Inspection on 02/08/06 for Dury Falls

This inspection was carried out on 2nd August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dury Falls 10/07/07

Dury Falls 05/12/05

Dury Falls 15/08/05

Dury Falls 22/03/05

Dury Falls 21/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Dury Falls 35 Upminster Road Hornchurch Essex RM11 3XA Lead Inspector Ms Harina Morzeria 2 nd Key Unannounced Inspection August & 23rd August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 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. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dury Falls Address 35 Upminster Road Hornchurch Essex RM11 3XA 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) 01708 447786 Mr Barry Stack Mrs Christine Ann Stack Ms Mary Ellen Leedham Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28) of places Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th December 2005 Brief Description of the Service: Dury Falls is a privately owned care home for 28 older people situated in a residential area of Upminster. The home is currently managed by two people who job share this position. Maureen Leedham is currently registered as the manager of the home with the Commission and Linda Springhall has submitted an application to be registered, which is being processed. The property is a 16th century, grade 2 listed, two storey building, with a garden to the front and side. Internally some of the original features, such as low ceilings and doorways and narrow corridors, have had to be retained, and this limits disabled access. There are two lounges and a dining room on the ground floor, as well as some bedrooms, toilets and a bathroom. The remaining bedrooms are on the first floor, which is accessed by a lift and stairs. There are 8 single and 10 double rooms, six of which are en - suite. The home is situated on bus routes, and within walking distance of a tube station. Personal care is provided on a 24-hour basis, with health care needs being met by visiting professionals, such as district nurses. There are a wide range of activities provided within the home although outings are limited. A hobby therapist is employed who is highly motivated and provides activities suitable for people with dementia. The current scale of charges range from £466 to £480 per week. Prospective service users are informed about the service via the Statement of Purpose and the Service User Guide as well as via a brochure, which is being updated at the present time. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in August. Over the course of the two visits the inspector spoke to residents, staff and relatives about the service provision at the home. The home was toured and records were checked and discussed with both the managers on two separate days as well as the general manager who was also present during both visits. Staff were spoken to about care practices that they have implemented in the home. They were also observed directly and indirectly providing care to the residents. A tour of the downstairs part of the home took place and a number of residents and staff records were examined. Feedback questionnaires were sent out to the staff, residents and their representatives. Two comment cards were received from health and social care professionals, six were received from relatives and four were received from the staff. What the service does well: The home has a comfortable atmosphere and visitors said that they feel welcome. Residents said that the staff are kind. The staff were observed to support residents in a caring and professional manner. They continue to develop their skills in working with people with dementia. Residents said that they feel able to talk to the manager or the staff if they had any concerns or worries. The routines of daily living and activities are generally flexible and varied to suit/meet the residents’ capacities. The home employs a hobby therapist who, together with the care staff, arranges an activity program for the residents which they enjoy. During the inspection, staff were seen to be interacting well with the residents. All residents were well groomed and staff are aware of individual needs and preferences and how these should be met. The visiting times are flexible and visitors commented that they are made to feel welcome by the staff. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Areas where the home could be doing better were discussed and agreed with the registered manager. The involvement of residents and relatives in the written care plans made by the home needs to be increased. The home accommodates a large number residents with dementia and clear plans and guidance as well as appropriate risk assessments for managing this must be in place. Systems must be in place to ensure that all incidents relating to the residents are properly recorded and that the senior staff monitor these so that any further action needed can be taken immediately. The quality assurance and monitoring system needs to incorporate the views of the residents, relatives, staff and other professionals involved in the residents’ care in order to assess whether the home is meeting its aims as stated in the Statement of Purpose. The home provides a small brochure to initial enquirers which needs to accurately reflect the service provided within the home. It should also be available in other formats suitable to inform people with dementia. At the previous inspection a laminated version of the Service Users Guide was being prepared with pictures and symbols to make it a more accessible Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 7 document for daily use and for residents with short-term memory loss. This is yet to be developed. Significant events are now being reported to the commission, however these lack detail and the manager has been made aware that accurate information as well as an action plan must be included when reporting these. The use of double bedrooms needs to be reviewed as not all residents are happy with the present arrangements. A comment received from a relative reflects this, “My sister is being very well looked after but is depressed about the fact that she is still having to share a room. She was promised a room of her own when she entered the home as soon as one became available”. This concern was also expressed by another resident spoken to by the inspector. An adult protection policy and procedure is available within the home, however the policy and procedure need to be reviewed and updated in order to ensure that proper procedures are followed in the event of an allegation being made. The registered persons must demonstrate that all staff are receiving regular supervision which is accurately recorded. All staff delivering supervision are required to attend a supervisory training course in order to deliver effective supervision to the staff. 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. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 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 Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 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): 1,2,3,4,5,6 Quality in this outcome area is adequate. The judgment has been made using the available evidence including a visit to the service. A Statement of Purpose is available and includes all the information residents need to make an informed choice about where to live. A pre - admission assessment is undertaken of all prospective residents prior to their admission to the home, in order to establish their needs and whether these can be met at Dury Falls. Residents generally have a written contract with the home. Residents and their representatives are invited to visit the home so that they know that the home they enter will have the staff who are able to meet their needs. Residents are able to obtain a Service Users’ Guide and a small brochure. Intermediate care is not a service provided by Dury falls, therefore standard 6 is not applicable. EVIDENCE: Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 10 The Statement of Purpose includes information about the service provided by the home and is written in a clear and precise manner to enable prospective residents and their representatives to make an informed choice about where to live. A brief brochure is also available for prospective residents which needs to be updated and accurately reflect the service provided by the home including the use of double rooms, as discussed during the inspection. Most residents have a contract/ written statement of terms and conditions with the home. However, a copy of the terms and conditions was missing for one of the residents tracked during the inspection. Each resident must have a contract and a copy of the home’s terms and conditions. This sets out what is included in the fees, the role and responsibility of the provider, and the rights and obligations of the resident, giving residents a clear understanding of what they can expect. A Service Users’ Guide to the home is also issued to each resident. These documents must be available in different formats suitable for people with dementia. Two files for residents were examined, which included an assessment of their needs as well as an assessment from the local authority. Further information was also obtained from health professionals, family members and the resident, prior to the resident’s admission to the home. Residents and relatives are invited to visit the home prior to the resident moving in. A newly accommodated resident was able to confirm that she visited the home with her family prior to making a decision. The home does not provide intermediate care. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgment has been made using the available evidence including a visit to the service. The health and personal care needs of each resident are set out in individual plans of care. These plans provide the staff with sufficient information to ensure that care needs are being met on a daily basis. However, care plans must include all information relating to an individual’s medical condition and be updated promptly when a resident’s needs change. There is a medication policy and procedure for staff to follow and the medication records are being completed correctly which safeguards residents with regard to their medication. Residents are treated with respect and arrangements for their personal care ensure that their right to privacy is upheld. Residents’ wishes in relation to death and dying are identified in their care plans. EVIDENCE: Each resident has their own care plan. Four of these care plans were examined by the inspector. Some of the care plans were being updated at the Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 12 time of inspection and therefore did not include updated information regarding changes in a resident’s needs. The care plans generally identify residents’ personal, social, cultural, religious and health needs and how these needs should be met. However, for one of the residents tracked there was no care plan for a specific condition he suffers from. The inspector was informed that this was due to the fact that he does not actively receive any medical assistance relating to this condition at present. However, reference should be made to this condition in a separate care plan so that staff are aware that the resident has this condition and to look out for any signs or symptoms in case the condition re - emerges. The plans include a risk assessment element. The daily records show how residents’ basic needs are being met on a daily basis. However, the daily records should be informative and relate to the specific care plan goals and the outcomes. Residents have access to healthcare services that meet their assessed needs both within the home and in the local community. All residents have access to dentists, opticians and other community services. The residents’ health is monitored and appropriate action is taken. The home seeks professional advise on healthcare issues, acts upon it and generally is able to provide the aids and equipment recommended. One resident uses cot sides however there was no risk assessment in place for the use of cot sides or a signed consent. The need for these was discussed with the manager who is required to reassess the individual’s needs and take appropriate action. There is evidence in the care plan of healthcare treatment and intervention and a record of general healthcare information including weight monitoring and nutritional information. The manager must ensure that evidence of the care provided for each resident is fully recorded in order to show how residents’ needs are being met. Any changes in residents’ needs must be fully recorded and the care plans and risk assessments must be updated/amended promptly to reflect any changes to the care required by the resident, in consultation with the resident, so that staff can provide appropriate care to the residents at all times. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. A hobby therapist has responsibility to ensure that the residents have a varied programme of activities which suits individual needs, preferences and capacities specially suited to people with dementia. Visiting times are flexible and people are made to feel welcome, when visiting the home enabling the residents to maintain contact with their family and friends. Residents are assisted to exercise choice and control over their lives. The meals in the home are well presented and nutritionally balanced. They offer both choice and variety to the residents. EVIDENCE: The inspector spoke to a number of residents to seek their views about living in the home. All the residents spoken to stated that they receive good care from the staff and all their needs are being met in a caring and professional manner. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 14 The visitors book showed that there is a steady stream of visitors to the home on most days. As well as friends and family, other visitors included in the hobby therapist, hairdresser, an entertainer, as well as church visitors. There are a wide range of activities provided within the home although outings are limited. The inspector saw the activities and outings leaflet which reflected a varied programme of activities. Other activities include quizzes, bingo sessions, reminiscence and watching videos. Residents confirmed that they are free to choose if they wish to participate in the activities or not. Several residents said they appreciated and enjoyed the activities offered by the hobby therapist who is highly motivated and provides activities suitable for people with dementia. Key workers should seek feedback from residents about the kind of activities they enjoy doing so that consideration can be given to providing some of these as well as arranging outings for those who wish to go out on a regular basis. Evidence was seen that residents are consulted via residents’ meetings which are held on a regular basis. Family and friends feel welcome and know they can visit the home at any time. Staff make time to talk to visitors and share information with the agreement of the resident. It is clear that the home encourages individuals and groups from the community to visit the home. Residents have a choice of where to see their relatives, including one of the lounges or in their own bedroom. Residents finances are mostly handled by their family members or representatives. One resident handles his own finances and the company handle finances for three residents. Two service users are subject to power of attorney. There is a clear financial policy and procedure in place to protect the residents. Residents are encouraged to bring their own personal possessions with them when coming to live at the home and this was evident when the inspector visited some of the residents’ bedrooms. Meals are mostly served in the dining room, but there were some residents who choose to eat on their own in the lounge or in their own bedroom. The meals observed on the day of the inspection looked appetising and nutritionally balanced and the residents were complimentary about the food. Alternatives are offered if a resident does not like the choices on offer. Care staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the resident, making them feel comfortable and unhurried. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 15 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): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents and some of their relatives felt able to make complaints, however information regarding the complaints procedure must be available to all residents and their representatives. An adult protection policy and procedure is available within the home, however the policy and procedure need to be reviewed and updated in order to ensure that proper procedures are followed in the event of an allegation being made. EVIDENCE: The home has policies and procedures in place in relation to reporting and investigating complaints. The complaints book was examined during the inspection and there were no complaints recorded. The inspector was informed that complaints are made verbally and dealt with immediately. They are therefore not recorded. Following a discussion with the acting manager and responsible individual they agreed that all complaints, even those of a minor nature should be recorded and responded to within certain timescales as well as to show how they were responded to and dealt with. The reason for recording complaints is so that any emerging patterns can be identified and measures can be taken by managerial staff to deal with this and implement procedures in order to avoid a recurrence. Residents and some relatives said that they felt able to make complaints and raise issues if they needed to. However, feedback cards received from relatives Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 16 indicates that not all relatives and representatives are aware of the home’s complaints policy and procedure. The responsible individual is required to ensure that the complaints policy and procedure are clearly displayed and brought to the attention of all relatives and representatives of the residents. Residents have said that they were pleased with the staff and did not report any concerns. The residents spoken to on the day of the inspection, were asked if they were unhappy about anything in the home and if they knew who to make a complaint to. The residents said that they would talk to the staff or the manager. All the residents said that they felt confident that they would be listened to and their complaints would be acted upon. The majority of the residents have relatives and friends who can advocate on their behalf, if they so wished. The policies and procedures regarding protection of residents do not cover all areas required. They are not regularly reviewed or updated. Links with external agencies i.e., CSCI, police adult protection teams and Local Authority adult protection teams must be clearly defined and developed. Staff spoken to demonstrated an awareness of the issues relating to adult protection and stated that they would report any issues to the manager. However, upon examination of the adult protection policy and procedure, the inspector noted that these must be reviewed and updated in line with the Regulations and other external guidance. Within the policy, it must be clear when incidents need external input and who to refer the incident to. Links with external agencies must be satisfactory and include CSCI, police and local authority adult protection teams. At the time of the inspection, the inspector was concerned about non-compliance with the procedure regarding adult protection issues. The proper procedure was not followed in relation to allegations made, as the incidents were not referred to or investigated via the proper channels. The registered person must ensure that all staff including managerial staff receive updated adult protection training and that all staff demonstrate an awareness of the content of the adult protection policy and know what immediate action to take and when and who to refer any incident on to by following the home’s policy and procedures. A copy of the home’s adult protection policy and procedures to be forwarded to the inspector once reviewed and updated. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 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): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. This judgment has been made using the available evidence including a visit to the service. The home has a welcoming atmosphere and provides the residents with a safe and well maintained environment. There are sufficient numbers of suitable toilets and bathrooms for the number of residents accommodated. The use of double rooms, and a lack of en - suite toilets means that not all bedrooms suit individual needs and preferences. Residents live in a home that is comfortable, clean and hygienic. EVIDENCE: The home has a warm and cosy atmosphere, with furniture and fittings which are suited to the age of the property. There is a rolling programme of redecoration, and some bedrooms have been redecorated. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 18 The home is a listed building and some of the original features of the building, such as narrow corridors and low doors restrict the use of wheelchairs. There are 10 double bedrooms and whilst some residents and their relatives express a preference for a shared room, this is not always individual choice. The sharing of rooms includes the use of empty beds for respite care i.e. a permanent resident sharing a bedroom with a stranger for a week or two, which is potentially very disruptive for the residents and doesnt allow them choice. As this home was in existence prior to the Care Standards Act 2000 and the introduction of the National Minimum Standards, the Commission can not set a requirement but a recommendation, which is repeated at this inspection, was set at previous inspections, that the use of double rooms be reviewed. See recommendation number 1. In addition the bedrooms do not have en suite toilets, so commodes are provided in each room. In shared rooms, even with the curtains, this provides limited privacy, and has the potential to affect the dignity of the residents. One residents’ preference for a single room has still not been met. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgment has been made using the available evidence including a visit to the service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. Residents benefit from a committed and experienced team of staff at the home, who have the skills and training to meet their needs. The procedures for staff recruitment are satisfactory but were not followed robustly in all cases thereby not ensuring protection to residents. EVIDENCE: A good deal of positive feedback about the staff at the home was received from the residents and their relatives. A typical comment being “the staff are very kind and caring.” The home has had a relatively stable workforce and in discussion with staff it was evident that they fully support the main aims and values of the home. Many of the staff have worked there for a number of years and have built up a good knowledge and understanding of the needs of the residents. Staffing levels for both care and domestic staff were adequate to ensure the residents’ needs continue to be met. Staff files showed that they have done training in essential areas, such as food hygiene, health and safety, administering medication, adult protection and first aid. A comprehensive training programme is in place, a lot of which is provided Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 20 internally and some externally. 74 of the staff team have completed NVQ Level 2 and many are undertaking Level 3 courses. This is above the national minimum standards. Upon examination of staff files, the inspector noted that although a robust recruitment procedure is in place, the home had not undertaken all the necessary recruitment checks to ensure the protection of residents. References had not been requested for a newly appointed member of staff. The registered person is required to ensure that the home’s recruitment procedure is thoroughly followed when new staff are employed and that all checks required by the Care Homes Regulations are obtained before staff commence work . Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is adequate. This judgment has been made using the available evidence including a visit to the service. Residents live in a home that is run in their best interests by a registered manager who job shares part of the post. Residents’ financial interests are safeguarded by the policy and procedures of the home. The staff team work well together to make sure that residents are safe and secure whilst living at Dury Falls. Staff receive supervision however this needs to occur on a regular basis in order to provide support and guidance to them. The residents’ rights and best interests are safeguarded by the home’s recordkeeping policies and procedures. Residents’ and staff health, safety and welfare are promoted and protected. EVIDENCE: Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 22 The manager’s post is a job share position and only one person is registered with the Commission for Social Care Inspection. The management team generally work together to improve services and provide increased quality of life for residents. Feedback from both the residents and staff was positive about the way in which the home is run. However, the inspector is concerned that the second manager has not yet registered as a fit person although she has been in post since October 2005. At the time of the second inspection visit, the inspector was informed that she has applied to register as the manager to fill the second half of the post. As there is a job sharing arrangement in this service the two individuals responsible for the day to day management of the service, must have clear guidelines, protocols and systems of working to ensure the service is managed effectively and consistently. Regulation 26 visits are undertaken by the responsible individual on a monthly basis and the reports are forwarded to the inspector. However, these visits need to be more detailed and thorough in order to reflect the quality of the service provided, noting any improvements required to make it a “good” service. An improvement plan will be required. The inspector is now notified of significant events and developments in the home, however discussion took place about the content of the notifications and the detail required which needs to be presented in a clear and consistent manner. A quality assurance survey to seek satisfaction levels amongst the residents, staff and relatives has been sent out by the home. The results and outcome of this survey will be available in a report published by the providers in order to assess whether the home is meeting its aims and objectives according to the Statement of Purpose. The home has policies and procedures, which are in the process of being reviewed and updated in line with current thinking and practice. Efficient systems need to be in place to monitor staff adherence to policies and procedures during practice. The home works to a clear health and safety policy, which all staff have been made aware of and must be working to. The inspector was informed that health and safety checks are carried out by the managers on a weekly basis however there was no evidence to support this. The registered person must ensure that home meets relevant health and safety requirements and legislation. Records are generally of a good standard and are routinely completed however some of the records need detail. Residents are aware of safety arrangements and have confidence in the safe working practices of staff. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 23 The home has an appropriate policy and procedures regarding safeguarding residents’ finances. If they wish and are able to, the residents are helped to take responsibility for managing their own money. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for residents’ money the home maintains clear records that are routinely kept up-to-date and can be used to track individual residents’ finances. However the inspector was informed that most of the residents’ finances are handled by their family members. A supervision policy and procedure is in place. Staff confirmed that they receive supervision on a regular basis from the manager and senior officers. However upon examination of the supervision records the inspector noted that there was no evidence that all staff receive regular supervision. The manager is aware that formal supervision is important as it allows the staff time and space to reflect on their practice with their manager/senior. Recording the supervision is important, as it provides a retrospective picture of development and change. The home must be able to demonstrate that all staff are receiving regular supervision which is accurately recorded. All staff delivering supervision are required to attend a supervisory training course in order to deliver effective supervision to the staff. The manager is committed to keeping records up to date and a requirement has been made elsewhere in this report regarding keeping care plans, risk assessments and other essential information regarding care given to residents up-to date. Fire drills and alarm testing is undertaken regularly. However, at the time of the inspectors first visit to the home the staff were unable to open a fire door leading to the side garden. The registered person must ensure that all fire exits remain accessible and uncluttered and can be easily opened in an emergency. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 3 3 2 3 2 Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP2 OP7 Regulation 5 15 Requirement Timescale for action 31/10/06 Each resident must have a contract and a copy of the home’s terms and conditions. The registered person must 31/10/06 ensure that evidence of the care provided for each resident is fully recorded in order to show how residents’ needs are being met. Any changes in residents’ needs must be fully recorded and the care plans must be updated/amended promptly to reflect any changes to the care required by the resident, in consultation with the resident, so that staff can provide appropriate care to the residents at all times. 3 OP16 22 The responsible individual is required to ensure that the home’s complaints policy and procedure are clearly displayed and brought to the attention of all relatives and representatives of the residents. All complaints must be logged and action taken to resolve them must be DS0000027842.V309157.R01.S.doc 31/10/06 Dury Falls Version 5.2 Page 26 4 OP18 12/13 5 OP29 18/19 6 OP31 OP32 9 7 OP36 18 recorded. The policies and procedures regarding protection of residents do not cover all areas required. They are not regularly reviewed or updated. The registered person to ensure that the home’s adult protection policies and procedures are reviewed/updated and all staff and managers receive updated training with in the stated timescale. Upon examination of staff files, the inspector noted that although the recruitment procedure is followed, the home had not undertaken all the necessary recruitment checks to ensure the protection of residents. References had not been received for a newly appointed member of staff. The registered person is required to ensure that the home’s recruitment procedure is thoroughly followed when new staff are employed. The management approach of the home must be consistent and the home must be run in the best interests of the residents. The inspector is concerned that the second manager has not yet registered as a fit person although she has been in post since October 2005. The registered person to demonstrate that all staff are receiving regular supervision which is accurately recorded. All staff delivering supervision are required to attend a supervisory training course in order to deliver effective supervision to the staff. The registered person must DS0000027842.V309157.R01.S.doc 31/10/06 31/10/06 31/10/06 31/10/06 8 Dury Falls OP38 12/13 31/10/06 Version 5.2 Page 27 ensure that the home meets relevant health and safety requirements and legislation. The registered person must ensure that all fire exits remain accessible and uncluttered and can be easily opened in an emergency. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP23 OP12 Good Practice Recommendations The use of double rooms should be reviewed, taking into account the preferences of each service user. Key workers should seek feedback from residents about the kind of activities they enjoy doing so that consideration can be given to providing some of these as well as arranging outings for those who wish to go out on a regular basis. Dury Falls DS0000027842.V309157.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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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