Care Home: Dolphin Lane

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What the care home does well There is a warm friendly and welcoming atmosphere in the home. Staff interact well with people who use the service. In the comments book at the home a visitor said, "They make you feel welcome everytime you come, everybody are very friendly, you can feel the love and care the moment you come through the door".The manager makes sure that a thorough assessment of the needs of the people who use the service is carried out. This means that people can be sure that the home will be able to meet their needs properly. People who use the service spoke highly of the home. One said, "This is the best place going, I love it here". Others said how welcome they had felt when moving in and how easy it had been to settle. Staff have made good progress in completing the new person centred care plans. They have involved people who use the service and worked hard to find out what people want out of life. One person said, "Staff went through it with me, I love this place". There is a good attitude to responsible risk taking to further the independence of people who use the service. Staff are there to guide and support people but do not `take over`. People who use the service have control over their own lives. One person said, "They have helped me through a lot, they are brilliant". A number of people who use the service have paid employment. Some others are making plans to move on into more independent living. People who use the service are given good support with their health needs. One person who uses the service spoke very highly of the support they had received. They said, "My key worker has been like a sister to me". The manager and acting manager have good leadership skills and are supportive to the people who use the service and the staff team. One person who uses the service said, "She`s doing a fantastic job, she helps me with all sorts". Another said, "They are both the best managers we have ever had". What has improved since the last inspection? The organisation has now included the costs on contracts for people who use the service. This means people are now aware of what it costs for their placement. New person centred care planning has been introduced. Staff are very clear that this puts the person using the service in control of planning their support needs and futures. A shelter has been made in the smoking area in the garden which means people are protected from the wet weather when going outside to smoke. An additional room has been created on the ground floor of the home. This has increased the number of rooms that are accessible by people with mobility problems.The manager has introduced a `buddy` system for staff`s induction training. This means that staff are linked up with another member of staff who gives them guidance and support during their induction. Staff said this worked well and helped them to settle in their role. The number of people who have achieved an NVQ (National Vocational Qualification) in level 2 or above has increased. The registered manager has completed the Registered Managers Award. The acting manager has now also enrolled on this course. What the care home could do better: The acting home manager agreed to introduce telephone checks on references to further verify them. This would be good practice and further protect the interests of people who use the service. The acting manager should make people who use the service more aware of the complaints procedure and how to make a complaint to someone outside of the staff team. This will make sure that people can air their views fully. CARE HOME ADULTS 18-65 Dolphin Lane 1 Dolphin Lane Thorpe Wakefield West Yorkshire WF3 3DN Lead Inspector Dawn Navesey Unannounced Inspection 6th December 2007 09:30 Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 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 Dolphin Lane DS0000001444.V356323.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 Adults 18-65. 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. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dolphin Lane Address 1 Dolphin Lane Thorpe Wakefield West Yorkshire WF3 3DN 01924 872080 01924 872620 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) www.craegmoor.co.uk J C Care Ltd Angela Galloway Care Home 13 Category(ies) of Learning disability (13), Physical disability (13) registration, with number of places Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user over the age of 65, named on variation dated 26th September 2006, may reside at the home. 9th February 2007 Date of last inspection Brief Description of the Service: Dolphin Lane is owned by J C Care, which is a subsidiary of Craegmoor Health Care. The registered manager is Angela Galloway. The home is situated in its own grounds and parking is available to the front and rear of the property. The home is on Dolphin Lane and is within easy walking distance of the main road. The area is well served by public transport. There are a number of local facilities and people who live at the home make good use of these. The care home is registered to provide accommodation and care services for up to thirteen residents, who have a learning disability. The home is spread over three floors, the basement being used for laundry facilities, maintenance office and a training/games room. There is no passenger lift, however some ground floor bedrooms are available. There are five single bedrooms on the first floor, seven on the ground floor and one double bedroom. At the time of the visit this room is being used as a single room. Current information about services provided at Dolphin Lane in the form of a statement of purpose, service user guide and the most recent inspection report published by the Commission for Social Care Inspection are available by contacting the home. The fees at the home are currently £612 per week but can vary according to the individual needs. Additional charges are made for hairdressing, chiropody, activities, magazines and transport. The costs for these vary depending on the choices made by people who use the service. This information was gained from the acting manager of the home on 6 December 2007. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and was carried out by one inspector who was at the home from 9-30am to 4-30pm on the 6 December 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. And also to monitor progress on the requirement and recommendations made at the last inspection. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. An AQAA (Annual Quality Assurance Assessment) was completed by the home manager before the visit to provide additional information. Survey forms were sent out to people living at the home, their relatives and health and social care professionals. Six of these have been returned and this information has also been used in the preparation of this report. During the visit a number of documents and records were looked at and some areas of the home used by the people living there were visited. Some time was spent with the people who live at the home, talking to them and interacting with them. Time was also spent talking to staff and the acting manager. Feedback at the end of the visit was given to the acting manager. I would like to thank everyone who contributed to the inspection process and to the home for their hospitality What the service does well: There is a warm friendly and welcoming atmosphere in the home. Staff interact well with people who use the service. In the comments book at the home a visitor said, “They make you feel welcome everytime you come, everybody are very friendly, you can feel the love and care the moment you come through the door”. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 6 The manager makes sure that a thorough assessment of the needs of the people who use the service is carried out. This means that people can be sure that the home will be able to meet their needs properly. People who use the service spoke highly of the home. One said, “This is the best place going, I love it here”. Others said how welcome they had felt when moving in and how easy it had been to settle. Staff have made good progress in completing the new person centred care plans. They have involved people who use the service and worked hard to find out what people want out of life. One person said, “Staff went through it with me, I love this place”. There is a good attitude to responsible risk taking to further the independence of people who use the service. Staff are there to guide and support people but do not ‘take over’. People who use the service have control over their own lives. One person said, “They have helped me through a lot, they are brilliant”. A number of people who use the service have paid employment. Some others are making plans to move on into more independent living. People who use the service are given good support with their health needs. One person who uses the service spoke very highly of the support they had received. They said, “My key worker has been like a sister to me”. The manager and acting manager have good leadership skills and are supportive to the people who use the service and the staff team. One person who uses the service said, “She’s doing a fantastic job, she helps me with all sorts”. Another said, “They are both the best managers we have ever had”. What has improved since the last inspection? The organisation has now included the costs on contracts for people who use the service. This means people are now aware of what it costs for their placement. New person centred care planning has been introduced. Staff are very clear that this puts the person using the service in control of planning their support needs and futures. A shelter has been made in the smoking area in the garden which means people are protected from the wet weather when going outside to smoke. An additional room has been created on the ground floor of the home. This has increased the number of rooms that are accessible by people with mobility problems. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 7 The manager has introduced a ‘buddy’ system for staff’s induction training. This means that staff are linked up with another member of staff who gives them guidance and support during their induction. Staff said this worked well and helped them to settle in their role. The number of people who have achieved an NVQ (National Vocational Qualification) in level 2 or above has increased. The registered manager has completed the Registered Managers Award. The acting manager has now also enrolled on this course. 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 summary of this inspection report can be made available in other formats on request. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the home will meet their needs following assessment. Also written and verbal information that is available provides enough information for them to decide whether the home will meet their needs. EVIDENCE: The Statement Of Purpose and Service User Guide, which provide information on the services provided by the home, have been produced in an easy read format, using large print and pictures. These are both kept on display in the entrance hall of the home where families and visitors can have access to them. People who use the service also have their own copy. The Service User Guide is currently being updated to include information on the organisation’s Your Voice meetings. These are meetings where people who use the service can put forward any ideas for change. The Statement of Purpose has also recently been updated. The acting manager was informed that this needs some additional information on who the home can provide a service for. She said she would make sure this was added. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 10 The needs of people who use the service have been assessed before they move into the home, to make sure the home can meet their needs. The manager or acting manager completes pre-admission assessments with people and then uses this information as a basis for care and support plans. It is clear that people who use the service are involved in the assessment. Most information is written in the person’s own words, saying what sort of service they need. People who use the service spoke highly of the home. One said, “This is the best place going, I love it here”. Others said how welcome they had felt when moving in and how easy it had been to settle. People who use the service have a contract with the organisation. The contracts now include costs for the placement at the home. People are now clearer about how their care is being paid for. They have also been produced in an easy read format to help people who use the service to understand them more easily. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7,8 and 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The organisation has recently introduced a new system of care planning. This is person centred and involves people who use the service. The plans are written in the first person, using the language and words of people who use the service. People who use the service have signed the plans and are aware of what is in them. One person said, “I would only sign it if I agreed with it”. Another said, “Staff went through it with me, I love this place”. Care plans looked at are detailed and give specific information to staff about care and support needs. Staff have very good knowledge of the support Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 12 needs of people who use the service. They were able to accurately and confidently describe the care and support they give. They showed they had a good understanding of what being person centred means. One staff member, in a returned survey said, “Whenever needs change or new needs arise for any service user all relevant paperwork is done e.g. risk assessments, additional care plans”. Staff said they had found the care plans useful with plenty of information in them, especially when first starting work at the home. One staff member said, “They have really helped me to get to know people”. Care plans have been evaluated and reviewed, with changes being made as needed. Key-workers have a monthly meeting with people who use the service to do this. One person who uses the service said, “We talk about normal things like cooking, cleaning and learning to look after yourself”. The care plans link well to risk assessments. There is a good attitude to responsible risk taking and how this can help people who use the service to greater independence. Risk assessments are up to date and reviewed. Throughout the day of the visit, people who use the service were involved in choice and decision-making. This included, the choice to go out, get involved in an activity, open mail with assistance or not and what to eat. Staff responded well to any choices or decisions made and respected them. People who use the service have a regular meeting. Topics at the meeting include any forthcoming events, food choices, likes and dislikes, shopping, activities and holidays. People are encouraged to voice their opinions. As mentioned in the Choice of Home section, the organisation has introduced monthly Your Voice meetings. One person who uses the service has been nominated as the representative for the area and can take forward any ideas and suggestions from people. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle and supported to develop their life skills. Social, educational, cultural and recreational activities meet their individual expectations. EVIDENCE: People who use the service enjoy a wide variety of activity. This includes, college courses, day centres, caring for a cat and a rabbit, shopping, meals out, parties and going to the pub. People are encouraged to keep in touch with family and friends and have developed good connections with people in the local community. One person who uses the service said they were looking forward to Christmas and all the celebrations they would be having. They were particularly looking forward to a visit from a local brass band. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 14 Staff are good at making sure a wide range of people’s needs are met. People are supported with any needs relating to their age, gender, disability, sexual orientation or beliefs. The cultural needs of people are given much thought. People who use the service enjoy a wide range of lifestyles and are supported by staff to do this. Some people prefer a more relaxed lifestyle and this is respected. Staff are also good at making sure opportunities are offered. During the visit, this was seen on a number of occasions. An increasing number of people have gained paid employment. People who use the service said that staff had been helpful and supportive when assisting them with this. One person said, “I am really happy, I have got the best job I have ever had”. Another said that having a job was part of the plan to gain independence and move on from the home into their own place. In a returned staff survey, one staff member said, “I would say we promote independence well. Service users all have filled weeks of chosen activities/college courses they enjoy and some service users even have paid employment”. The home has its own transport but makes good use of public transport. Staff said this is to encourage people’s independence and prepare them for moving on if that’s what they want. People who use the service are also able to walk about in the local area. Some people have taken on road safety awareness training with a local organisation to help them increase their safety. Staff were seen to support people with respect and thought for their dignity. Staff gave good examples of how they support people to be more independent. They said they are encouraged to get involved in household tasks, budgeting and food preparation. Staff said they felt their role was “To advise and prompt, not to do for people”. A person who uses the service said, “They help me with all sorts, shopping, clothes and that”. Another person said, “Staff are around if you need them but let you get on with things yourself”. There was plenty of social interaction between the staff and people who use the service. The atmosphere is relaxed and there was lots of laughter throughout the day. One person who uses the service said, “We always have a lot of fun”. Menus look to be well balanced and nutritious. Menus are put together based on the likes and dislikes of people who use the service. This is done through the residents’ meeting. If someone wants something different to what is on the menu, this can be done. A good variety of food is available and staff make sure there is a good selection of fresh produce and home cooked food available. People who use the service get involved in doing the weekly shop. They also shop locally on a daily basis for fresh produce. On the day of the visit a cooked breakfast/brunch was served. This was enjoyed and comments were very positive. A variety of lunches was made to suit people and at a time convenient to them. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Staff gave good support with any personal care needs and made sure they were carried out in private to respect people’s dignity. The support people need is well documented in the care plans and makes sure the needs of the people who use the service are properly met. In a returned survey, a relative said, “They provide the relevant care to cater for my relatives needs. My relative enjoys her time at Dolphin Lane and always looks well cared for”. The care plans and health action plans also have details of any health professionals that people see. These include, GP (General Practitioner), dentist, specialist nurse, psychologist and chiropodist. Good, detailed records are kept of any health appointments and their outcome. The acting manager Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 16 makes sure that staff are made available to accompany people who use the service on hospital appointments and admissions. One person who uses the service spoke very highly of the support they had received. They said, “My key worker has been like a sister to me”. The acting manager also makes sure that people who use the service are given the opportunity to access whatever health support they need. Some people who use the service have specialist health needs. These include diabetes and mental health needs. Referrals to health professionals have been made when needed and in a timely fashion. Staff have received training in the health needs of the people who use the service. One staff member said, “We always get training on what is needed”. The acting manager uses resources well and accesses training from a variety of sources. This includes, community health practitioners and the organisations own training department. She also uses the Internet to gain information and makes sure this is circulated to staff. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked and showed no errors in administration. However, a handwritten entry had been made on the MAR sheet without it having been countersigned. The acting home manager was aware that this should be done to minimise the risk of errors and apologised for the oversight. Some recent errors had been thoroughly investigated and action taken to prevent any re-occurrence. People who wish to take responsibility for their own medication are enabled to do this. A risk assessment is completed first to make sure it is safe for them. Some people take a minimal role in administering their own medication. Staff keep the medication in the locked cupboard and the person using the service takes their own medication out of the pack. This gives people some independence without the worry of total responsibility for their medication. One person who uses the service said this worked well for them. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect people who use the service from abuse. EVIDENCE: The home has a complaints procedure displayed in the entrance to the home. This has been produced in an easy words and pictorial format to make it more easily understood. Some of the people who use the service said they would talk to staff if they were unhappy with anything. Most people spoken to were not familiar with the procedure for making a complaint. It would be good practice to make people more aware of the procedure and how to make a complaint to someone outside of the staff team. Staff are aware of how to support people to make complaints and could describe the procedure. Staff have received training on the protection of vulnerable adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. Some people who use the service have good support plans in place which describe how they may be vulnerable when out in the community and how this can be avoided. The organisation has a detailed policy on the protection of vulnerable adults and whistle blowing. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 18 Good records are kept of the finances and monies of the people who use the service. This means their money is kept safe. The home has a cash handling policy which makes sure two people handle money and any financial transactions. They also have a thorough handover procedure. People who use the service have access to their money whenever they need it. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment in the home is homely, clean, safe and hygienic. Staff’s practices, in the main, control the spread of infection. EVIDENCE: The home is spacious, homely, clean and well laid out, providing sufficient room for all people who live there. The bedrooms of the people who use the service have been decorated and furnished to suit them as individuals and their interests and personality. They are all en-suite. People who use the service spoke highly of and with pride about their rooms. One person said, “I am very happy with my bedroom, I have all my own things and the decorating is nice”. The home is very clean and fresh smelling throughout. Staff and people who use the service work hard to keep up this standard. People who use the Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 20 service said they enjoyed being involved in the cleaning, as long as everyone took their turn. The home is nicely decorated and has furniture and furnishings of a good standard. A maintenance officer is employed by the home. He makes sure any maintenance work is attended to and has a programme of regular redecoration for the home. Since the last inspection, a new bedroom has been created on the ground floor. The kitchens are domestic in style and food hygiene practice is good. Foods are being stored according to manufacturers instructions. Some people who use the service smoke. A sheltered area has been provided in the garden to enable people to smoke outside in the bad weather. The garden is attractive and there is plenty of parking available. Staff wear protective clothing when attending to any personal care needs of people who use the service. They also make sure they do this when cleaning or when cooking. Staff have received training in infection control and were able to say what infection control measures are in place. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support people who use the service, and to support the smooth running of the home. EVIDENCE: There are enough staff on duty to meet the needs of the people who use the service. There are usually two or three staff on through the day and one staff member comes on duty in the afternoon and works until 11pm to allow for evening activities. Overnight a member of staff sleeps in at the home and the people who use the service can call upon them in emergency. They also have the support of an on-call manager. The acting manager works daytime hours through the week but said she often calls in at weekends to monitor the quality of the service. People who use the service said they felt they have enough staff. One said, “They have helped me through a lot, they are brilliant”. Staff said they were well staffed and always had enough time to do their job. They said that the only time they are short staffed is when people are sick or they have Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 22 vacancies. The home had one staff vacancy at the time of the visit. In a returned survey, a relative said, “A slight concern is the staff turnover. There seems to be a new face everytime we visit. This is not to say that they do not do a wonderful job as my relative is genuinely happy there”. In the AQAA, the manager said that three staff out of a team of eight have left in the last twelve months. Recruitment is properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. The acting home manager agreed to introduce telephone checks on references to further verify them. This would be good practice and further protect the interests of people who use the service. Staff’s training is mainly up to date. Some staff are waiting to do some training to complete their induction. Very good records are kept of staff’s training and when their updates are due. It is clear who has done what training. In the AQAA, the manager said they have introduced a ‘buddy’ system for staff’s induction. This means that staff are linked up with another member of staff who gives them guidance and support during their induction. Staff said this worked well and helped them to settle in their role. Induction training is based on the Skills for Care, Common Induction Standards. Staff spoke well of their training. They said they found it useful and it had helped them to provide a better service. Half of the staff team have now completed an NVQ (National Vocational Qualification) in level 2 or above. Two more staff are also working on this qualification. Any specialist training is arranged as and when required. In a returned survey, one staff member said, “When any needs arise from our clients we are given extra training”. All staff said they felt they had a very good team and the manager and acting manager were very supportive and give good direction. Staff said they felt communication and teamwork within the home is good. Staff receive regular supervision from the manager and monthly team meetings take place. In a returned survey, a staff member said, in response to ‘what does the home do well’, “Regular supervisions where objectives are given to complete each month”. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed, the interests of the people who use the service are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The registered manager of the service is currently working as acting Business Service Manager for the organisation. The deputy manager is working as the acting home manager of the service. The acting home manager said she has been receiving plenty of support and contact from the manager and that she frequently comes to the home. Since the last inspection the registered manager has completed her Registered Managers Award. The acting manager Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 24 has now also enrolled on this course and has undertaken a number of other management related courses such as recruitment and selection. People who use the service spoke highly of the acting manager. One person said, “She’s doing a fantastic job, she helps me with all sorts”. Another said, “They are both the best managers we have ever had”. Staff also said they were very happy with the acting manager. One said, “She is good, a good leader and she makes sure things get done”. In a returned survey, a relative said, “The manager has addressed any issues that we may have”. They also said, “They could provide better updates about things my relative gets up to. We seem to find things out after the event so better communication is required”. The area manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to people who use the service and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. The area manager recently nominated the home for a ‘leading light’ award within the organisation. This was based on quality standards noted in her visits. The acting manager, staff and people who use the service are very proud of this achievement. Also the organisation sends out questionnaires to people who use the service and relatives asking for their views of the home. A number of these were looked at and comments included, “I like living here, it’s great”, “I get along with all staff they are very friendly” and “The food at my home is great, we pick our menus”. The acting manager has also introduced a comments book for any visitors to the home. Comments included, “They make you feel welcome everytime you come, everybody are very friendly, you can feel the love and care the moment you come through the door”. Maintenance staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting, water temperatures and checks on the house vehicle. Maintenance records are well kept. Environmental risk assessments are completed. Water temperatures are checked regularly and shower heads and trays are bleached regularly. The maintenance officer makes sure the electrical wiring safety and gas safety checks are carried out. The certificates for these were seen at the visit and were up to date. The home has a comprehensive range of policies and procedures in place. The acting manager makes sure staff read and understand these. In a returned survey, a staff member said, “New policies and procedures are given and we sign when we have read them. Any new paperwork is gone through with staff and made aware/familiar with”. In the AQAA, the manager said that all policies and procedures were reviewed and up to date. Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 3 3 X X 3 X Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 1 YA34 The acting manager should consider the introduction of telephone checks to verify staff’s references. This will further protect the interests of people who use the service. The acting manager should make people who use the service more aware of the complaints procedure and how to make a complaint to someone outside of the staff team. This will make sure that people can air their views fully. 2 YA22 Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI Dolphin Lane DS0000001444.V356323.R01.S.doc Version 5.2 Page 28 - 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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