Inspection on 22/12/06 for The Dorothy Lucy Centre

This inspection was carried out on 22nd December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Dorothy Lucy Centre 22/02/06

The Dorothy Lucy Centre 13/09/05

The Dorothy Lucy Centre 11/01/05

The Dorothy Lucy Centre 27/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Dorothy Lucy Centre Northumberland Road Maidstone Kent ME15 7TA Lead Inspector Mrs Ann Block Key Unannounced Inspection 22nd December 2006 09:00 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 The Dorothy Lucy Centre DS0000037761.V321022.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. The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Dorothy Lucy Centre Address Northumberland Road Maidstone Kent ME15 7TA 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) 01622 678071 01622 762877 Kent County Council Mrs Julie Carol Parsooramen Care Home 28 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (18) of places The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ten beds may be used for service users between 55 years of age and 65 years of age who have physical and mental conditions usually associated with older persons. 22nd February 2006 Date of last inspection Brief Description of the Service: The Dorothy Lucy Centre is a detached, purpose built property with accommodation on the ground floor only. It is owned and operated by Kent County Council. An integral part of the building comprises a day care facility offering services to older people and used by other organisations where appropriate. The Dorothy Lucy Centre itself comprises three units. Allington is a respite unit for older people. Mereworth is a respite unit for older people with mental health needs. Leeds unit offers older people an assessment and rehabilitation service to direct where their needs can be best met, such as a return home or to longer term care. The Dorothy Lucy Centre has capacity for 28 service users who generally stay for around a week in Allington and Mereworth or to a maximum of six weeks in the Leeds unit. The service is located on the outskirts of Maidstone where there are the usual facilities of a town. There is access to public transport close by. Space for car parking is available and there is a garden for service users to use. All bedrooms are for single occupancy and each is equipped with a staff call point. The Homes staffing team comprises the Manager, Team Leaders and care staff who work a roster to give 24-hour cover. The service also employs other staff for catering, domestic and maintenance tasks. A qualified Occupational Therapist employed by the O.T Bureau and an Occupational Therapy Assistant work at the service each weekday. Fees at the date of report were £351.91 per week. The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of a key unannounced inspection which included an unannounced site visit to the service carried out by regulatory inspector Ann Block on 22 December 2006 between 8.57 am and 4.42 pm. The site visit included talking with a number of service users, observation of daily living, talking with a visitor, talking with staff and the manager and a walk round tour of the premises. Service users and staff gave their full cooperation to the process of gathering evidence for quality of life for service users. To further obtain views of the service comment cards and survey forms were sent to a sample of service users, families and professionals. Written and verbal comments were very complimentary of the service, comments received included: I came here last Christmas and couldn’t wait to come again, I love it here, they are so friendly and the food is super. (Resident) We find The Dorothy Lucy Centre to be a happy & friendly place, clean & supportive. I have no worries about Mum being there, as I know she will be looked after. (Relative on behalf of a resident) We are so glad Dad could come here, you hear such awful things about care homes, but we have been really reassured by him being here and feel more positive about his move into permanent care. (Relative) Could not wish for better care. Staff always kind and helpful. Have no worries when my husband is in (your) care. (Relative) Very pleased with care provision at The Dorothy Lucy Centre. Clients always give positive feedback regarding their experience there. (Professional) What the service does well: The Dorothy Lucy Centre offers a much needed service offering older people periods of respite care and a place where future needs can be assessed through rehabilitation and evaluation. That local people appreciate this service was summed up in the comments: The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 6 ‘(They are) always ready to help in taking R at other times when I am ill’ ‘It is such a relief to know there is somewhere like (The Dorothy Lucy Centre) for my father’ Staff recognise that the high turnover of service users can bring increased pressure on resources but through excellent management are able to offer each person in their care as high a standard of service as possible whilst at the Centre. People know that there might be some shortfalls but they are able to talk about any problems, know they will be listened to and action taken. People feel their loved ones will be safe and know health needs will continue to be met by staff who are kind and thoughtful. Service users like the centre and feel it is friendly and welcoming. They like the food and feel well looked after. Visitors feel welcomed to the home and appreciate being involved in the care of their relative if the relative wishes. What has improved since the last inspection? What they could do better: Overall, the service is good with those improvements required and recommended which are in the manager’s control being based on good practice including: The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 7 Whilst recruitment is generally sound, improvements to recording employment history and reason for leaving work with vulnerable people should be made. Ongoing work to enhance direct work with service users by good, current care records would ensure all staff have a reference system when providing care and support. Those service users with dementia would be better able to choose their main meal if other methods of presenting choice were introduced. Other areas where there is room for improvement rely on Kent County Council co-operation. These include: Ensuring pre admission information is comprehensive and up to date would enable staff to have current information when a service user is admitted. Ensuring information about the service is available in accessible and easy to read formats. Redecoration and refurbishment should be on a programmed basis with Kent County Council working with the manager to ensure good standards of décor and facilities are maintained. Offering staff client specific training, such as dementia awareness, would enhance staff skills and confidence when working with service users. 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. The summary of this inspection report can be made available in other formats on request. The Dorothy Lucy Centre DS0000037761.V321022.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 The Dorothy Lucy Centre DS0000037761.V321022.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have a place where admission processes for respite, rehabilitative and assessments stays is well managed by the service. EVIDENCE: The Dorothy Lucy Centre has a statement of purpose and service users guide. The statement of purpose is revised as necessary and gives good detail of the aims of the service. Copies of the service users guide are placed in service users rooms. The service users guide seen in one room was of poor quality and would not be accessible to the service user accommodated there as it was poorly printed and set out. The manager agreed there were no other formats available for service users such as large print, taped or video formats. She also agreed that the current copies were poorly presented and not suitable for The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 10 service users. Given that the service has a regularly changing service user group, there is the need to provide accessible and clearly presented information about the service, including key information. The service is unusual in that there is a very high turnover of service users which results in a need for good and responsive administration systems in addition to cooperation from placing agencies. Over the years, the manager and senior staff have become increasingly adamant to ensure assessment information is provided before any admission. As the service is managed by Kent County Council with referrals coming through social services, assessments are normally carried out by care managers or health professionals. Staff agreed that sometimes this information was not detailed enough or accurately reflected the current situation. Work carries on to try to ensure good up to date communication with placing agencies. The manager and senior staff are aware of the client group they can offer a place to and will refuse an admission if the person does not meet the admission criteria. All recognise the pressure on other services but will not compromise life for those living and working in the service by inappropriate admissions. Staff said that there would always be someone available to meet and greet any admissions, usually it would need to be a Team Leader, as medication would have to be checked in by them. One service user arrived during the site visit for respite care over the Christmas period. She said that staff had been there to meet her and show her to her room. She hadn’t unpacked yet but said staff would help her to do that later. She was very pleased to be back at The Dorothy Lucy Centre and was looking forward to spending Christmas there, having good memories of previous stays. Many service users are ‘returners’ having regular visits to the service for periods of respite care. Others are new to the service, some following a crisis at home. Staff felt that this was the area where it was most difficult to get full assessments and sometimes people were admitted for what was said to be rehabilitation whereas the person actually needed long term care. This determination will be made by the occupational therapist who will, with the occupational therapist assistant and staff working on the unit, carry out an ongoing assessment of the persons abilities following which they consult with the service user, family and professionals. The Dorothy Lucy Centre DS0000037761.V321022.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health and care needs are well met but could be improved by better records. EVIDENCE: Each service user has a care plan and supplementary records. The records are held over a range of systems. Staff knew where information was held and felt comfortable that it was accessible to them. Records of a person’s day are recorded on each shift. Care plans used information provided by the placing agency, normally the care manager, supplemented with information such as from relatives and gained when working with the service user. Information and records from previous stays were included in the care planning process. All spoken with agreed that due to the high turnover of service users, emphasis was placed on good outcomes for service users which could lead to a The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 12 deficit in updating records. This was evidenced in practice where service users spoke highly of the care they were given and staff had a good understanding of individual health and care needs and how these should be met. Staff felt there was a deficit in records of personal information such as a pen picture. Many staff have worked in the service for some time. Current practice is for staff to work across all three units so they get to know the different ways of working with service users in each unit. Staff spoken with knew what the risks were for each person in their care and ensured risk situations were properly managed. Service users and relatives spoken with felt confident that the service user would be as safe as possible whilst at the service. Risk assessments are carried out but also need work to make sure ‘how’ the risk is to be reduced or removed is routinely recorded. The service continues to have good relationships with local health professionals including the mental health team who have offered to support staff and provide training and a contact point where necessary. The district nursing team visit as required and there are good links with the local medical centres. Any ongoing health needs are normally identified before admission and information passed to the relevant health professionals to transfer short term treatment to The Dorothy Lucy Centre. Nearly all care staff have successfully completed the thirteen week medication course. Only senior staff are permitted to administer medication but since completing training, the manager is comfortable that care staff can witness medication on admission and discharge. Good practice was observed in the administration of medication. By necessity, medication practices are directed by systems which include receipt of medication in their original containers, administration directions transcribed from the container and witnessed by another person and commendable care in receipt and return of medication. Lockable storage is provided both for overall drug administration and for those who self medicate under a risk assessment process. It remains Kent County Council policy that staff may not carry out any invasive procedures. Service users felt that staff treated them with dignity and this was witnessed during the site visit. Service users who presented with difficulty in comprehension or confusion were treated as people with rights to privacy, dignity and respect. Whilst there were no service users with significant cultural needs at the time of the site visit, staff spoke of how these were managed. The Dorothy Lucy Centre DS0000037761.V321022.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to fill their days in the manner they prefer. EVIDENCE: As the majority of service users stay for short periods of time, the aim is to provide activities on a day to day basis which offers variety to service users accommodated at the time. Service users can choose whether they wish to join in with an activity, usually provided during the quieter afternoon times, or whether they want to continue with their own pursuits such as reading, watching TV or just chatting. Some service users like to join in with service users on another unit, which they are able to do. Service users can also continue attendance at the Dorothy Lucy Centre day centre or with another local day centre for people with mental health needs if they choose. Those in the rehabilitation/assessment unit spend time with the occupational therapist using facilities which assess and improve confidence in using daily living skills such as using stairs, enhancing mobility and basic cookery such as making tea. The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 14 A hairdresser visits regularly and many service users said they looked forward to having their hair done. Cultural needs are met and include the option of attending a recently set up Asian group in The Dorothy Lucy Centre day unit. Service users maintain contact with the local area if they choose. Many have regular visitors who say they feel welcomed to the home. Relatives will be included in any decision making if the service user agrees or if it is identified that the relative is best placed to act as advocate. Service users may bring in their own belongings which are then recorded on a personal possessions record. Service users are advised that they have access to records held about them but in practice, few choose to do so. Access to records by others is on a need to know basis only and with the service user’s agreement. Service users spoke well of the meals provided. Lunch sampled was excellently cooked and portions were generous with second helpings on offer. The menus provide a healthy balanced diet and take seasonal produce and celebrations into account. The cook offers a choice each day which is made known to service users in the morning. There is currently no other system for use by service users with comprehension or short term memory problems. Specific likes and dislikes are recorded in the care plan and dietary requirements known to the cook and care staff. Snacks, drinks and biscuits are available during the day. Meals are normally taken on the individual units and served from hot trolleys. Service users wishing to eat in their rooms may do so. Breakfast is normally prepared on the units but service users may request a cooked breakfast if notice is given to the kitchen. The Dorothy Lucy Centre DS0000037761.V321022.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have systems in place to make comment about the service and are protected from harm. EVIDENCE: A complaint policy and procedure is made known to service users and their representatives. In those rooms visited, a Kent County Council complaint leaflet was also available. Complaints are taken seriously with a log kept of complaints made, supplementary records are held in individual files. The number of compliments and commendations far outweighed the number of complaints. Comments from service users and visitors said they had had no cause to make a complaint. Previous inspection reports referred to service users feeling confident in talking to staff about any concerns they had. A relative confirmed that he felt he could discuss any issues with staff on the unit. Staff received regular and updated training in adult protection issues. Staff spoken with were aware of reporting procedures and how abuse might present. They were careful in their work that the risks of harm or abuse were removed as far as possible. The manager understood that joint working within Kent The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 16 adult protection procedures was not a negative situation but a good forum to discuss any issues which might further enhance safe practice. The Dorothy Lucy Centre DS0000037761.V321022.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have a clean and safe environment in which to spend a short break but which would be enhanced but some redecoration and refurbishment. EVIDENCE: The Dorothy Lucy Centre was purpose built some years ago and originally was used in part for social services offices. Latterly the offices have been moved and the area is now used as the day care facility an occupational therapy area. The occupational therapy area is inadequate to offer good facilities for rehabilitation or assessment and lacks storage space. The day care unit has separate entrances from the main service but also has internal access. Staff said this had not caused any problems in fact, many service users liked the The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 18 ease of access when they wanted to attend the day centre or go for occupational therapy and to the hairdresser. The units each have their own identity although based on a similar ground plan with single bedrooms, communal space, toilets and bathroom. Used by the service overall is the kitchen, laundry and main offices. Secure grounds surround the building and can be accessed from each unit. Staff said they normally accompanied those service users on the dementia unit for safety. The manager said that routine maintenance and health and safety issues were maintained by Kent County Council and the handyman, but there was no planned refurbishment or renewals programme. The handyman had decorated some rooms when he could but there are areas which remain looking ‘tired’. One area of carpet needs replacing due to staining, the manager said it was regularly and thoroughly cleaned. Overall however, the home presented well. It was bright and cheerful, warm and as homely as possible given the structure of the building. Service users liked it and said they felt comfortable there. Rooms are of good size and can be personalised although most service users bring few effects with them due to the length of the stay. There are two long term residents remaining from when the service was intended for long term stay and their rooms are very well personalised. There are financial and logistical difficulties in providing each bedroom with a hoist or making them fully wheelchair accessible but equipment will be provided where necessary for safe moving and handling. As staff said, the service acts more like a hotel than long term accommodation and the décor and facilities reflect this. Laundry facilities are provided which offer a good service given the high turnover of service users and the need to ensure the right clothing is returned promptly, especially where a service users is due to return home. Service users thought care was taken with their washing and all looked well and appropriately dressed. Good systems are in place to reduce the risks of cross infection including disposable clothing and good practice. The Dorothy Lucy Centre DS0000037761.V321022.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have properly recruited and well motivated staff who meet care and social needs. EVIDENCE: Verbal and written comments from service users and relatives referred highly to the staff team. Comments made included: ‘The staff are really friendly here’ ‘It’s nice to see welcoming faces again’ ‘They make an effort to do what I need’ The staffing roster allows for two staff based on the higher dependency unit, with one on each of the other units supported by a floating carer, senior staff and ancillary staff. Staff can be deployed to any unit where there is a need for additional staff, senior staff are also available for support. Waking night staff are employed. Staff and service users thought there were generally sufficient staff on duty, bank staff and occasional agency staff supplement contracted staff. Managerial, administrative and senior staff are particularly necessary The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 20 given the high turnover of service users and the need to ensure records and admissions procedures are followed for the wellbeing of service users. Many staff have worked at the service for some years and felt the team work well together. Service users benefit from this setting and the atmosphere was relaxed and open. Staff spend time talking to service users and showed a genuine interest and respect for service users wellbeing. Staff are encouraged to complete NVQ training. The percentage of staff with NVQ level 2 in care or above was not provided. Staff said they could apply to attend a range of training courses but it was usually ‘first come first served’. Priority is given to core training including health and safety training. Staff follow an induction procedure when appointed which includes shadowing more experienced staff. Not all staff have updated training in working with people with dementia although one unit caters primarily for that client group. Recruitment records seen evidenced that overall good recruitment practice was carried out with good documentation, POVA and criminal records bureau systems and evidence of physical and mental fitness. The manager was reminded of the need to validate the reason for leaving any work with vulnerable people and record the reason for gaps in employment as this had been missed at a recent recruitment. The Dorothy Lucy Centre DS0000037761.V321022.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed and safe service. EVIDENCE: Service users and staff spoke highly of the manager, all felt she was approachable and really valued each person. Throughout the site visit there were excellent and relaxed interactions between the manager, other staff and service users. Staff mentioned situations where she had been particularly supportive. As at previous inspections, throughout the site visit the manager demonstrated a commendable honesty, openness and commitment to a high The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 22 quality service. She has over 20 years experience in care, a Diploma in Management, was a NVQ Assessor D32/33 and has managed the Dorothy Lucy Centre since 1997. Kent County Council regularly audits the Dorothy Lucy Centre. The records of these audits were also used as Regulation 26 reports to the Commission. As part of a quality assurance process service users and their representatives or relatives are consulted for their views of the service. Regular staff meetings are held where all grades of staff meet together. In addition there are senior meetings and shift handovers. Staff felt that their views were listened to and they could talk openly about their views of the service. A supervision system is in place with staff supervised within a line management structure. Supervision may take the form of meetings other than termed ‘supervision’ where more appropriate, such as mentoring and support. Staff who provide supervision are trained or experienced in the process. The Dorothy Lucy Centre controls monies directly for two service users, records of transactions are properly maintained. Service users now sign against any monies given to them; two people routinely verify other transactions with receipts checked. Sound systems are also in place for short stay service users who bring with them small amounts of money. Each room has a lockable space which can be used. Records seen were properly maintained and stored securely. Policies and procedures were not inspected on this occasion. Staff said they were asked to read policies when updated and were made aware of any procedural changes. Good health and safety practices were seen, including those to minimise the risks from cross infection, fire and moving and handling. Staff spoke of receiving up to date training in these areas and were able to state the process in the event of fire. Information provided by the manager records that maintenance of supplies, services and equipment was carried out within correct timescales and action taken where there were any defects. Accidents and injuries are properly recorded and notified. The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 23 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 2 x 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 x 3 3 3 3 The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2) Requirement The registered person shall keep the service users plan under review in that care plans must be accurately reflective of service users current needs. This requirement remains from the inspection of 22 February 2006. The reason for leaving any previous work with vulnerable people must be confirmed, as far as practicable, in writing. Timescale for action 28/02/07 2 OP29 19 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1.3 Good Practice Recommendations It is strongly recommended that the service users guide should be available in accessible formats and suitably presented to include key information about the service. The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 25 2. OP3.2 Work should continue to ensure that comprehensive, current information about each service user admitted to the service is obtained before admission. A system should be implemented to offer informed choice of meal especially to those with comprehension or short term memory problems. It is recommended that a pro-active programme of redecoration and refurbishment be implemented. This recommendation is repeated from the inspections of 13 September 2005 and 22 February 2006. It is recommended that the stained carpets and worn chairs should be replaced. This recommendation is repeated from the inspections of 13 September 2005 and 22 February 2006. Whilst it is recognised that gaps in employment history are explored at interview, a written record should be made of the explanation. In addition to core training staff should receive training specific to their roles and responsibilities, this should include updated training in care for people with dementia. 3. OP15.7 4. OP19 5. OP19 6 OP29 7 OP30 The Dorothy Lucy Centre DS0000037761.V321022.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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