Inspection on 29/05/06 for Dane House

This inspection was carried out on 29th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dane House 16/07/07

Dane House 14/12/05

Dane House 18/07/05

Dane House 06/12/04

Dane House 01/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Dane House 52 Dyke Road Avenue Brighton East Sussex BN1 5LE Lead Inspector Debbie Calveley Key Unannounced Inspection 29th May 2006 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 Dane House DS0000013976.V291696.R01.S.doc Version 5.1 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. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dane House Address 52 Dyke Road Avenue Brighton East Sussex BN1 5LE 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) 01273-564851 01273-507161 www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Tracey Fiona Davis Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (5) of places Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-five (25). That service users should be aged sixty-five (65) or over on admission. That a maximum of five (5) service users may have a physical disability and be aged between forty-five (45) years and sixty-five (65) years on admission. 14th December 2005 Date of last inspection Brief Description of the Service: Dane House is a converted family house situated in a residential area of Hove. The home is registered to provide nursing care for twenty-five service users in the category of old age. A variation to the category has enabled the home to provide care for up to five service users with a physical disability. Dane House is a large detached property, with a conservatory to the rear of the house leading to a pleasant rear garden with a pond and good quality garden furniture. The accommodation offered consists of nineteen single bedrooms, ten with ensuite facilities and three double bedrooms, two with ensuite bathrooms. There are ample communal bathrooms with adaptations for the disabled. The lounge area is large with comfortable furniture, which leads into a conservatory currently being used as a dining area. There are other quiet areas on the ground floor with comfortable chairs, which can be used by the residents. Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2006 range from £690 to £760, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over 6.5 hours on the 29 May 2006. There were twenty service users in residence on the day, of which six were case tracked and spoken with. During the tour of the premises six other service users of both sexes were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including care plans, medication records and recruitment files. Three members of care staff, two trained nurses and the cook and housekeeper were spoken with in addition to discussion with the Registered Manager and the administrator. Comment cards received from four service users and two relatives were generally positive and that both groups were satisfied with the services provided. Five social and healthcare staff surveys were also received during the inspection process and also were positive regarding the service Dane House provides. The information contained in the returned surveys has been incorporated into this report. What the service does well: What has improved since the last inspection? The pre-admission assessments viewed were more comprehensive than found previously, ensuring that the home is able to meet the identified needs prior to admission. The carpets in the home have been gradually replaced since the last inspection. The laundry room has been upgraded to include hand washing facilities and an impermeable floor. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 6 What they could do better: The care plans still need to be improved to ensure all the care needs of residents are recorded along with clear guidance to staff on how to meet these needs. The medication practices in the home for the administration and ordering of medication need to improve to ensure the health needs of the residents are met and supported. It was found that inadequate curtains to the front of the home and a missing ensuite door might compromise the privacy and dignity of residents. The feedback from the residents and their relatives, both verbally and written indicates that the activities provided still do not meet their expectations, are not well attended and do not stimulate all the residents. An activity programme needs to be developed to include activities that will be enjoyed and looked forward to by all the residents.” it would be nice to have more activities, especially for the residents in the lounge” “some games, cards and jigsaws made available would stimulate the residents, some are very capable once they start playing cards or bingo”. The social care plans were not fully completed on the majority of residents and there is no formal record of what the residents participate in on a regular basis. Whilst the home is comfortable and homely with a good standard of cleanliness, the maintenance of the home in general needs to be maintained more robustly to ensure the safety and well being of residents and staff. The staffing levels, whilst seen to be adequate on the day of the inspection have been mentioned in feedback from visitors, staff and residents as variable, dependant on the staff on duty and the changing needs of residents, this needs to be reviewed and audited on a regular basis to ensure that the staffing levels remain sufficient. The feedback regarding formal supervision was identified as a concern as staff informed the inspector that they had not received supervision or appraisals and did not feel supported in their role. From further discussion with the manager, supervision has lapsed. It was acknowledged by the manager that the staff have been unsettled lately, and that steps need to be taken to improve the situation before it impacts on the residents. Supervision needs to recommence along with staff meetings that have an agenda so that staff feels supported to discuss any concerns they have. The recent staff meetings have not been successful or beneficial for any of the staff. Robust Health and Safety systems need to be adopted and recorded to ensure staff and residents safety. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 7 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. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 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 Dane House DS0000013976.V291696.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The Statement of Purpose and Service Users Guide give prospective residents the information required, enabling them to make an informed choice about where they live. Visits to the home by prospective residents and their family prior to admission are encouraged so they can meet staff and fellow residents before making a decision. EVIDENCE: The Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. During the inspection it was found that not all of the residents have a copy of the Service Users Guide and four residents were not aware of that one existed. Three of the residents spoken with were aware of the Service Users guide and found it informative. All residents receive a contract of terms and conditions on admission to the home; four residents confirmed that they had received a contract. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 10 A senior member of the staff, who completes a pre-admission assessment using the homes assessment tool, assesses all prospective residents Three assessments were seen fully completed, one was incomplete and did not give much detail about the reasons for the proposed admission and what care was to be provided, It was confirmed by two residents that their family were involved in the preadmission assessment. The assessment is undertaken at the residents’ place of residence, and input from other relevant professionals is sought when and as required. Three of the ten residents spoken with said they remembered visiting the home before admission, which made the move easier. One relative spoken with said that they had chosen the home because they liked the atmosphere when they visited and it was not to far for them to travel. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Generally care plans provide an adequate framework for the delivery of care, however these need to provide clear guidance to care staff on all the care needs of residents and be accessible. The home was found to be meeting resident’s health and general needs with accessed additional community support when needed. The management of the medication systems in the home did not support the health needs of the residents at this time. EVIDENCE: Six residents care plans were viewed from the pre-admission assessment through to the formation of care plans and daily notes. It was found that some health needs had been identified and planned for, however some were incomplete, not regularly reviewed and there was no evidence to show that all residents or their representatives are involved in compiling and reviewing the plans. One example was a resident that had recently had a hip replacement but the care plan and risk assessments had not been updated to in respect of Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 12 moving and handling, pain control and mobility. There were instructions from the hospital regarding exercises and a physiotherapy plan, but this was not put in to a care plan with instructions for staff to follow Other care plans were also lacking in follow through when an identified need has changed. Fluid and turning charts for frail, heavily dependent residents had not been completed since 6 am, and it was 1500 hours when they were viewed, and one resident’s input was recorded as only 50 mls for eight hours. This is an important part of the residents care and staff need to be correctly documenting residents input to be able to present the information for expert intervention if required and prevent dehydration, confusion and urinary tract infections. The care plans are kept in the locked clinical room and as discussed before the care staff are not able to access them easily are not always aware of additions to care plans or changes to the care. The lack of entries in the key worker diaries could be liked to this factor. Care staff also mentioned when spoken with, the difficulty of accessing the residents’ records to check on details if they needed to. Different methods of maintaining the confidentiality of resident’s sensitive information whilst ensuring care staff have access to the daily needs/changes of residents were discussed during feedback. There is a staff handover checklist, but on reviewing the shortfalls found on the care plans, it is not proving beneficial as a checklist of compliance by the staff. The clinical room was found clean and tidy, but the maintenance of the room, in regard to fixtures and fittings needs attending to. The cupboards and fridge were clean and found to be well stocked and not over crowded. Daily temperatures are recorded. On viewing the medication administration charts, gaps were identified and the morning medications for the ground floor had not been signed for. There was also evidence seen of medication being out of stock for three weeks. This is not acceptable and staff need to ensure that the medications are ordered before they have run out, thus ensuring that residents receive their medication as prescribed. Verbal orders need to signed and dated by the staff member receiving the instructions so any queries can be tracked. Throughout the inspection it was observed that residents were treated with dignity and respect. One resident said “everything is good, the staff are nice girls and I like living here”, another said “ I am here on holiday, I always come here when my daughter goes away, its my second home, the food is adequate, I love the conservatory and the garden”. It was found that inadequate curtains to the front of the home and a missing ensuite door might compromise the privacy and dignity of residents. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents would benefit from a daily programme of activities based on their preferences. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: The activity programme has been suspended due to illness, and the only activity still in place is the exercise to music class once a week. It was confirmed by staff that there are no activities at present, but they do talk to residents. Residents spoken with said they missed the activity lady and hoped she was better soon. An action plan regarding the provision of activities in the home needs to be formulated as the residents admitted to being bored and not having anything to look forward to. The feedback gathered from surveys and verbally from residents and relatives regarding activities was mixed, some residents enjoy the range of activities offered but others said it was not for them. Two residents said they chose not to go and preferred to spend their time in their room. One friend of a resident said there was an exercise class, but nothing else her friend could take part in. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 14 Outcomes for residents would be more positive if residents could make suggestions in the form of a survey regarding how they would like to spend their time and if the social care plans of residents were completed in full, listing their interests and likes as well as dislikes. From talking to the residents and collating the information from surveys received it was confirmed that the routines of daily living have a degree of flexibility; residents can request meals at a different time if they are going out and in their preference for getting up and for going to bed and of how and where they spend their time. There is open visiting and one relative said they were welcomed to the home, whenever they visited. “ The staff are always welcoming” “have always found it easy to talk to the staff”. Residents are able to handle their own finances if they wish to, and if they are able. In every bedroom there is a lockable facility to safeguard valuables. Furniture and other belongings are welcomed by the home if the resident wishes to bring them with them. Certain rooms were seen to have been personalised by residents and their families. The chef confirmed that he personally visits all residents with the following days choices. The menus are set menus for the organisation and demonstrate choice and variety and indicated a well balanced diet. One resident did mention that they “do not get home made cake with afternoon tea any more which was a shame”. The menus rotate on a four weekly basis and change according to the seasons. Fresh fruit is readily available. The midday meal offered on the day of the inspection was pork ‘Somerset’ casserole with two vegetables and boiled potatoes or salmon fish cakes served followed by chocolate sponge, vegetarian/vegan alternative was available, soya mince with vegetables and potatoes. Fried eggs and chips was also served to one resident. A resident who is a vegan said that the chef does consult with him on a regular basis regarding his diet and that the food was okay. Three residents spoken with said they prefer to eat in their rooms, as they enjoy their privacy, but the “food is always hot and tasty”. “”I think there is room for improvement for the food that is served to make it more appetising”. The kitchen was clean, tidy and well organised. The chef said the staff do tell him when residents appetite is poor and he then informs the manager. A more formal record could be beneficial in identifying nutritional problems. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: There is a policy and procedure is in place for dealing with complaints and this is also outlined in the Statement of Purpose and Service Users Guide. It was noted that Service Users Guides are no longer in residents’ rooms, which needs to be amended so that the residents can access information as they need to. Three residents were unsure of a complaint procedure, but said they would talk to the staff on duty. One resident’s friend said they were not aware of the actual procedure, but would seek out the manager. A copy of the complaint procedure is displayed on a notice board on the ground floor. Other relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The manager is aware of the timescales set down for dealing with complaints and a complaints register is available. One area that was discussed with staff is the management of complaints received from staff regarding the way they are treated or spoken to by residents. This is an area that needs to be explored to ensure that staff feel safe and supported by the management team, to ensure that the outcomes are positive both for the resident and the staff concerned. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 16 The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect vulnerable residents. There is evidence of on-going training for all staff in Adult Protection. There have been no Adult Protection concerns raised since the last inspection. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The standard of decor within the home continues to improve as part of an ongoing programme with all areas homely and comfortable for residents. EVIDENCE: Dane House continues to provide a comfortable and safe environment for the residents. There are some maintenance issues that need to be addressed which include a missing door on a residents ensuite which compromises privacy and dignity, a broken porcelain pedestal in a communal bathroom, which could injure residents and staff. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and this was evident during the visit. All personal items are listed in the individual care plans. Residents are offered the opportunity of having a lock and key for their bedroom, risk assessments are in place for this. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 18 All residents have a lockable facility for the storage of personal items and valuables. One resident said that he keeps all his private papers in a locked drawer, and feels that this enables him to take control of his life. There is an ongoing maintenance programme, but feedback received stated that maintenance has taken second place to the garden and things were not getting done when reported, such as changing light bulbs, fixing broken light switches, shower doors and the previously mentioned pedestal and ensuite door. The home provides adequate communal rooms that are well used. The lounge area was found warm, comfortable and homely. The conservatory was both clean and comfortable and is also used as the dining room. The garden and patio areas have both wheelchair access and seating, the feedback suggests that “more use of the garden areas would be nice for my relative especially as the weather is improving”. There are toilet, washing and bathing facilities to meet the needs of the residents, including showers and assisted baths. One shower door was found broken. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. The corridors are wide enough for self-propelling wheelchairs. There is a call bell facility in all areas of the home, the staff need to ensure that all residents have access to a call bell or have a regular check to ensure their needs are met. There are still a large number of divan beds in use for residents receiving nursing care. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Some though had no bulb or lampshade. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. Polices and procedures for infection control are in place and are updated regularly. The home was clean, however a couple of bedrooms had a strong offensive odour on the day of the inspection, the housekeeper was aware and was planning to attend to the carpets the following day as she had not been able to do so on this day. The feedback from residents and from surveys received complimented the homes cleanliness, one resident said, “the housekeeper is wonderful, she works very hard to keep the home looking nice” “everyone is very nice and the place is kept clean”. The staff spoken with said that an extra pair of hands would be beneficial to keep on top of the cleaning as one housekeeper is just not enough. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. The laundry room is small, though now upgraded to include hand washing facilities and an impermeable floor, however from comments received it appears that it is sometimes disorganised. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff training has improved, but residents would be better protected by regular reviews of staffing levels based on resident’s dependency levels and staff feedback. EVIDENCE: The staffing rota was viewed and the night shift comprises of one trained nurse and one carer, with a carer coming in at seven am. Feedback from staff and the residents implied that the smoothness and efficiency of the night staff was variable depending on who was working. The morning shift consisted of one trained nurse and three carers; a recent addition to the morning shift is a seven to eleven carer. The afternoon shift is staffed by one trained nurse and two carers. However from verbal feedback and from surveys received the staffing levels are still considered inadequate at times to meet the needs of the residents. “ We are not able to give the time required to do little things for residents”, “we are still short staffed” “at times when we visit there seem to be very few staff around” “ I do not think there are enough staff especially at weekends”. The staffing levels need to be flexible according to the changing needs and numbers of the residents. Regular feedback from staff relatives and residents would be beneficial to ensure the staffing levels are adequate. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 20 Recruitment files on five members of staff were viewed and contained all the relevant information required by the standard. Criminal Record Bureau and P.O.V.A checks were in place as were the necessary two references and employment history; trained nurses had verification of their PIN numbers and expiry dates. Overseas nurses files evidenced the necessary work permits and health checks. The files demonstrated the appropriate induction training had been completed in respect of the job they were to undertake in the home. Staff interviewed confirmed a satisfaction with the training provided and stated that they received training sessions related to medical conditions, which gave them insight into the residents needs. Staff and records seen confirmed that they had undertaken compulsory training such as manual handling, adult protection, first aid, food hygiene and fire safety. NVQ training is available and staff are encouraged to complete this. Some of the staff spoken to were disillusioned regarding the NVQ and that it was taking so long to complete. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. At present Dane House do not have a strong management structure to provide leadership and guidance and to ensure health and safety, supervision and quality monitoring systems are fully used. EVIDENCE: The manager is suitably qualified and experienced to run the home. She takes responsibility for the day-to-day running of the home and is supernumery to the care staff; she is also on call for any emergencies. The residents and relatives are aware of who the manager is and her role in the home. The formal quality assurance and quality monitoring systems in place enable the management to objectively evaluate the service and ensure it is run in service users best interests. Three of the Residents spoken with said they felt Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 22 that the staff took an interest in what they said about the home, whilst one said, “ none of them have any idea about being old and living with lots of other old people” “the staff are great, they care about us”. There are systems in place to safeguard resident’s financial interests; with policies and procedures in place for staff to follow in respect of gifts and rewards from residents and their families. Feedback from staff regarding staff supervision was a concern in that they said they have not been having any supervision or appraisals. When discussed further with the manager, it appears that they have had supervision, but not recently. As the staff morale is low at present, this needs to recommence so staff feel supported. Due to changes in the staff team the staff feedback indicated that they were unsettled. Four staff surveys received from various members of the staffing team indicated that “there was little support from the management team” “no one listens to our feelings” “we never see the higher management for more than a couple of minutes” “ we are all feeling unsupported”. The staff feel that the home manager is not as visible as before, this could be because the office is now at the top of the building, and is out of sight. The staff meetings held have also been mentioned by four staff members as unhelpful and very stressful. There seems to be a large amount of disillusionment amongst the staff, and the recommencement of regular staff meetings, supervision sessions and appraisals would be beneficial to all the staff. Staff training in moving and handling, infection control, COSHH, first aid, fire safety and food hygiene are undertaken and recorded, and all staff are receiving further training in nutrition, specific diseases such as motor neurone and diabetes and prevention of adult abuse. Documents relating to safe working practices and Health and Safety were available and found to be satisfactory as were accident records. Weekly testing of the call bell system and water delivery temperatures are undertaken and recorded to ensure residents health and safety are protected. During the inspection a number of areas of Health and Safety were noted and these included; Footrests were not being used when transporting residents in wheelchairs. Inappropriate footwear of residents when in the communal areas. Call bells not in reach of some disabled residents and no record available of how the residents are kept safe and comfortable. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 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 2 3 3 2 3 2 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 2 2 Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Requirement Timescale for action 29/08/06 15(2)(b)(c That a comprehensive plan of )12(1) care is generated from a comprehensive assessment is drawn up for/with each service user, and it is reviewed at least once a month. (Previous timescale of 30/09/05 & 01/04/06 not met.) 13(1)(b) That all documentation in respect of residents health needs are kept up to date, reviewed regularly and assessable to all staff as per schedule 3. In particular the fluid and turning charts of the frail residents. (Previous timescales of 30/09/05 & 01/04/06 not met.) 2 OP8 29/05/06 2 OP37 17(1)(a) That all documentation in 29/05/06 respect of residents health needs are kept up to date, reviewed regularly and assessable to all staff as per schedule 3. In particular the fluid and turning charts of the frail residents. (Previous timescales of 30/09/05 & 01/04/06 not met.) DS0000013976.V291696.R01.S.doc Version 5.1 Page 25 Dane House 3 OP9 13(2) 4 OP9 13(2) That medication is ordered in 29/05/06 sufficient time to ensure that the medication is administered consistently. Medication administration record 29/05/06 charts must reflect current medication profile and must be a true and accurate record. That changes to orders of medication are signed, dated and recorded. (Previous timescale of 18/06/05 & 14/12/06 not met.) That the home is conducted in a manner, which respects the privacy and dignity of residents. That the ensuite door is replaced and that the front windows are suitably draped. That an activity programme is devised to ensure all service users social needs are met and that there is a suitable care plan in place. (Previous timescale of 30/09/05 & 01/04/06 not met.) That the internal maintenance of the building be more robust. That all residents have access to a call bell or a system in place that ensures residents are checked regularly. That all residents have access to a call bell or a system in place that ensures residents are checked regularly. That adjustable beds are provided for residents receiving nursing. That the home ensure that at all times there are sufficient numbers of staff are appropriate for the health and welfare of residents. That all staff receive formal supervision at least six times a year. DS0000013976.V291696.R01.S.doc 5 OP10 12 (4) 29/05/06 6 OP12 16(2)23 (2) 12(4) 29/08/06 7 8 OP19 OP38 23 (2) (b) 16 (c) 29/05/06 29/05/06 8 OP22 16 (c) 29/05/06 9 10 OP24 OP27 16 (c) 18 (1) 29/08/06 29/05/06 11 OP31 18 (1)(2) 29/08/06 Dane House Version 5.1 Page 26 11 12 OP36 OP38 18 (1)(2) 12 (1) 13 (5) That all staff receive formal supervision at least six times a year. That robust health and safety practice is adopted to include thorough environmental risk assessments, including wheelchairs and footwear. 29/08/06 29/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP1 OP3 OP15 OP12 Good Practice Recommendations That all residents are reissued or offered a copy of the Service Users Guide. That the residents admitted for respite/holiday preadmission assessment clearly states the reason for admission with an appropriate physiotherapy and That a more formal method of recording poor appetite, little eaten or difficulty in eating be implemented. Than an action plan be developed for the provision of activities in the event of illness and vacant post. Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dane House DS0000013976.V291696.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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