Inspection on 22/02/06 for The Dorothy Lucy Centre

This inspection was carried out on 22nd February 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 22/12/06

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 Gary Bartlett Unannounced Inspection 22nd February 2006 !0;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.V273031.R01.S.doc Version 5.0 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.V273031.R01.S.doc Version 5.0 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.V273031.R01.S.doc Version 5.0 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 that have physical and mental conditions usually associated with older persons. For the period of 20/06/05 to 05/08/05 care can be provided to one person under the age of 65 years on the Rehabilitation unit. This is restricted to the person whose date of birth is 09/05/1941. 13th September 2005 2. 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 run by Kent County Council for 3 days per week. The Home 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 is a recuperative care unit offering a service that gives older people a chance to receive rehabilitation with the aim of returning to living in their own home.The Home currently offers occupancy to 28 Service Users. All bedrooms are used for single occupancy and each is equipped with a staff call point.The Dorothy Lucy Centre 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. The Homes staffing team comprises the Manager, Team Leaders and care staff that work a roster that gives 24-hour cover. The Home also employs other staff for catering, domestic and maintenance tasks. A qualified Occupational Therapist, employed by the O.T. Bureau works at the Home weekdays with an Occupational Therapy Assistant. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in the Home from 10.00 a.m. until 1.45 pm. During that time some residents and staff were spoken with and parts of the Home and some records were inspected. The focus of the inspection was to inspect the Standards not assess at the last inspection and to assess compliance with the notified requirements and recommendations. Consequently, this report should be read in conjunction with the inspection report dated 13 September 2005. The Manager and staff were helpful and gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? Better pre-admission assessment information was being supplied to the Home to ensure service users were appropriately placed and the Home could meet their needs. The service users statement of terms and conditions had been amended so it had a stated period of notice appropriate to the service being delivered. All bedrooms had been provided with net curtains to preserve the occuopants’ privacy. Some areas had been redecorated. The pavement hight had been reduced outside two fire exits to make the areas safer for service users. Staff supervision had improved to help ensure quality of care. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 6 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 contacting your local CSCI office. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Improved pre-admission assessment information supplied to the Home ensure service users needs could be met. Each Service user had a clear contract of the terms and conditions of their residency. EVIDENCE: Several service users mentioned that staff had been very helpful and kind in assisting them to settle in. The Manager described how they had amended the service users statement of terms and conditions so it had a stated period of notice appropriate to the service being delivered. It had been identified at the last inspection that some information received by the Home prior to service users’ admissions had been out of date and lacked the detail necessary for the specialist assessment of care needs to be made. The Manager stated this had been raised with the local authority departments The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 9 concerned and as a consequence better information was now provided, so ensuring the Home could better meet service users needs. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Service users’ health and welfare would be better promoted by care plans being more consistently maintained and risk assessments being recorded when necessary. Service users’ health needs were met with good liaison with relevant health care professionals. Service users were protected by adherence to good practice guidelines in the storage and administration of medicines. Personal care was offered to service users in a way that protected their privacy and dignity and promoted independence as far as was practicable. EVIDENCE: Each service user had a care plan and the Home was continuing to look at possible ways of improving the format. The care plan inspected in detail had not been accurately completed and was not reflective of the service users current needs. A risk assessment had not been recorded as a result of recent incidents, potentially putting service users and staff at risk. The Manager spoke of ongoing training for staff in care planning. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 11 The standard of records of daily care was very good and indicated the Home continued to have a good working relationship with the local health professionals, supporting service users in their health care needs. The Medication Record Administration Record (MAR) sheets that were inspected had been completed appropriately. Medicines were seen to be stored appropriately and were only dispensed by staff trained and authorised to do so. There was some discussion about the advantages of minimising access to the medicines room by not using it for washing up staff cups etc. Service users said staff were always friendly, courteous and respected their privacy and dignity. Since the last inspection, all bedrooms had been provided with net curtains to preserve the occuopants’ privacy. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 12 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): These Standards were met at the last inspection and not assessed on this occasion. EVIDENCE: The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 13 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): These Standards were met at the last inspection and not assessed on this occasion. EVIDENCE: The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 14 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 and 26 The Home continued to provide a safe and clean environment that would have benefited from some refurnishing and refurbishment. EVIDENCE: Service users said they liked the Home and thought their bedrooms and the communal areas were comfortable. Those parts of the Home inspected were clean and commendably free from unpleasant odours. The Home was using a device for a trial period to assess its effectiveness in reducing unpleasant smells. Kent County Council continued to fail to provide a pro-active redecoration and refurbishment programme for the Home. However, parts of the Home were decorated as funds permitted. Despite the staff’s best efforts, some areas still looked tired and worn. For example, the carpeting in many areas was in need of replacing due to heavy staining. The pavement hight had been reduced outside two fire exits to make the areas safer for service users. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 15 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 and 30 The Home provided appropriate staffing levels to meet service users’ needs. Recruitment processes are robust and offer protection to people living at the Home. EVIDENCE: Service users spoke very highly of staff. Comment included: • “They are lovely.” • “They are helpful and kind.” The Manager described how they considered the allocated staffing hours to be adequate to meet the present needs of the residents. The staff rosters inspected took account of peak times of activity and did not show excessive hours or exhausting shift patterns having been worked. Some staff mentioned that if they were concerned about the pressures of work, they were comfortable in talking with the Manager or other senior staff who would be supportive. This was an unannounced inspection and the Manager had prior engagements in the Home. Consequently, senior staff were required to give any assistance required during the inspection and in doing so they demonstrated a sound understanding and competency in the day to day running of the Home. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 16 The Manager described how there was a programme of ongoing training for staff and NVQ training was encouraged. A newly recruited staff member described how they had been required to complete a detailed application form, supply references, attend an interview, and appropriate Criminal Records Bureau Checks and POVA checks had been obtained before they were appointed. The staff member also described a good system of induction and shadowing before they were allowed to work on their own. Such practices ensured only appropriately checked people whose competency had been assessed were allowed to work at the Home. The same staff member demonstrated a good understanding of the different skills required in provided respite and rehabilitation care to those of long-term residency. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 17 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): 35, 36, 37 and 38 The Home protected service users’ financial interests and provided a safe environment for them to live in. EVIDENCE: The Home encouraged service users to manage their own financial affairs or to have assistance from their families / representatives. Where the Home held cash on behalf of service users, there were adequate systems for recording amounts. There was some discussion about the advantages of using individual record books for service users and of obtaining the signature of the service user or their representative when receiving or giving monies. The amount of money held on behalf of a service user was checked and balanced with the records. Service users did not express any concerns about the Home’s management of monies or valuables held on the their behalf. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 18 The Manager described how staff supervision had been rescheduled since the long-term sickness of some senior staff had been largely resolved. Senior staff confirmed this. Staff were seen to be diligent in minimising risks to residents by carefully placing equipment to avoid obstruction and in ensuring COSHH requirements were adhered to. A staff member spoken with had a good understanding of emergency procedures. The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 2 3 The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 20 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),17, Sch3 & 4 Requirement The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service users plan under review in that care plans must be accurately reflective of service users current needs. An action plan must be received by CSCI by the stated timescale. The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be recorded in response to incidents and deteriorating changes in situation. An action plan must be received by CSCI by the stated timescale Timescale for action 17/03/06 2. OP7 13(4) 17/03/06 The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 21 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. 5. Refer to Standard OP9 OP19 OP19 OP28 OP35 Good Practice Recommendations It is recommended access to the medicines room be minimised by not using it for washing up staff cups etc It is recommended that a pro-active programme of redecoration and refurbishment be implemented. This continued to be an outstanding recommendation It is recommended that the stained carpets and worn chairs should replaced. This continued to be an outstanding recommendation. It is recommended that a minimum ratio of 50 trained members of staff (NVQ2 or equivalent) be achieved It is recommended the signature of the service user or their representative is obtained when receiving or giving monies on their behalf The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 The Dorothy Lucy Centre DS0000037761.V273031.R01.S.doc Version 5.0 Page 23 - 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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