Inspection on 09/08/05 for Dunley Hall

This inspection was carried out on 9th August 2005.

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 26/01/06

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 Nr Stourport-on-Severn Worcestershire DY13 OTX Lead Inspector Nic Andrews Announced 9 and 11 August 2005 - 9:20 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. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dunley Hall Address Dunley Nr Stourport-0n-Severn Worcestershire DY13 OTX 01299 822040 01299 828128 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) Mrs Monica Arjan McGlynn trading as Minster Grange Residential Home Ms Elizabeth Joy Flood CRH 19 Dementia - over 65 Old age Physical disability - over 65 19 19 19 Category(ies) of DE(E) registration, with number OP of places PD(E) DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There were no conditions other than those referred to on the previous page of this report. However, the conditions of registration had been breached earlier in the year by the admission of a service user who was below the age of 65 years. The registered manager had submitted an application to the CSCI on behalf of the registered provider for a variation in conditions of registration in order to rectify the situation. The application was under consideration at the time of the inspection. Date of last inspection 21 February 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. 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 E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection that took place over one and a half days. Service users’ records, staff records and other relevant policies and documentation were inspected. A tour of the premises was also made. Individual and group discussions were held with seven service users and with four of their relatives/friends. Separate discussions were also held with two members of staff and with a peripatetic NVQ Assessor. Time was also spent with the registered manager. The majority of the comments made by the service users with whom discussions were held were positive. They stated that there was a happy atmosphere in the home, their rooms were kept clean and tidy and they were well cared for. The food was described as ‘good’ and ‘excellent’. Both they and their relatives said that they were provided with sufficient information about the home prior to admission to enable them to make an informed choice. They all said that they were made to feel welcome. One service user said that the staff were ‘kind and attentive’. One service said that she felt comfortable and settled. However, she also expressed her concern over an issue that had occurred that had involved a former member of staff and the results that had ensued. She said that she did. The matter was discussed separately with one of the service user’s relatives and also with the registered manager. The two members of staff with whom discussions were held also spoke positively about the home and their work. They felt that there was a ‘good tam spirit’ and that the staff worked hard and were committed to providing a high standard of care. One staff member said that there was improved job satisfaction and greater involvement and responsibility. She also felt that the key worker system was effective. Both members of staff confirmed that they had received a copy of their job descriptions and contracts. One member of staff said that she would like more time to spend talking individually to the service users. The peripatetic NVQ Assessor commented favourably about the home. She referred, in particular, to the positive way that the staff were encouraged and supported in their training and their work by the registered manager. She said that the staff were well motivated and that the home had an open, noninstitutional approach to care. As part of the inspection process ‘Comment Cards’ were issued to a number of service users, their relatives/friends and to visiting professionals. A total of 38 Comment Cards were returned completed. Seven of the 19 Comment Cards received from the service users contained entirely positive responses to the questions that were asked. The majority of DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 6 the responses in the other 12 Comment Cards were also positive. However, six of the service users did not always like the food, six wished to be more involved in decision making within the home and one felt that the home did not always provide suitable activities. Eleven of the 15 Comment Cards received from the service users’ relatives/friends contained entirely positive responses and 3 of them also included additional positive comments about the home. The majority of the responses in the other 4 Comment Cards were also positive. However, two of the relatives/friends did not feel that there was always sufficient numbers of staff on duty, two were not aware of the complaints procedure and two were not aware of the availability of inspection reports. Three of the 4 Comment Cards received from visiting professionals contained entirely positive responses and 1 also included additional positive comments about the home. The Comment Card from the fourth visiting professional contained mixed responses and also included additional negative comments. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 7 contacting your local CSCI office. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 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 standard(s) 1 and 2 The statement of purpose and service users’ guide contained detailed and comprehensive information about the services provided by the home. The information was sufficient to enable prospective service users to make an informed decision about the home prior to admission. Each service user had been issued with a statement of the terms and conditions of residence (contract). EVIDENCE: A copy of the home’s statement of purpose and a copy of the home’s service users’ guide were made available for inspection. Both documents referred to the registered provider’s now former role as manager of another care home in Redditch. This reference should be amended. Apart from this one minor correction, the contents of both documents were comprehensive and detailed and contained all of the relevant information required by the Regulations and the National Minimum Standards. The registered manager confirmed that all of the current service users had been issued with a copy of the service users’ guide. A copy of the home’s statement of terms and conditions of residence (contract) was made available for inspection. In the section of the contract that provided DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 10 information about the home’s complaints procedure, there were two references to the now former National Care Standards Commission. However, this reference was amended during the inspection to the Commission for Social Care Inspection. As with the home’s statement of purpose and service users’ guide, the contents of the contract were comprehensive and detailed and contained all of the information listed in the National Minimum Standards. The registered manager confirmed that all of the service users had been issued with a contract. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 11 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 The care plans contained relevant information and were reviewed at least every month. However, the care plans must include more specific and detailed guidance about the way in which the service users’ needs are met. EVIDENCE: The care plans in respect of a number of service users were examined and the home’s response to the requirement that was made in regard to care plans as a result of the previous inspection was assessed. The requirement was that all the service users’ care plans must be reviewed by staff at the home at least once a month and a record of the date of the reviews and specific details of the outcome i.e. any changes to the care plan, maintained. The requirement had been implemented. However, the care plans tended to describe the service users’ needs and did not describe in sufficient detail how the needs would be met. This issue was discussed with the registered manager who acknowledged that the care plans must contain very clear and specific details that describe how the service users’ needs would be met. The home’s response to the recommendation that was made as a result of the previous inspection regarding Standard 11 was assessed. The recommendation was that the process of discussing and recording the service users’ wishes concerning terminal care and the arrangements after death DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 12 should be completed. The registered manager confirmed that the relevant information had been recorded on the front sheet of the admission papers in respect of approximately 66 of the service users. The recommendation had, therefore, not been fully implemented and still stands. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 13 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 the service users were well catered for and the food provided was balanced and nutritious. The menu offered both variety and choice. EVIDENCE: The registered manager confirmed that food was discussed regularly at the service users’ meetings. The service users’ were also consulted daily on their choice of meals. One of the service users was provided with very soft food. However, none of the service users required liquefied meals. Two service users had their food cut into very small pieces in order to avoid the risk of choking. None of the service users required special diets for health, cultural or religious reasons. However, food preferences were noted and respected. A copy of the home’s four-week menu was made available for inspection. The menu was balanced and nutritious. It was stated that none of the current service users required staff assistance with feeding. No special equipment was needed at the present time. However, the home did have specially adapted cutlery and plates available for use by service users, if necessary. All of the service users with whom discussions were held during the inspection commented positively about the standard of food provided. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 14 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 and 18 Complaints were handled objectively and procedures were in place to help ensure that service users are protected from abuse. EVIDENCE: The home had a satisfactory complaints procedure. However, the copy of the complaints procedure that was included in the home’s Policies and Procedures Handbook did not include a clear reference to the Commission for Social Care Inspection (CSCI). The error was corrected during the inspection. A record of the complaints made against the home was maintained. The record of the three most recent complaints was examined and there was evidence to show that the complaints had been responded to appropriately. The service users with whom discussions were held during the inspection felt confident that any concerns they had would be taken seriously, responded to quickly and dealt with appropriately. The Commission for Social Care Inspection had not received any complaints about the home during the previous twelve months. The home had a satisfactory policy and procedure on the protection of vulnerable adults from abuse. The home’s response to the requirement that had been made as a result of the previous inspection to amend the policy was assessed. The requirement had been implemented. The home also had a satisfactory ‘whistle blowing’ policy. One allegation of abuse (neglect) had been reported to the registered manager within the previous twelve months. The matter had been dealt with appropriately using the home’s disciplinary procedures. The registered manager was advised to refer the person who may be unsuitable to work with vulnerable adults for consideration for inclusion on the Protection of Vulnerable Adults register. The home had a policy called ‘Management of Violence’ to help ensure that physical and/or verbal DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 15 aggression by service users was understood and dealt with appropriately by the staff. The home also had a policy and procedure on ‘Service Users’ Money and Property’. The contents of both policies were satisfactory. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 16 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, 20, 21, 22, 24 and 25 The service users were cared for in a safe, comfortable and well-maintained environment. However, there was a need to make improvements to some of the individual and communal facilities. EVIDENCE: The home was safe and well maintained and suitable for its stated purpose. Access to the home was gained via a long driveway. The registered manager stated that it was intended to completely re-surface the driveway following the completion of the proposed extension to the home. It was confirmed that, in the meantime, continuing efforts were made to fill any holes that appeared in order to ensure that the surface of the driveway was maintained in a safe and hazard-free condition. The home’s response to the recommendation that was made as a result of the previous inspection in regard to Standard 19 was assessed. The recommendation was that a programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and implemented. The recommendation had been implemented. However, the registered manager was advised to include in the programme both the proposed dates for the implementation of renewal/items of work and the dates DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 17 when the work had been completed. A gardener visited the home once a week to help maintain the grounds. The garden and grounds were accessible to the service users. A copy of the letter from the Environmental Health Officer dated 18 February 2005 was made available for inspection. The registered manager confirmed that most of the issues referred to in the letter that required attention had been addressed. The registered manager confirmed that the items that were still outstanding would be addressed when the kitchen was refurbished as part of the proposed work to provide an extension to the premises in the near future. The home provided adequate communal space. There were two, well furnished lounges and a separate dining room. The home had a ‘no smoking’ policy. Therefore, all of the communal space was smoke free. Any service users that smoked were asked to smoke outside the premises. There was a large garden at the front of the premises and a smaller garden at the rear. The gardens provided seating and were accessible to people in wheelchairs. The lighting and furnishings in communal rooms were domestic in character and of a good standard. As a pre-existing care home i.e. a home that was registered prior to 31 March 2002, the home provided the required number of toilets and bathing facilities. Eight of the thirteen single bedrooms and all three double bedrooms had an en suite facility. In addition, the home provided one bathroom that contained a bath with a hoist but no toilet on the ground floor. There were also three separate toilets for communal use on the ground floor. There were two bathrooms without toilets and two separate toilets for communal use on the first floor. One of the bathrooms on the first floor was not used except for storage and the bath was stained. This facility was, in effect, a wasted resource. One of the toilets on the first floor opposite bedroom 3 did not have a wash hand basin. The toilet was not big enough to enable a wash hand basin to be installed. There was also a staff toilet on the first floor. Four of the service users required the permanent use of a wheelchair. The four service users that required the use of a wheelchair had an en suite facility that was accessible to them without a wheelchair. The door to the bathroom on the ground floor should be clearly marked as a bathroom. Liquid soap and paper towel dispensers were not available in all of the communal bathrooms and toilets. 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 regard to the provision of disability equipment and environmental adaptations. The recommendation had not been implemented and still stands. A passenger lift was installed that enabled service users to access the accommodation provided on the first floor. Access to five bedrooms on the first floor accommodating a total of eight service users was gained via three steps. The registered manager confirmed that risk assessments had DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 18 been carried out in respect of the service users accommodated in this part of the building regarding the use of the stairs. Handrails had been provided in the corridors. Suitable equipment had been provided for one service user who was visually impaired. A staff call system with an accessible alarm facility had been provided in all the rooms. The home’s response to the three requirements and two recommendations that were made in regard to Standard 24 as a result of previous inspections was assessed. The first requirement that two double electric sockets must be provided in all the bedrooms occupied by service users had been implemented. The second requirement that the doors to the service users’ bedrooms must be replaced with single action locks had not been implemented and still stands. The third requirement was that permanent screening must be provided in each of the double bedrooms. If the service users that occupy the double rooms decline the provision, details of the discussions and decisions about this should be recorded in the assessment of the service users’ needs and the matter kept under review. The registered manager confirmed that permanent screening had been provided in one of the double bedrooms. The service users that occupied the two other double bedrooms had declined the provision of permanent screening. Their decision and that of any future occupants of the double bedroom in regard to the provision of permanent screening should be kept under review. However, the requirement was regarded as having been implemented. The first recommendation was that the service users should be provided with keys to their bedrooms unless their risk assessment suggests otherwise. The registered manager stated that all of the current service users had been asked whether they wished to have a key to their bedroom. None of the current service users wished to have their own key. However, their decisions had not been recorded. The second recommendation was that each service user should be provided with a lockable storage space for medication, money and valuables and a key that they can retain (unless the reason for not providing a key is explained in the care plan). The registered manager confirmed that the requirement had been implemented. The service users’ bedrooms were inspected in order to ensure that they contained all of the items listed in Standard 24. It was noted that the bedrooms were clean, comfortable, well decorated and personalised. However, it was also noted that there was no bedside lighting in bedrooms 4, 5, 9 and 10. Comfortable seating for two people was not provided in all of the bedrooms e.g. bedrooms 5 and 6. No reason for the absence of these items was recorded in the service users’ care plans. There was no table in bedroom 4 and no bedside table in bedroom 1. There was no lock on the door of bedroom 14. The heating, lighting, water supply and ventilation of the service users’ accommodation were of an acceptable standard. The service users with whom discussions were held during the inspection expressed satisfaction with their accommodation. The home was centrally heated. The registered manager stated that a new boiler had been recently installed. The registered manager was advised that portable heaters are a safety hazard and must not be used DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 19 except for short periods in highly exceptional circumstances following a risk assessment. Radiators were guarded and emergency lighting was provided throughout the home. However, the pipe work in bedroom 6 needed to be boxed. The registered manager provided written evidence to show that a risk assessment had been carried out by an outside contractor in respect of ‘Legionnaires Disease’ and ‘Water Supply Regulations 1999’ on 14 March 2004. The temperature of the hot water was kept to a satisfactory level by the provision of thermostatically controlled mixer valves that had been fitted to the hot water outlets used by service users. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 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 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) 27, 28 and 29 The number and deployment of staff was sufficient to meet the needs of the service users and the staff were committed to developing their knowledge and skills through NVQ training. However, the practice of obtaining two written references must always be adhered to in order to ensure that the staff recruitment procedure remains robust. EVIDENCE: A satisfactory staff rota was maintained. In addition to the registered manager who was contracted to work 40 hours per week, the home provided two deputy managers for a total of 55 hours per week, a household co-ordinator who worked 25 hours per week and five senior carers who worked a total of 130 hours per week. The registered manager confirmed that, in addition to senior staff, there were always three care staff on duty in the mornings and evenings. The registered manager also confirmed that there were always two members of staff on duty on the premises at night, one on waking duty and one asleep and on call. A separate staff sleeping-in room was provided. None of the staff were under the age of 21 years. Cleaning staff were employed for 28 hours per week. The home’s response to the recommendation that was made in regard to NVQ level 2 training as a result of previous inspections was assessed. The recommendation had not been fully implemented and still stands. However, it was pleasing to note that progress was being made to implement the recommendation. Only one member of staff had completed the NVQ level 2 training. However, sixteen members of staff were undertaking NVQ level 2 training. The registered manager said that the staff hoped to complete their DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 21 training in approximately six to eight months. In addition, three members of staff were undertaking NVQ level 3 training. The staff hoped to complete the NVQ level 3 training in approximately twelve months. The home did not employ any trainees or any agency staff. The home had an equal opportunities policy. References to the home’s commitment to promoting equal opportunities were included in the statement of purpose and service users’ guide. The files of two members of staff were inspected. The files contained relevant information and most of the required documentation e.g. photograph, application form, proof of identity etc. However, one of the files contained only one written reference. The registered manager confirmed that all of the staff had been given a copy of the code of conduct and practice issued by the General Social Care Council. It was also confirmed that all the staff were issued with a statement of their terms and conditions of employment (contract) following the successful completion of their probationary period. The home’s response to the requirement that was made in regard to the provision of individual training and development assessments and profiles as a result of the previous inspection was assessed. The requirement had not been fully implemented and still stands. The registered manager confirmed that training needs were discussed in staff supervision meetings and appropriate training was identified. However, the individual training records did not include the future training needs of the staff as identified through supervision. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 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 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) 31, 36, 37 and 38 The manager of the home is competent and experienced and her approach is positive and inclusive. The home maintains appropriate records and the health and safety of the service users and staff is promoted. However, the frequency of staff supervision needs to be improved. EVIDENCE: The registered manager was competent and had relevant experience. She had been the registered manager for approximately 21 months. The registered manager held the Diploma in Social Work and had completed the Advanced GNVQ in Health and Social Care in 1998. The registered manager had also undertaken more recent training and was motivated to continue to promote her own professional understanding and development. She had completed a four-day training course on Managerial Assessment of Proficiency run by the Chamber of Commerce in March 2005. In February 2005 the registered manager completed a sixteen-week, distance-learning health and safety course run by Wolverhampton College. She had also attended the development and DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 23 training event ‘Having Your Say’ organised by Worcestershire Social Services Department on 2 March 2005. One month prior to commencing her employment at Dunley Hall, the registered manager had undertaken a one-day training course on the protection of vulnerable adults from abuse. There were clear lines of accountability in the home and the registered manager stated that all of the staff were aware of the new team structure. The home’s response to the one requirement and two recommendations that were made in regard to Standard 33 as a result of previous inspections was assessed. The requirement that was made regarding the introduction of a quality assurance system had not been implemented and still stands. The first recommendation regarding the provision of an annual development plan had not been implemented and still stands. The registered manager was given appropriate advice on this issue. The second recommendation was that the views of family and friends and of stakeholders in the community e.g. GPs, chiropodist, voluntary organisation staff, are sought on how the home is achieving goals for service users. The recommendation had been implemented. In March 2005, an informal meeting had been held at the home to which the relatives and friends and other stakeholders had been invited. The registered manager stated that the meeting was well supported and there had been positive feedback from those attending. The registered manager intended to hold a similar event each year. It was confirmed that there was also an intention to introduce questionnaires in order to obtain the views of those with a legitimate interest in the welfare of the service users and the services provided by the home. This task had been delegated to a member of the senior staff. The home’s response to the recommendation in regard to the provision of a business and financial plan for the establishment that was made as a result of the previous inspection was assessed. The recommendation had not been implemented and still stands. The registered manager stated that she was responsible for supervising all of the senior staff. The deputy managers were responsible for supervising all of the care staff. The forms that were used for recording supervision meetings contained a reference to all of the issues listed in Standard 36.3. It was confirmed that individual supervision meetings were held regularly with all of the care staff but not at the frequency specified in the National Minimum Standards. The registered manager stated that supervision meetings were not being held at the required frequency mainly as a result of the absence of a senior member of staff who was on long-term sick leave. However, one of the two staff files that were examined contained a record that showed that only two supervision meetings had been held within the previous ten months i.e. 6 October 2004 and 24 July 2005. The requirement that was made in regard to supervision as a result of the previous inspection had, therefore, not been fully implemented and still stands. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 24 All of the records required by Regulation were being maintained apart from the reports on the conduct of the home that were compiled following visits to the home made in accordance with Regulation 26. The copy of the most recent report made in accordance with Regulation 26 was dated 6 August 2004. The most recent Regulation 26 report that had been sent to the Commission for Social Care Inspection was dated 7 January 2005. The service users had access to the records held about them by the home. There were references to the service users’ right of access to their records in both the statement of purpose and in the service users’ guide. The records were kept in a secure place. The requirement that was made as a result of the previous inspection regarding the need to make an application for a variation in the home’s conditions of registration had been implemented. The home’s response to the requirement that was made in regard to Standard 38 as a result of the previous inspection was assessed. The requirement was that all the staff must be trained in infection control to ensure safe working practice. The registered manager confirmed that infection control training had been carried out on 23 June 2005 by a trainer from Kidderminster College. Nineteen members of staff had undertaken the training. The registered manager stated that some staff had yet to undertake the training. However, the requirement was regarded as having been implemented. The registered manager also confirmed that all of the staff had undertaken moving and handling training within the previous twelve months, fire safety training had been provided for all the staff in July 2005 by an outside contractor and all of the senior staff and night care staff had received first aid training to the level of an appointed person in January 2005. The registered manager confirmed that there was always at least one member of staff with a first aid qualification on duty at all times. The registered manager also confirmed that arrangements had been made for staff to undertake food hygiene training in the near future. A new boiler had been provided in December 2004. The boiler and the central heating system were due to be serviced in September 2005. PAT testing was carried out on 6 July 2005. An electrical safety certificate had been provided in March 2004. Thermostatically controlled mixer valves had been fitted to all of the hot water outlets used by service users. The home’s fire fighting equipment had undergone an annual service by an outside contractor in May 2005. Risk assessments, including a fire risk assessment, had been carried out. However, it was noted that there were no opening restrictors on the windows in bedrooms 3, 9 and 12 or on the windows near to bedroom 8 in the corridor on the first floor. During the lunchtime period it was also noted that two service users were transferred in wheelchairs without the use of footrests. Footrests must always be used when service users are transferred unless, in highly exceptional circumstances, their risk assessments indicate to the contrary. The home had a Health and Safety Policy manual, an accident book and COSHH and RIDDOR information/documentation. The home also displayed fire evacuation procedures and exit signs. There were safety notices in the laundry and food was labelled. The majority of the staff had embarked on NVQ training. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 25 However, the home also had an Induction Training manual produced by Worcestershire County Council that met TOPSS specification. DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 26 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 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 2 2 x 2 2 x STAFFING Standard No Score 27 3 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x 2 2 2 DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 27 YES 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 7 Regulation 15 Requirement The care plans must contain clear, specific details that describe the way in which the service users needs will be met. The items stored in the bathroom on the first floor must be removed and the bathroom refurbished and used appropriately for its intended purpose. Liquid soap and paper towel dispensers must be provided near to the wash hand facilities in all of the communal toilets and bathrooms. The doors to the service users bedrooms must be replaced with single action locks. (Previous timescale 30 September 2005). All of the items of furniture specified in Standard 24.2 must be provided in rooms occupied by service users. If the provision of any item poses an unacceptable risk to the service user or they decline the provision, details of the discussions and decision about this should be recorded in the assessment of the service users needs. Timescale for action 31 October 2005 31 October 2005 2. 21 23 3. 21 13,16 31 October 2005 4. 24 16 31 October 2005 31 October 2005 5. 24 16 DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 28 6. 7. 25 29 13 19 8. 30 18 9. 33 24 10. 36 18 11. 37 26 12. 38 13 13. 38 13 The exposed pipe-work in bedroom 6 must be boxed. Two written references must be obtained before appointing any member of staff and any gaps in employment records must be explored. 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 30 April 2005 not met). A quality assurance sysytem must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 30 June 2005 not met). 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. (Previous timescale of 30 June 2005 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 Commision in accordance with Regulation 26. 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. Footrests must be attached to wheelchairs and used when wheelchairs are used to assist service users. E52 S55364 Dunley Hall V235203 090805.doc 31 October 2005 With immediate effect. 31 October 2005 31 October 2005 31 October 2005 30 September 2005 31 October 2005 With immediate effect. DUNLEY HALL Version 1.40 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. 2. 3. 4. Refer to Standard 11 18 21 22 Good Practice Recommendations The process of discussing and recording the service users wishes concerning terminal care and the arrangements after death should be completed. Staff who may be unsuitable to work with vulnerable adults should be referred for consideration for inclusion on the Protection of Vulnerable Adults register. All communal toilet and 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 decision of the service users regarding whether to have a key to their bedrooms should be recorded in their care plans. 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. 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. A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. 5. 6. 24 28 7. 8. 33 34 DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI DUNLEY HALL E52 S55364 Dunley Hall V235203 090805.doc Version 1.40 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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