communal toilet and bathing facilities should be clearly marked. The registered manager stated that all of the communal toilets had been appropriately marked but not the bathrooms. The recommendation had, therefore, not been fully implemented and still stands. The home’s response to the recommendation that was made in regard to Standard 22 as a result of the previous inspection was assessed. The recommendation was that the advice of a qualified occupational therapist should be sought in order to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. The recommendation had not been implemented and still stands. The registered manager was supplied with relevant information regarding this issue following the inspection. The home’s response to the two requirements and one recommendation that were made in regard to Standard 24 as a result of the previous inspection was assessed. The first requirement was that the locks on the doors to the service users’ bedrooms must be replaced with single action locks. The registered manager stated that the locks that were fitted to the bedroom doors already met the required standard. It was, therefore, agreed that the requirement would be deleted and that the home would seek confirmation from the Fire Safety Officer, preferably in writing, that the locks on the bedroom doors were of a satisfactory type. The second requirement was that all of the items of furniture specified in Standard 24.2 must be provided in rooms occupied by service users. The service users’ bedrooms that were referred to in the previous report that did not contain all of the items listed in Standard 24.2 were inspected. In regard to bedroom 4 there was no table and the bedside lighting was not in working order. In regard to bedroom 10 there was no bedside lighting. The requirement had, therefore, not been fully implemented and still stands. It was also noted that a lock had not been fitted to the door of bedroom 14 and the door did not close properly on its rebate. The registered manager also confirmed that a lockable storage space had not been provided in the bedrooms for each service user. The previous recommendation was that the decision of the service users regarding whether to have a key to their bedrooms should be recorded in their care plans. The recommendation had not been implemented and still stands. The home’s response to the requirement that was made in regard to Standard 25 as a result of the previous inspection was assessed. The requirement was that the exposed pipe-work in bedroom 6 must be boxed. The requirement had not been implemented. A Notice of Immediate Requirement was given to the registered manager at the conclusion of the inspection in regard to this issue. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 19 The registered manager made the home’s infection control policy available for inspection. The contents of the policy were satisfactory. However, the policy should be signed and dated by the registered manager and reviewed at least every twelve months. The laundry was appropriately sited and contained all of the necessary facilities and equipment. The laundry had suitable floor and wall surfaces i.e. impermeable and readily cleanable. The wash programme on the newly purchased commercial washing machine included a clinical disinfection with a sluice facility. The registered manager stated that the level of incontinence within the home was increasing. However, the problem was being managed with the support of the district nurse and the continence adviser. No unpleasant odours were apparent in the parts of the home that were inspected. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 20 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): 30 Satisfactory arrangements had been made to ensure that the staff were trained and competent to do their jobs. EVIDENCE: The home’s response to the recommendation that was made in regard to Standard 28 as a result of the previous inspection was assessed. The recommendation was that arrangements should be made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent by 31 December 2005. The recommendation had not been fully implemented. However, it was pleasing to note that the home had made significant progress in implementing the recommendation. The registered manager stated that the recommendation would be fully implemented in the very near future. In the meantime, the recommendation becomes a requirement. The home’s response to the requirement that was made in regard to Standard 29 as a result of the previous inspection was assessed. The requirement was that two written references must be obtained before appointing any member of staff and any gaps in employment records must be explored. The files in respect of six members of staff who had been appointed to work at the home since the previous inspection were inspected. It was noted with concern that only three of the files contained two written references. The requirement had not been implemented. A Notice of Immediate Requirement was given to the registered manager at the conclusion of the inspection in regard to this issue. It was also noted with concern that four of the staff files did not contain a check from the Criminal Records Bureau (CRB). The registered manager Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 21 stated that a disclosure application had been made to the CRB in respect of the members of staff concerned but the results had not yet been received. The registered manager was reminded of the correct procedure in respect of applying for POVA first and CRB checks prior to the appointment of all members of staff. A Notice of Immediate Requirement was given to the registered manager at the conclusion of the inspection in regard to this issue. It was also noted that in the case of one member of staff a CRB check that had been obtained in respect of her previous employment had been accepted by the home without a new disclosure application to the CRB having being made. The registered manager was reminded that CRB disclosures were not ‘portable’ and that a new disclosure application had to be made by the home in respect of all new staff. A Notice of Immediate Requirement was given to the registered manager in regard to this issue at the conclusion of the inspection. It was also noted that in the case of one member of staff there was no proof of identity available in their file and in the case of another member of staff the file did not include a photograph. The registered manager was also given advice regarding the correct procedure to follow in cases where prospective staff had declared a conviction/caution for offences. The registered manager confirmed that new staff members undertook their induction training through Learndirect, an independent training organisation. Subsequently, the staff went on to complete NVQ 2 training. It was confirmed that two members of staff had recently completed the induction training and three members of staff were due to undertake it. In addition, the home had its own induction programme. The staff who were over the age of 25 years had commenced the NVQ level 2 training in September 2005. The staff members who were below the age of 25 years intended to commence the NVQ level 2 training in September 2006. The registered manager stated that the staff training that had been undertaken in the recent past had included medication ‘MDS’ by Boots in November 2005 and moving and handling and first aid in December 2005. Training in infection control was planned for 2 February 2006. The two deputy managers were intending to undertake training in adult protection on 1 February 2006. They would also commence the next stage of their medication training ‘Care of Medicines’ on 23 February 2006. The home’s response to the requirement that was made in regard to Standard 30 as a result of the previous inspection was assessed. The requirement was that all staff must have individual training and development assessments and profiles that include details of all their training needs and how these will be met in the future. The requirement had not been fully implemented and still stands. The registered manager confirmed that an ‘Individual Training Record’ had been produced in respect of each member of staff. However, the forms had not been fully completed and did not include an assessment of training needs. The registered manager stated that training needs were discussed in depth during the supervision meetings and, therefore, it would be easy to include a summary of any relevant decisions made about training in the individual training and development assessment and profiles. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 22 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 and 35 The systems for monitoring the quality of the service and the standard of care needed to be improved. Satisfactory procedures for safeguarding the service users’ finances were in place. EVIDENCE: The home’s response to the requirement and recommendation that were made in regard to Standard 33 as a result of the previous inspection was assessed. The requirement was that a quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. The requirement had not been implemented and still stands. The recommendation was that there should be an annual development plan for the home, based on a systematic cycle of planning, action, review, reflecting aims and outcomes for service users. The recommendation had not been implemented and still stands. The registered manager stated that a service user survey had been conducted in January 2006 but the results had not yet been analysed or published. There was no written evidence available to demonstrate the home’s commitment to lifelong learning and development for each service user linked Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 23 to the implementation of their individual care plans. The registered manager said that meetings were held with the service users approximately every three months. The last meeting was held on 13 November 2006. In addition, the key workers had daily contact with the service users and regular, informal contact was maintained with their relatives. The registered manager said that she operated an ‘open door’ policy. The registered manager also stated that she intended to seek the views of the service users’ relatives and friends by issuing a questionnaire. The home’s policies and procedures had been reviewed in the light of the National Minimum Standards. Action had not been progressed within agreed timescales to implement some of the requirements identified in previous CSCI inspection reports. The home’s response to the recommendation that was made in regard to Standard 34 as a result of the previous inspection was assessed. The recommendation was that a business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. The recommendation had not been implemented and still stands. The registered manager confirmed that fourteen service users had handed money over to the home for safekeeping. The money was kept in a lockable cash tin in a lockable cupboard. It was stated that in the absence of the registered manager or deputy manager the cash tin was locked in the home’s safe. The money was kept in individual plastic wallets with the names of the service users clearly marked on the outside. Receipts were issued. Records of the service users’ individual accounts were maintained. However, the records that were crosschecked with the amounts held were not up to date. This was because the hairdresser was not being paid at the time of each visit. In the case of one service user five payments to the hairdresser going back to November 2005 were still outstanding. The registered manager was advised to ensure that the service users’ financial records were kept up to date. It was confirmed that no member of staff or anyone connected with the running of the home acted as the agent or appointee on behalf of the service users. The home had a secure safe. The registered manager confirmed that the home currently held items for safekeeping on behalf of two service users. The registered manager confirmed that a record of the items held for safekeeping was maintained. The home’s response to the requirement that was made in regard to Standard 36 as a result of the previous inspection was assessed. The requirement was that care staff must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career development needs. The registered manager supervises the two deputy managers and the two deputy managers supervise the other care staff. The registered manager stated that she and her colleagues were ‘trying really hard to keep the frequency of supervision meetings on target’. It was clear from the detailed records that were being kept that the discussions that were held in supervision meetings were positive and meaningful. The registered manager Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 24 felt that because the recent staffing difficulties had been largely overcome it would be easier to hold regular supervision meetings. The requirement was, therefore, regarded as having been implemented. The Standard on supervision will be one of the Standards that will be fully assessed during the next inspection. The home’s response to the requirement that was made in regard to Standard 37 as a result of the previous inspection was assessed. The requirement was that visits to the home by the registered provider must take place at least once a month and copies of a written report on the conduct of the care home must be supplied to the registered manager and the Commission in accordance with Regulation 26. The registered manager stated that she had copies of all the reports made by the registered provider. However, it was noted that, since the previous inspection in August 2005, the Commission had received only three copies of the reports made in accordance with Regulation 26 i.e. the Commission had not received a report for September or December 2005. The requirement, therefore, had not been fully implemented and still stands. Advice was given to the registered manager on how the contents of the reports could be improved. The home’s response to the two requirements that were made in regard to Standard 38 as a result of the previous inspection was assessed. The first requirement was that opening restrictors must be fitted to the windows in bedrooms 3, 9 and 12 and to the window in the corridor near to bedroom 8 on the first floor. The requirement had not been implemented and still stands. A Notice of Immediate Requirement was given to the registered manager in regard to this issue at the conclusion of the inspection. The second requirement was that footrests must be attached to wheelchairs and used when wheelchairs are used to assist service users. The registered manager confirmed that this requirement had been implemented. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X X Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? YES 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 The work that has commenced to improve the contents of the care plans and to ensure that they are dated and signed by the service user whenever capable and/or representative (if any) and reviewed by the care staff at least once a month must be completed. The administration of Controlled Drugs must be witnessed by another designated and appropriately trained member of staff at all times and their signature recorded in the Controlled Drug register. The list of the names and signatures of all the staff involved in the administration of medication must be updated and accurately maintained. Fixed screening must be provided in bedroom 2 in order to ensure the service users’ privacy and dignity. The items stored in the bathroom on the first floor must be removed and the bathroom refurbished and used DS0000055364.V281254.R01.S.doc Timescale for action 31/03/06 2 OP9 13 30/01/06 3 OP9 13 06/02/06 4 OP10 16 31/03/06 5 OP21 23 30/06/06 Dunley Hall Version 5.1 Page 27 6 OP21 13,16 7 OP24 16 8 OP24 16 9 OP24 16 10 OP25 13 11 OP28 18 12 OP29 19 13 OP29 19 14 OP29 19 appropriately for its intended purpose. (Previous timescale of 31/10/05 not met). Paper towel dispensers must be provided near to the wash hand facilities in all of the communal toilets and bathrooms. (Previous timescale of 31/10/05 not met). All of the items of furniture specified in Standard 24.2 must be provided in rooms occupied by service users, including the items referred to in this report in relation to bedrooms 4 and 10. (Previous timescale of 31/10/05 not met). A suitable, single action lock must be fitted to the door of bedroom 14 and action must be taken to ensure that the door closes properly on its rebate. A lockable storage space must be provided in all of the bedrooms for each service user with a key that he or she can retain. The exposed pipe-work in bedroom 6 must be boxed. (Previous timescale of 31/10/05 not met). Arrangements must be made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent. Two written references must be obtained before appointing any member of staff and any gaps in employment records must be explored. (Previous timescale ‘with immediate effect’ not met). An enhanced disclosure check from the Criminal Records Bureau must be obtained for all new staff before their appointments are confirmed. An enhanced disclosure check from the Criminal Records DS0000055364.V281254.R01.S.doc 03/02/06 31/03/06 31/03/06 30/06/06 03/02/06 31/12/06 30/01/06 30/01/06 03/02/06 Page 28 Dunley Hall Version 5.1 15 OP29 19 16 OP30 18 17 OP33 24 18 OP37 26 19 OP38 13 Bureau must be applied for in respect of all existing staff who have not undergone a CRB check since their appointment at the home. A photograph and proof of identity in respect of each member of staff must be obtained and kept in the home. All staff must have individual training and development assessments and profiles that include details of all their training needs and how these will be met in the future. (Previous timescale of 31/10/05 not met). A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 31/10/05 not met). Visits to the home by the registered provider must take place at least once a month and copies of a written report on the conduct of the care home must be supplied to the registered manager and the Commission in accordance with Regulation 26. (Previous timescale of 30/09/05 not met). Window opening restrictors must be fitted to the windows in bedrooms 3, 9 and 12 and to the window in the corridor near to bedroom 8 on the first floor. (Previous timescale of 31/10/05 not met). 28/02/06 31/03/06 31/03/06 30/06/06 03/02/06 Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 29 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 OP3 Good Practice Recommendations The form used by the home for assessing the care needs of prospective service users should be revised in order to ensure that there is sufficient space to record all of the relevant information. The process of discussing and recording the service users wishes concerning terminal care and the arrangements after death should be completed. The range of social and recreational activities provided by the home should be increased in order to stimulate and engage the interest of more service users in accordance with their needs, choices and abilities, including those with a dementia illness, and a record of the activities provided maintained. All communal bathing facilities should be clearly marked. The advice of a qualified Occupational Therapist should be sought in order to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. The Fire Safety Officer should be asked to confirm, preferably in writing, that the locks on the bedroom doors are of a suitable type. The decision of the service users regarding whether to have a key to their bedrooms should be recorded in their care plans. The home’s policy on infection control should be signed and dated by the registered manager and reviewed at least every twelve months. There should be an annual development plan for the home, based on a systematic cycle of planning, action, review, reflecting aims and outcomes for service users. The results of service user surveys should be published and made available to current and prospective service users, their representatives and other interested parties, including the CSCI. Written evidence should be provided to demonstrate the home’s commitment to lifelong learning and development for each service user linked to the implementation of their individual car plans. The views of family and friends and of stakeholders in the DS0000055364.V281254.R01.S.doc Version 5.1 Page 30 2 3 OP11 OP12 4 5 OP21 OP22 6 7 8 9 10 OP24 OP24 OP26 OP33 OP33 11 OP33 12 OP33 Dunley Hall 13 14 OP34 OP35 community should be sought on how the home is achieving goals for service users. A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. The records of the service users’ finances maintained by the home should be accurate and kept up to date. Dunley Hall DS0000055364.V281254.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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