Inspection on 01/02/07 for Dalmuir Home

This inspection was carried out on 1st February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dalmuir Home 11/10/07

Dalmuir Home 24/10/05

Dalmuir Home 18/05/05

Dalmuir Home 30/09/04

Dalmuir Home 05/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dalmuir Home 25 Gresham Road Limpsfield Oxted Surrey RH8 0BU Lead Inspector Deavanand Ramdas Unannounced Inspection 1st February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dalmuir Home DS0000013621.V327588.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. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dalmuir Home Address 25 Gresham Road Limpsfield Oxted Surrey RH8 0BU 01883 715630 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) Mr Mike Noorbaccus Mrs Myrna Noorbaccus Mr Mike Noorbaccus Mrs Myrna Noorbaccus Care Home 16 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (11), Learning disability over 65 years of age of places (2), Old age, not falling within any other category (16) Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the 16 older persons (OP) accommodated, up to 12 persons may fall within the category DE(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Of the 16 older people accommodated, 1 (one) may be in the category LD(E), learning disability and 1 (one) may be in the category LD(DE) and over 60 years of age. Of the people accommodated with dementia 1 may be under 65 4. Date of last inspection 24th October 2005 Brief Description of the Service: Dalmuir Home is registered with the Commission for Social Care Inspection to provide accommodation and care to sixteen service users under the category of older people. The home is located in a residential area close to public amenities and other facilities. Accommodation is on three floors accessed by lift or stairs and comprises of an office, lounge, dining room, kitchen, laundry area, bathrooms, toilets and single and shared bedrooms some of which have en-suite facilities. The home has a garden which is private and secure with wheelchair access. and parking is available. The range of fees charged by the home is £575.00 to £640.00 per week. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes site visit as part of the key inspection process by the Commission for Social Care Inspection henceforth referred to as the CSCI. The visit was carried out by D. Ramdas, regulation inspector and included a tour of the premises, interviews with staff and service users, and a review of documents and records. The visit commenced at 11:00hrs and finished at 16:30hrs. The inspector would like to thank the provider, deputy manager, staff, service users, relatives and visitors for their contribution to the inspection. What the service does well: The home has an experienced registered manager who provides management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘management is very good, open and always prepared to help’’ and a visitor remarked ‘‘the home is managed nicely, it has got better over the eight years I have been coming here’’. Meals at the home are good and offer variety and choice. During discussions a service user remarked ‘‘the food is really nice’’ and a visitor commented ‘‘the food is lovely, fresh vegetables and nicely presented’’. The home has a policy on equal opportunity. Observations confirmed staff treated service users with dignity and respect and the home’s induction programme had a statement pertaining to equality and diversity matters. The inspector noted care plans reflected the needs of individual service users and during discussions a service user stated ‘‘staff are very good to us, if they weren’t I wouldn’t say so’’. The home had good arrangements for assessing the needs of service users and care planning is based on best practice. During discussions a relative commented ‘‘I am pleased with the care my sister is receiving at the home’’. The home is committed to staff training and development and the home has an IIP (Investor in People) accreditation. Training in National Vocational Qualification henceforth referred to as NVQ is excellent and during discussions a member of staff stated ‘‘when I joined I did induction and foundation training’’. The arrangements for staffing the home are good. During discussions a service user stated ‘‘we are really well looked after’’ and a relative commented ‘‘staff are very caring, always talking to service users’’. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 6 The home has good complaint procedures and a review of information indicated no complaints were recorded about the home since the last inspection by the CSCI. During discussions a relative stated ‘‘I am delighted with care, I have no complaints’’. The inspector noted no safeguarding adult matters were recorded about the home and during discussions a relative remarked ‘‘I have no adverse comments at all’’. What has improved since the last inspection? 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. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing needs are good ensuring the needs of prospective service users are assessed before admission to the home. EVIDENCE: The deputy manager stated service users are admitted to the home on the basis of an assessment of needs. The inspector sampled records and noted the home had a policy on admission to the home dated 2006 and a care needs assessment checklist which covered personal care, health needs and social support. During discussions a relative commented ‘‘I am pleased with the care my sister is receiving at the home’’. The deputy manager commented the home does not offer intermediate care and this standard was not assessed. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning are good ensuring service users’ needs are reflected in an individual care plan. The systems for health care are good ensuring service users have access to healthcare services to promote health. Medication management is good and safeguards the welfare of service users. The arrangements for privacy and dignity are good ensuring service users are treated with respect and their right to privacy upheld. EVIDENCE: The deputy manager stated the home had introduced an electronic care planning system. The inspector noted care plans were based on best practice and included risk assessments pertaining to mobility and the prevention of falls to promote safety. Further evidence confirmed the home had a policy on care planning and during discussions a service user commented ‘‘we are really well looked after’’. Following discussions with the manager a requirement has been made for care plans to be reviewed at least monthly to reflect the changing needs of service users. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 10 The home had arrangements for meeting the health care needs of service users. A review of records confirmed service users were registered with a local GP (General Practitioner) and the home had input from other professionals including a district nurse, incontinence nurse advisor and a psychiatrist to meet the emotional needs of service users. During discussions a visitor commented ‘‘I have seen improvements in service users’’ and a relative remarked ‘‘my sister has improved, she is much stronger and walking up and down the stairs’’. The home had a policy on medications and staff have training in medications to safeguard the welfare of service users. A review of records confirmed the home had a service level agreement with a local chemist to supply medications to the home and kept a record of medications received by and disposed of to prevent mishandling of medications. Medication record sheets had a recent photograph of service users attached and were dated and signed by staff. The home had a pharmacy audit dated 15/09/06 with appropriate management action taken and observations confirmed medications were appropriately stored to promote safety. Following discussions with the deputy manager a recommendation has been made for the home to have a list of staff names with specimen signatures and medications in the form of solutions to be dated on opening to promote health. The deputy manager stated the home had a policy on privacy and dignity and staff have training in privacy and dignity reflected in the home’s structured induction programme. Observations confirmed staff addressed service users by their preferred names and the deputy manager knocked on doors before entering bathrooms and bedrooms. Observations confirmed the home had a telephone in the hallway for easy access and shared bedrooms have screens to maintain privacy and dignity. During discussions a relative commented ‘‘staff are very caring, always talking to service users’’. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for social contact and activities need strengthening to satisfy the social and recreational needs of service users. Community contact is good promoting family links. The systems for autonomy and choice are good enabling service users to exercise choice and control over their lives. Meals at the home are good and offer variety and choice. EVIDENCE: The deputy manager stated the home employed an activity co-ordinator and service users have individual activity plans. A review of records confirmed activity plans were dated January 2007 and included fitness and exercise, reminiscence, art and bingo and the activity co-ordinator worked two sessions per week to provide social and recreational activities. Following discussions with the deputy manager a requirement has been made for information about activities to be in a format which is understandable to service users. In addition, the home must review the provision of activities including the number of hours worked by the activity co-ordinator to ensure it is adequate to satisfy Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 12 the needs of service users. During discussions a member of staff stated a service user who liked music had a CD player and jazz CD’s for her enjoyment. The home had a visitor’s policy with no restrictions on visiting times. A review of records indicated information about visiting times in the statement of purpose and observations confirmed family and friends visited the home. During discussions a relative commented ‘‘I can visit at anytime, I just turn up’’. The inspector noted the home had community contact and volunteers from a local church visited the home to do activities. The deputy manager stated the home promoted choice and service users were able to bring personal possessions to the home. A review of records confirmed relatives acted as appointees and one service user had an advocate to safeguard his financial affairs. The home employed a chef to plan and prepare meals at the home with the involvement of service users. A review of records indicated the home had written menu plans and kept a record of meals at the home. Observations confirmed mealtime was relaxed and unhurried with service users being given sufficient time to eat and hot and cold drinks were available. Meals were nicely presented and during discussions a service user commented ‘‘the food is really nice’’ and a visitor remarked ‘‘the food is lovely, fresh vegetables and nicely presented’’. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints process is good enabling service users, relatives and friends to feel confident that their complaints will be listened to, taken seriously and acted upon. The arrangements for protection are good and safeguard the welfare of service users. EVIDENCE: The home had a policy on complaints and the deputy manager stated the home kept a record of complaints about the home. The inspector noted the complaints policy was reviewed in October 2006 and no complaints were recorded about the home. During discussions a member of staff remarked ‘‘I am aware of the complaints policy’’ and a relative stated ‘‘I am delighted with care, I have no complaints’’. A review of evidence at the CSCI confirmed no complaints were recorded about the home. The home had a policy on elder abuse and staff have training in safeguarding adults to protect service users from harm. Further evidence indicated the home had a whistle blowing policy and staff have additional training in dementia and challenging behaviour to ensure any verbal and physical aggression by service users is understood and dealt with appropriately by staff. The inspector noted the home had a copy of the local authority (Surrey County Council) procedures on protection of vulnerable adults which was out of date and a recommendation has been made in respect of this matter to ensure staff have up to date information on which to make decisions about Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 14 safeguarding adult matters. During discussions a service user stated ‘‘staff are very good to us, if they weren’t I wouldn’t say so’’. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 15 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&26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are good ensuring the home is comfortable and homely for service users. The arrangements for hygiene are good ensuring the home is clean and hygienic for service users. EVIDENCE: The home is suitable for its stated purpose and is accessible, comfortable and homely. The provider confirmed the home had a development plan and the inspector noted bedrooms have been decorated and refurbished with the lounge due for decoration and refurbishment this financial year 2007-2008. A review of records confirmed the home had a visit from the local authority (Surrey County Council) environmental health department with appropriate management action taken. Observations confirmed the garden was private and secure with wheelchair access and during discussions a relative commented ‘‘the home has a nice feel about it’’. Following discussions with the deputy manager a recommendation has been made for the home to consult with the Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 16 local authority (Surrey County Council) fire prevention officer to ensure fire safety arrangements are adequate to protect service users and staff in the home. On the day of the inspection the home was clean, well ventilated and free from mal odour. Observations confirmed hand washing facilities were prominently sited in the kitchen and laundry, and the home had gloves, aprons and hand wash to prevent the spread of infection in the home. A review of records confirmed the home had a policy on infection control, a service level agreement with an approved contractor for the disposal of clinical waste and staff have training in infection control to prevent the spread of infection in the home. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are good ensuring sufficient numbers of staff on duty to meet the needs of service users. NVQ training is good ensuring service users are in safe hands at all times. Recruitment and vetting practices need strengthening to safeguard the welfare of service users. Staff training is good ensuring staff are trained and competent to do their jobs. EVIDENCE: The deputy manager stated the home had written duty rosters and adequate staffing levels. The inspector sampled records and noted the home had a registered manager, a deputy manager, senior care staff, care staff, a cook, cleaner and activity co-ordinator to meet the needs of service users. A review of duty rosters confirmed four staff on the morning shift, three staff on the evening shift and two waking night staff to support service users. The inspector noted the cook worked full time with responsibility for food and meals and the cleaner worked twenty five hours per week to ensure the home is maintained in a hygienic state. During discussions a relative commented ‘‘staff are very caring and always talking to service users’’. The home had a policy on staff training and an IIP (Investor in People) accreditation which reflected commitment to ongoing staff development. Further evidence confirmed staff have training in NVQ with over fifty percent of Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 18 staff having the qualification. During discussions a member of staff stated ‘‘generally training is very good’’. The home had a policy on recruitment of staff and the deputy manager stated staff are vetted before being employed by the home. A review of staff recruitment files confirmed staff have completed application forms, two written references, statement of terms and conditions, CRB (Criminal Record Bureau) disclosure information and copies of GSCC (General Social Care Council) code of conduct. Following discussions with the manager a requirement has been made for staff recruitment files to include a recent photograph of the employee and staff application forms to be revised to include a full employment history to safeguard the welfare of service users. The home had a policy on induction, an induction checklist and a NCHA (National Care Homes Association) staff handbook which covers health and safety, communication and recording, aims and objectives, equality and diversity, quality assurance and other appropriate and relevant training. The inspector noted staff induction checklists were completed, dated and signed by the employee and supervisor. During discussions a member of staff commented ‘‘when I joined I did induction and foundation training’’ and a visitor remarked ‘‘staff are caring and do above and beyond what is expected’’. Following discussions with the deputy manager a recommendation has been for the home’s induction programme to reflect Skills for Care common induction standards. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day to day management of the home is good ensuring the home is run and managed by a person fit to be in charge of the home. The systems for quality assurance are good ensuring the home is run in the best interests of service users. Policies and procedures are good and safeguard the financial interests of service users. The arrangements for health and safety are good promoting the health and safety of staff and service users. EVIDENCE: The home has an experienced registered manager with the RMA (Registered Manager Award) qualification and provides management stability, leadership Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 20 and direction to the staff team. The inspector noted the home has a management structure with clear lines of communication and accountability. During discussions a member of staff stated ‘‘the management is very good, open and always prepared to help’’ and a visitor commented ‘‘the home is managed very nicely, it has got better over the eight years I have been coming here’’. The home had a policy on quality assurance and used questionnaires to obtain feedback about the service provided. The deputy manager stated the home is in the process of arranging an internal audit to obtain feedback from service users, family, friends and other stakeholders as appropriate. The inspector sampled records and noted completed questionnaires dated January 2006 reflecting overall satisfaction with the home. Further evidence confirmed the home met the requirements made by the CSCI to improve practice at the home and during discussions a relative stated ‘‘I have no adverse comments about the home’’ and ‘‘I would recommend the home, staff are very caring’’. The deputy manager remarked the home has a policy on service users’ money and valuables and provided a lockable drawer for the safe keeping of money and valuables, if required. As previously stated in this report relatives have responsibility for service users’ money and one service user had a solicitor who acted as an advocate to safeguard his financial interests. The inspector noted the registered manager did not act as appointee for any of the service users in the home and the deputy manager stated this was company policy to safeguard the interest and welfare of service users. The home had a policy on health and safety, a named staff with responsibility for health and safety matters, and staff have training in health and safety, fire safety, food hygiene, first aid and other appropriate and relevant training. A review of records confirmed the home had a policy on COSHH (Control of Substances Hazardous to Health) with products appropriately stored in a locked cupboard to promote safety. The kitchen appeared clean and hygienic with appropriate arrangements and practices in place to promote food safety. As previously stated the home had a visit from the local authority (Surrey County Council) environmental health department on the 18/01/06 with management action taken. The inspector noted the home had a gas safety certificate dated 26/06/06, a fire alarm inspection dated 30/05/06 and service inspection records pertaining to fire safety, emergency lighting and other equipment were up to date and valid to safeguard the welfare of staff and service users. Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14(2)(a) (b) Requirement The registered person must ensure care plans are reviewed regularly, at least monthly, to reflect the changing needs of service users. The registered person must ensure information about activities is in a format which is understandable to service users with a memory impairment to promote communication and decision making in the home. The registered person must review the provision of activities in the home including the number of sessions provided by the activity co-ordinator to ensure it is adequate to meet the needs of service users. The registered person must ensure staff recruitment files have all the relevant records including a recent photograph of the employee to protect service users from harm. The registered person must ensure staff application forms are revised and updated to include a full employment history DS0000013621.V327588.R01.S.doc Timescale for action 01/03/07 2 OP12 16(2)(n) 01/05/07 3 OP12 16(2)(m) 01/05/07 4 OP29 7,9,19 Schedule 2 20/03/07 5 OP29 7,9,19 Schedule 2 01/05/07 Dalmuir Home Version 5.2 Page 23 of prospective employees to safeguard the welfare of service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP9 OP18 Good Practice Recommendations The registered person should consider ensuring a list of staff names with specimen signatures is available at the home to promote good practice. The registered person should consider ensuring medications in liquid form are dated on opening to promote health. The registered person shall consider ensuring the home has an up to date copy of the local authority (Surrey County Council) procedure on the protection of vulnerable adults to promote good practice. The registered person shall consider ensuring the home consults with the local authority (Surrey County Council) fire prevention officer to seek advice on the adequacy of current fire safety arrangements at the home The registered person shall consider ensuring the home’s induction programme reflects Skills for Care common induction standards to promote good practice. 4 OP19 5 OP30 Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Dalmuir Home DS0000013621.V327588.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!