Inspection on 23/09/08 for Da-Mar Residential Care Home

This inspection was carried out on 23rd September 2008.

CSCI found this care home to be providing an Adequate service.

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

Da-Mar Residential Care Home 24/04/08

Da-Mar Residential Care Home 17/08/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 05/12/2008.

CARE HOMES FOR OLDER PEOPLE Da-Mar Residential Care Home 83-87 Moore Street Northampton NN2 7HU Lead Inspector Katrina Derbyshire Unannounced Inspection 23rd September 2008 09:55 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 Da-Mar Residential Care Home DS0000067519.V372333.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. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Da-Mar Residential Care Home Address 83-87 Moore Street Northampton NN2 7HU 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) 01604 791705 01604 715850 da_mar@tiscali.co.uk Mr Anthony L Lampitt Mr Anthony L Lampitt Care Home 29 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (29) of places Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Older persons, not falling within any other category - Code OP. Dementia - Code DE. The maximum number of service users who can be accommodated is 29. 24th April 2008 2. Date of last inspection Brief Description of the Service: Da-Mar is a privately owned care home providing personal care for up to 29 people who are 65 years of age and over, 10 of whom may also have dementia. The care of people with dementia is a new element of registration for this home. Da-Mar is located in a residential area close to the town centre of Northampton and near to local shops. The building has been extended twice and offers communal accommodation, bedrooms and bathrooms over three floors. People with a physical disability are accommodated in the newer rear part of the home where a stair lift is available from ground floor to first floor. People have access to a secluded garden and car parking spaces can be found to the side of the home. The current range of fees is from £331.60 to £400.00 approx with the home accepting both private and funded placements. This information was taken from the service user guide given to the inspectors at this inspection. In addition extra charges are made for hairdressing and chiropody services and newspapers. Any charges incurred for private dentistry or ophthalmic services are the responsibility of the individual. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Following the previous key inspection carried out on 25th April 2008 we required the owner to submit an improvement plan. On receipt of this we met with the owner and manager and asked for a re submission, which was done. This plan had to demonstrate how improvements to the standard of care were to be made following the requirements that we made. We maintained communication with the home, alongside Social Services during this time. This was an unannounced key inspection carried out on the 23rd of September 2008. Two inspectors carried out the inspection; one inspector used the Short Observations For Inspection (SOFI) tool, to carry out a two hour close observation session on three of the people using the service, who were chosen at random following discussion with the home manager. These residents suffered with some level of dementia and were unable to discuss what it is like for them living in the home. This tool enables us to observe and experience life in the home, as it is for the residents. In addition the care of three people was looked at in detail. Tracking people’s care is the methodology we use to assess whether people who use social care services are receiving good quality care that meets their individual needs. Through discussion, observation and reading records, we track the experiences of a sample of people who use a service. During the visit the communal areas of the home were seen alongside some of the individual rooms. Time was spent with many of the people who live at the home in one of the sitting areas. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The focus of this inspection was to look at the key standards. What the service does well: Medication at the home continues to be managed in a safe manner. One person continues to have responsibility for ordering any needed prescriptions Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 6 and makes sure that there is enough stock kept at the home, so people receive their prescribed medication when they should. The storage of medication is also safe, and charts are signed by staff to show when medication has been given. People spoken to at this visit as they did at the last inspection all confirmed that they had received their medication when they should. What has improved since the last inspection? What they could do better: Some of the areas that need to be improved upon include: Improvements in responding to complaints still need to be made. One complaint received by the manager in May had not been responded to in writing, even though the homes complaints procedure states that all complaints will be replied to in this way. In addition there is a book and its called the ‘Moan book’ and a document that describes what staff should do in the event of a complaint or moan. The word moan is not always seen as a Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 7 positive word to use, especially within this context. When a person feels strongly enough to raise a concern, this should not be just seen as them moaning. Management and staff must welcome their feedback, listen to what they have to say and respond positively so that the person feels that they are valued. The standard of care records is inconsistent. Improvements in some of the files that we looked at were noted, however some documents had not been completed in full. These records are important as they give the guidance to staff on how they should be supporting each person and if there is a particular risk for example to falling or with the persons diet. 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. Da-Mar Residential Care Home DS0000067519.V372333.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 Da-Mar Residential Care Home DS0000067519.V372333.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, 2, 3, 4 & 6 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The care provided to people with dementia is inconsistent so not everyone’s needs are being fully met therefore not reaching their full potential. EVIDENCE: The care files examined included pre-admission assessment. Assessments included information from visiting the person at the hospital, or wherever he or she was living prior to admission and information from any referring social worker or health professional. There were sections covering the social, Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 10 psychological and physical needs of the person. One assessment was difficult to understand; on seeking clarification from the manager on its contents she was not able to explain either so it was not clear on the level of need of the person. There is a need for assessments to be comprehensive and clear, the manager acknowledged this at the time of the visit. Copies of the terms and conditions of residency were seen alongside contracts. These gave an outline of fees, responsibilities and notice periods. We had met with the owner and manager since the last inspection; one of the areas that were discussed was serving notice to people without sufficient reason or giving the required notice period. It was noted no one had been served notice since that time. The statement of purpose was examined. The document provided information on the staffing, accommodation and services available at the home. We carried out a two-hour close observation session on three people, chosen at random following discussion with the manager. We used the Short Observation for Inspection (SOFI) tool to record entries every five minutes, identifying interaction and engagements with each of these individuals. All these people had some level of dementia. Throughout this period we noted that two of the people we were watching, had regular interaction and stimulation initiated by staff, and they were able to engage for short periods. This was encouraging. However the third sat with his eyes shut for the whole two-hour period, and apart from a member of staff moving his feet, without speaking to him, to allow another person to pass by safely, there were no other attempts at interacting with him. Intermediate care is not provided at the home. Da-Mar Residential Care Home DS0000067519.V372333.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 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Good medication management ensures people receive their medication. However inconsistencies in the way some staff support people means they are not always treated in a dignified way or have their needs met in full. EVIDENCE: The care documentation seen in most instances for the person gave sufficient detail to show some of the individual needs of the person when they were first Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 12 admitted to the home, although as assessed at the inspection in April 2008 remained inconsistent in their standard an example of this was certain areas such as activities and social needs had no entries made for one person. Changes to the persons well being however was now being reflected in care plans. Examples included one person developed an increase in the level of support that they needed with moving and this had been updated within their plan of care so staff knew the type and level of support that they should provide. Accident forms had been completed following any accident or incident. Documents and staff demonstrated that follow up had taken place and when needed medical attention had been sought in a timely manner. One of the inspectors observed that one person sitting in the large lounge area due to a medical condition was leaning heavily to their right side. This meant that the posture of the person would not provide a comfortable sitting position. Although staff had been walking past this person constantly none had provided any assistance. Only when the inspector raised this matter, did a staff member go and get a pillow to provide them with support. The person themselves when asked agreed that they needed this help. Information submitted by the home stated that everyone was registered with a General Practitioner and received medical support through referrals from them. Records seen at this visit and people spoken to confirmed that this was correct. Staff if needed would escort people to appointments at the local hospital for example. A District Nurse was seen to be visiting at this inspection; this was following a request from staff at the home. In addition documents were seen from varying healthcare professionals within the records to show that they had received varying treatment, including support from dieticians and physiotherapy Departments. Medication storage in the home was noted to be satisfactory as was the ordering of medicines. The recording of medication stocks and balances were sufficient so an audit of the medication systems was possible. The medication administration records were seen to contain the signature of staff and showed that medication had been given as prescribed. There was a lose antibiotic tablet within one box, this should have been returned to the chemist as it was out of its original packing. Observation was undertaken throughout the inspection of the interaction between staff and people living at the home. Most of the staff were seen to be pleasant in their manner and took time to engage people in conversation. However one carer was seen on two separate occasions wiping peoples faces with blue wipes with no explanation or communication, this was undignified for the people involved. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 13 Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 14 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 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. There is inconsistency in meal choice and delivery this results in some people not having an acceptable experience at mealtimes. EVIDENCE: We visited several people who were spending time in their rooms. One told us. “I’m 92 years old, it’s perfect, I’m really well looked after, the staff are marvellous, there’s every consideration given to you. I couldn’t fault it”. People were being encouraged to socialise and join in activities, however the choice was ultimately up to the individual. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 15 The home has recently recruited a new activity organiser to the team. She is enthusiastic and has had previous experience in this field of work. She is presently carrying out assessments on each person to ascertain both their abilities and their preferences relating to activities. Throughout the morning there were various one to one activities such as dominoes and solitaire ongoing. One person was listening to story cassettes, and generally the care staff were interacting with the people living in the home. However we were unsure if there was always this degree of interaction, as one person said. “I’ve never seen this many staff here before”. At this point there were five staff in the lounge area for a period of at least 10 minutes. We were a little concerned as to who was interacting with the people that had chosen to stay in their individual rooms during this time. Relatives were welcomed into the home during our visit, and the staff were friendly and willing to assist them as necessary. This home has recently recruited a new cook to the staff team. On the day of this inspection she was undergoing her induction programme. An agency chef who had been working in the home for three weeks was assisting her. Although the manager informed us there is normally a four-week menu plan, she explained that whilst the agency chef has been working in the home, this has not been followed particularly closely. The midday meal on the day of this visit was steak and kidney casserole with dumplings, vegetables and potatoes. It smelt and looked appetising, however we did notice one or two people having some difficulty chewing the meat. The dessert on offer was peach pie and ice cream. It was disappointing to see no choices being offered. Meals were just put in front of people. We also saw people having their plates cleared away, and people having their faces wiped with blue wipes, without any explanation or communication taking place. This was not acceptable. We carried out a two-hour close observation session on three people, chosen at random following discussion with the manager. We used the Short Observation for Inspection (SOFI) tool to record entries every five minutes, identifying interaction and engagements with each of these individuals. All these people had some level of dementia. Throughout this period we noted that two of the people we were watching, had regular interaction and stimulation initiated by staff, and these people were able to engage for short periods. This was encouraging. However the third sat with his eyes shut for the whole two-hour period, and apart from a member of staff moving his feet, without speaking to him, to allow another person to pass by safely, there was not attempts at interacting with this person. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 16 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 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Systems in place at this home for receiving and investigating complaints is not always sufficient to assure people that their concerns will be received, listened to and acted upon. EVIDENCE: The complaints procedure as detailed within the service user guide given to the inspectors stated that all complaints received would be responded to in writing. One complaint received in May 2008 had not been responded to in this way even though we had made a requirement about this at the previous inspection. In addition a ‘Moan book’ was seen to be in place. The manager advised that it was if “they wanted to have a moan, you know when its not a proper complaint”. Used within this context this is a negative response to feedback from people living at the home and must cease. Attempts had been made to address other areas of our requirement and there were easy to read leaflets on Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 17 display to people to let them know how they could complain and how they should be responded to. Information received by the Commission for Social Care Inspection between the last inspection in April 2008 and this one demonstrated that the manager was now making referrals to the Northants safeguarding team when needed. Records examined at this visit showed that 90 of staff had now undertaken training in the safeguarding of vulnerable adults. However the copy of the local protocols in the home on safeguarding adults was actually for Leicestershire not Northants. The manager stated that was the only copy she could get hold of, although this had not stopped any referrals being made it is not acceptable to have the wrong guidance and confusing. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 18 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 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The amount of communal space available results in overcrowding at times and congestion at mealtimes; this causes some people to become agitated and can increase the risk of accidents. EVIDENCE: During this visit we toured the whole building. Generally the environment in this home was clean. The corridors of this home are presently being decorated. The manager explained that they had chosen different colours for different Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 19 floors of the home, to assist people with dementia to find their way around more easily. Individual’s bedrooms were decorated and furnished in a personal way with ornaments and photographs that reflected the person’s family and life history. One bedroom that we visited boasted over 100 china teapots on display. This collection was clearly very precious to its’ owner. With the exception of one bathroom on the top floor where a mattress and wheelchair were being stored, the bathrooms and toilets were clean and tidy, and the people had the choice of mechanical aids to assist them with bathing. The main lounge was rather overcrowded. The room was wall to wall with armchairs and small coffee tables. When we arrived there were nine people seated in this area, others arrived throughout the morning. At lunchtime the whole area became rather congested as people living at the home and staff all attempted to move to the dining room, some using walking aids and some requiring wheelchair assistance. This resulted in some people becoming quite agitated, and could have resulted in trips or falls. Similarly at lunchtime, the dining room became rather overcrowded, as the majority of people had chosen to have their meal in this area. For one person who required assistance with her meal, this resulted in a member of staff having to stand over her as she ate, as there was insufficient space for her to sit down. No odours were detected at this visit. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 20 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 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Inconsistencies in the training of staff mean that people do not always have their needs met by staff who have a full understanding of their needs. EVIDENCE: During this visit we had the opportunity to speak to six members of staff, who worked in different capacities within the home. All said that they felt well supported, and that both the manager and the owner were approachable and accessible to them. We observed poor moving and handling techniques being used by one staff in particular. This included an ‘underarm drag lift’ to try to assist someone to stand up. The homeowner also witnessed this and intervened. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 21 This member of staff advised us that although she had done an induction week, and had watched health and safety videos, she had not done any training in moving and handling or safeguarding since working at the home. As described within the Daily life section another member of staff was seen wiping peoples faces with blue wipes, she did not ask them if they needed assistance and did not communicate with them at all during this time, this is unacceptable. Review of the files for three recently recruited staff confirmed that good recruitment practices being maintained with criminal record bureau checks and references obtained prior to staff working in the home. Therefore the previous immediate requirement had been met. Review of the staff training records showed that there were still outstanding training to be undertaken by some staff. Evidence was seen that sessions were to be carried out within the next 3 weeks, these included first aid, manual handling and food hygiene. It was noted that some staff had received dementia awareness training, however records indicated that not all staff had received dementia care training. In view of the inconsistent practice detailed within this report this must take place for everyone. Changes to the number of staff on duty during certain times of the day had been made since the last inspection resulting in an increase at certain points in the day. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 22 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, 33, 35 & 38 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Management systems still need to improve to ensure an acceptable level of service is provided for all of the people living at the home. EVIDENCE: Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 23 The acting manager has been working in this role since 1st of august 2005. She has submitted her application to the Commission for Social Care Inspection to become the registered manager on the 10th of April 08. There had been a significant decline in standards at the home from the inspection in August 2006 and the one that took place in April 2008. It is acknowledged that there has now been many improvements following the April 2008 inspection, however more are needed to be made. Managements understanding and interpretation of some of the National Minimum Standards and requirements is still not fully sufficient and further support and guidance needs to be provided, details of the areas are described throughout the report. There are now quality assurance systems in place, which include sending questionnaires to relatives to ascertain their views on the quality of care provided. Monthly audits had taken place each audit looking at a specific area including food preparation and bedroom presentation. An analysis of the returns from the questionnaires still needed to be carried out, so that an action plan can be developed to ensure improvements are made in response to people’s views. Health and safety checks had been taking place including a gas service on 18/04/08 and servicing of fire equipment on 07/05/08. The portable appliance testing however was overdue; this should of taken place in June 2008, when we identified this staff in the inspectors presence booked for this to be done on 03/10/08. Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement Assessments of peoples needs must be completed in full and linked to the care plans to make sure that their needs are met in full. (This requirement had a timescale of 31/05/08 which has not been met in full) Management must demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of all individuals admitted to the home. In the case of people with dementia, the service provided must be based on current good practice and reflect relevant specialist and clinical guidance so that people receive sufficient stimulation, care and emotional support in their lives. (This requirement had a timescale of 30/06/08 which has not been met in full) A care plan containing sufficient information that is clear must be in place for each assessed need and kept up to date when DS0000067519.V372333.R01.S.doc Timescale for action 23/09/08 2. OP4 12,16 & 23 23/09/08 3. OP7 15 23/09/08 Da-Mar Residential Care Home Version 5.2 Page 26 changes occur, to ensure people receive the care and support that they require. (This requirement had a timescale of 30/06/08 which has not been met in full) 4. OP10 12(4)(a), People must always receive from all staff support offered in a dignified manner and in order to maintain an acceptable level of comfort. Choices of food must be always available to the people living in the home even when the cook is off. Food must then be served in a way that people are not rushed. This is to ensure peoples nutritional needs are met in accordance with their personal needs, choices and preferences. All complaints received must be accepted in a professional manner and then responded to in accordance with the homes own policy. This is to ensure people and their relatives feel confident enough to raise a concern and feel listened to and their concerns are acted upon appropriately. (This requirement had a timescale of 31/05/08 which has not been met in full) A copy of the local safeguarding protocols must be secured so that all staff have access to the information and guidance to protect the people living at the home. 31/10/08 5. OP15 16(2)(i) 31/10/08 6. OP16 22(3) &(4) 29/09/08 7. OP18 12(1), 13(6) 31/10/08 8. OP19 23(1)(a), (2)(a), 2(g) Communal space whilst 31/12/08 providing sufficient number of seating must not be overcrowded. This is to ensure the risk of accidents are reduced. DS0000067519.V372333.R01.S.doc Version 5.2 Page 27 Da-Mar Residential Care Home 9. OP30 18(1)(a) &(c)13(5) & (6) Staff must have received as a minimum specific training relating to the individual needs of a person before being allowed to provide care to them, to ensure their safety and the protection and safety of people using the service. (This requirement had a timescale of 24/04/08 which has not been met in full) Management of the home must be effective and sufficient to ensure people receive the care and support required to meet their individual needs. (This requirement had a timescale of 31/05/08 which has not been met in full) 23/09/08 10. OP31 9(1), (2)(b)(i) & 12(1) 23/09/08 11. OP33 24(1),(2) &(3) There must be a system for 23/09/08 quality monitoring that seeks the views of people living in the home, so that standards improve and people have an opportunity to influence the running of the home. (This requirement had a timescale of 31/08/08 which has not been met in full) Staff must have a minimum of six supervision sessions per year, this is to ensure their practice is monitored and any areas for development are identified and plans then made for further training if required. (This requirement had a timescale of 31/08/08 which has not been met in full) 23/09/08 12. OP36 18(2) Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Da-Mar Residential Care Home DS0000067519.V372333.R01.S.doc Version 5.2 Page 30 - 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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