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Reports


Inspection carried out on 11 May 2018

During a routine inspection

Dalvey House is a care home that does not provide nursing care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to accommodate19 people. At the time of this inspection there were 16 people were living at the home, the majority of whom were accommodated for frailty of old age. An extension and building work were in progress at the time of the inspection.

There was no registered manager in post when we carried out this inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The previous manager ceased working at Dalvey House in the summer of last year. The service was managed by interim management arrangements until the appointment of the new manager in January 2018. This person was in the process of registering to become manager of the home when we carried out this inspection.

The last inspection was carried out 13 November 2015 and was rated as ‘Good’.

The inspection was unannounced and took place on 11 and 14 May 2018 and was carried out by one inspector on both days of the inspection.

Staffing levels were meeting people’s needs; however, the staff were stretched at times, there was high use of agency staff, which could affect the consistency of staff for people and the morale of the staff team.

The manager had systems in place to maintain and promote safety in the home. Environmental risks had been identified and action taken where appropriate. The delivery of people’s care had also been risk assessed to make this as safe for people as possible. The manager agreed to review record keeping so maximise the effectiveness of monitoring when this was needed and also to ensure that people’s dignity was maintained.

The care planning format was being reviewed and care plans were being re-written. At the time of inspection the plans were not all standardised so that it was difficult to find information.

Staff were recruited in line with robust policies and all the necessary checks had been carried out by close of the inspection.

Medicines were well-managed and people received their medicines as prescribed by their doctor.

Staff had received training in safeguarding and were aware of their responsibility to report concerns.

Staff were supported through indirect and formal supervision as well as an annual performance review.

The home was working collaboratively with health services so that people’s needs were met.

People’s consent was sought and granted with regards to the way they were cared for and supported. Where people could not make specific decisions because they lacked mental capacity, staff were following The Mental Capacity Act 2005 and any decisions made in people’s best interest.

The home provided a good standard of food with people having choice of what they wanted to eat and their individual needs catered for.

Staff were kind, caring and compassionate in their interactions with people.

There was a programme of activities to keep people occupied; however, this could be improved as the activities co-ordinator only worked for two days a week. The manager was trying to recruit an additional person for this role.

Complaints were responded to and the procedure was well-publicised.

Since the last inspection, the registered manager had ceased working at the home and a new manager appointed.

There were auditing and monitoring systems being followed seeking overall improvement.

Inspection carried out on 13 and 16 November 2015

During a routine inspection

This was an unannounced comprehensive inspection carried out by one inspector on 13 and 16 November 2015. We last inspected the home in January 2014 when we found the service was compliant with regulations and the standards required at that time.

The home had a registered manager who had been employed since December 2014 and registered in November 2015. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The home is registered to accommodate 19 people and at the time of inspection 17 people were living at the home, the majority of whom were accommodated for frailty associated with old age.

Dalvey House provided a safe service to people. Staff had been trained in safeguarding adults and were knowledgeable about how to refer any concerns of abuse.

Risks to people’s health concerning delivery of their care or concerning the physical environment, had been assessed to make sure that people’s care and the home ran as safely as possible .

Accidents and incidents were monitored and audited to see if there were any trends that could make systems and care delivery safer.

The home employed sufficient staff to meet people’s needs.

Robust recruitment procedures were followed to make sure competent and suitable staff were employed to work at the home. The home had a full complement of staff at the time of inspection.

Medicines were managed safely in the home.

The staff team were well-trained and there were systems in place to make sure staff received update training when required.

The home was meeting the requirements of the Mental Capacity Act 2005, with appropriate applications made to the local authority for people at risk of being deprived of their liberty.

People’s consent was gained for how they were cared for and supported.

Staff were supported through one to one supervision and annual appraisals.

People were provided with a good standard of food and their nutritional needs met.

People were positive about the staff team and the good standards of care provided in the home. People felt their privacy and dignity were respected.

Care planning was effective and up to date, making sure people’s needs were met.

The home provided a full programme of activities to keep people meaningfully occupied.

The home had a well-publicised complaints policy and when a complaint was made, they were logged and responded to.

There were systems in place to monitor the quality of service provided to people.

There was good leadership of the home and a positive ethos and culture prevailing in the home.

Inspection carried out on 29 January 2014

During an inspection to make sure that the improvements required had been made

We carried out this inspection on the 29 January 2014, to follow up on compliance actions made at the last inspection of the home in September 2013.

During this unannounced inspection we spoke with the manager, three people living at the home and one relative. There were 17 people living at Dalvey House at the time of our inspection.

People living at Dalvey House were positive about their experience of living at the home. No one had any complaints or concerns about how the home was run and managed.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The provider had suitable quality assurance procedures in place to manage the health and welfare of people living in the home. People were able to comment on the service provided.

Inspection carried out on 13 September 2013

During an inspection to make sure that the improvements required had been made

We carried out this inspection on the 13 September 2013, to follow up on compliance actions made at the last inspection of the home in April 2013.

We spoke with the manager, three people living at the home, one relative and one visitor. There were 19 people living at Dalvey House at the time of our inspection.

People that we spoke with were positive about the way the home was run and managed. No complaints or concerns were raised with us during our visit.

People were not protected from risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

We found the home did not have a robust quality assurance system in place to ensure standards in the home were maintained.

Inspection carried out on 17 April 2013

During a routine inspection

We carried out this inspection of Dalvey House on the 17 April 2013. We spoke with the manager, six people living at the home, one relative and two members of the staff team.

People living at Dalvey House were very positive about their experience of living at the home. No one had any complaints or concerns about how the home was run and managed.

People told us that they had good relationships with the staff, who were described as 'kind'. They told us that the home was kept clean and warm. People said there were activities to keep them occupied.

People who lived at Dalvey House benefited from thorough processes and procedures being followed when new staff were recruited, which meant they were protected from harm.

People were cared for in a clean, hygienic environment.

We found the home did not have a robust quality assurance system in place to ensure standards in the home were maintained.