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Inspection on 23/09/08 for Danmor Lodge

Also see our care home review for Danmor Lodge for more information

This inspection was carried out on 23rd September 2008.

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

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has warm and friendly atmosphere. There are good quality care plans in place that are easy for staff to follow. The people living at the home have good relationships with staff and they are relaxed with them. There is a stable staff group and staff know the people who live at the home well. People living in the home are supported to maintain their independence and enduring interests, which enhances their quality of life. People have good access to local General Practitioners and specialist healthcare when required. Visitors are made welcome and people are encouraged to maintain contact with family and friends.

What has improved since the last inspection?

The working hours of the activities coordinator have increased. People told us that there is a greater variety of activities. All of the requirements given at the last inspections have been met. The care plans for people now include all of their needs and are reviewed on a regular basis and or when their needs change. Any risks to people have now been assessed and minimised where possible. Staff who administer medication have now been trained. A new controlled drugs cabinet has been purchased and all medications are stored correctly. Medications that are no longer in use have been returned to the pharmacy.People are treated with respect and dignity when being offered personal care and support. All staff now have regular support and supervision meetings with the manager. A COSHH register has now been established that details the substances in use at the home.

CARE HOMES FOR OLDER PEOPLE Danmor Lodge 14 Alexandra Road Weymouth Dorset DT4 7QH Lead Inspector Ms Jo Johnson Unannounced Inspection 09:30 23 September 2008 rd 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 Danmor Lodge DS0000062426.V368166.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. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Danmor Lodge Address 14 Alexandra Road Weymouth Dorset DT4 7QH 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) 01305 775462 01305 781454 Danmor Lodge Ltd Mrs Susan Hasler Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary needs on admission to the home are within the following category: 2. 3. 4. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 27. One person as known to CSCI within category DE (E) may be accommodated. One person within the category MD and one person within the category DE (E) may be accommodated. 6th September 2007 Date of last inspection Brief Description of the Service: Danmor Lodge has been owned by Mr & Mrs Hasler since 1994. Mrs Hasler is the Registered Manager in charge of the day to day running of the home. It is a detached property, set in its own grounds/gardens situated close to local shops and a short bus ride from the town centre of Weymouth. The home is registered to accommodate a maximum of 27 residents service users over 65 years of age. Accommodation is on the ground, first and second floors; two passenger lifts and a ramp enable smooth access to all parts of the home without the necessity to negotiate steps. Communal facilities include two lounges, conservatory, dining room, 3 assisted bathrooms, a conventional bathroom and a separate toilet. Danmor Lodge is a non-smoking home. The garden is laid to lawns with flower borders and at the front of the house is a patio. There is unrestricted street parking outside the home and some car parking in the grounds. Readers of this report may find it helpful if they have any queries about fees to contact the Office of Fair Trading www.oft.gov.uk. The manager had copies of the last report available within the home. The Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 5 report of this inspection is available from enquiries@csci.gsi.gov.uk. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by us is upon outcomes for people who live at the home and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. This report uses information and evidence gathered during the key inspection process, which involves a visit to the home and looking at a range of information. This includes the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The manager/owner supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. Surveys were distributed by the manager/owner to people who live at the home, health/social care professionals and staff. Ten surveys from people and their relatives, four health/social care professionals and eight staff surveys were returned. The findings of these surveys have been included in the report. We undertook a random inspection on 17th July 2008 following concerns that were raised with us in relation to medication management and staffing. This was the first unannounced key inspection for the inspection year 2008/9. Two inspectors were present for this key inspection which was unannounced (we did not let the home know that we were coming) and took place on 23rd September between 9.30 am and 3.30 pm. The inspection involved; • • • Speaking with eight people who live at the home. Their views have been included in the report. Observations of and generally talking with the people who live at the home and the staff on duty, senior carer and the manager. Three people were identified for close examination by reading their care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’, where evidence is matched to outcomes for people. DS0000062426.V368166.R01.S.doc Version 5.2 Page 7 Danmor Lodge • A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. We would like to thank the people who live at the home, the manager/owner and staff for their hospitality and cooperation during the inspection visit. What the service does well: What has improved since the last inspection? The working hours of the activities coordinator have increased. People told us that there is a greater variety of activities. All of the requirements given at the last inspections have been met. The care plans for people now include all of their needs and are reviewed on a regular basis and or when their needs change. Any risks to people have now been assessed and minimised where possible. Staff who administer medication have now been trained. A new controlled drugs cabinet has been purchased and all medications are stored correctly. Medications that are no longer in use have been returned to the pharmacy. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 8 People are treated with respect and dignity when being offered personal care and support. All staff now have regular support and supervision meetings with the manager. A COSHH register has now been established that details the substances in use at the home. What they could do better: Communal records should not include personal details but refer staff to look at the original record. Medications such as eye drops should be administered after an individual has finished what they are doing and in private. Staff should sign the medication administration record when they administer any medication. The correct contact details for the commission should be in the complaints information. The whistle blowing policy should be reviewed and include the correct contact details of the commission. Effective cleaning monitoring should be established so that any unpleasant smells or stained toilets are reduced before they become obvious. The risks of the use of ‘steradent’ and surgical spirits for people who are confused should be assessed. Liquid soap that has been decanted into dispensers should be labelled. The application form and reference request should seek information about whether staff have been subject to disciplinary action. Staff induction should be based on the Skills for Care induction standards. Copies of Regulation 37 notifications should be kept. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 9 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. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 10 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 Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. People who are considering moving into the home benefit from having their care needs assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager told us that people and or their families come and visit the home before making a decision about moving in. One person who had recently moved into the home told us that they had come to look around before moving in. Ten surveys from people told us that they had enough information before moving into the home. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 12 The manager or deputy manager undertakes a pre admission assessment before determining whether they can meet someone’s needs. A fuller assessment, risk assessments and a social history assessment are completed with people as soon as they move in. From this a care plan is developed. The assessments for the last two people to move into the home were seen. Information was sought from care management assessments, and where appropriate other health professionals. People spoken with, surveys and records seen told us that they had enough information about the home and have a contract. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 13 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. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. In the main, medication practices are safe and make sure that people have their medication as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at three peoples’ care records and care plans. The manager told us that they have recently introduced a different assessment and care planning system. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 14 Each person had a care plan, daily records and monitoring records. Care plans were based on information gained during the initial care needs assessment and were being developed as staff got to know the individuals. Risk assessments were completed for falls, tissue viability, mobility, and nutrition. People were weighed on admission to the home and this was recorded in their plans. There was additional information available on medical conditions. The care plans seen were of a good quality and were easy to follow. For example: One person is diabetic and has been identified as being nutritionally at risk. There were detailed records of their daily nutritional and fluid intake. There was easy to follow information in relation to their diabetes. Health professional advice had been sought for this individual and this was detailed in their plan. We observed that the individual was offered a number of choices at the midday meal before being offered a nutritional supplement drink. Care plans had been reviewed on a monthly basis and as and when people’s needs have changed. Daily records are written for each person and reflected how they have spent their time and the care and support they have received. Some of the language used was not always sensitive to individuals. The manager had already identified this and was planning to discuss further with staff. We saw a handover book, which was a communal record that included personal details that were, also recorded in the daily records. There was also a communal record of people’s weights in the bathroom. Any communal record should not include personal details but refer staff to look at the original record. People living in the home looked well cared for and were clean, their hair had been combed and nails were trimmed and clean. They were well presented and wore clothes that were suited to the time of year. Garments were clean and well maintained. People spoken with said that staff take care to make sure they are well dressed and their appearance is cared for. One person commented that the “laundry comes back in dribs and drabs”. Staff observed had good relationships with the people living at the home and were patient and encouraging. Staff respected people’s privacy and dignity, by knocking on their doors and offering personal care discreetly and in private. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 15 Discussion with the manager, staff, and observation of care plans and daily records tell us that people living in the home have access to health professionals such as GP, dietician, dentist and specialist consultants and chiropodist. Since the random inspection, the management of medicines has improved. A new controlled drugs cabinet has been purchased. Medicines were stored correctly and the excess stock had been returned to the chemist. A monthly audit has now been introduced. The controlled drugs were stored correctly. They were audited and balanced with controlled drugs records. Only staff that have completed the safe handling of medicines training now administer medication. Four staff, including the manager, have recently attended an advanced medication training course. One staff member was observed to administer eye drops to an individual during lunch in the dining room. The individual said, “I can’t see for ten minutes” after the drops have been administered. Medications such as eye drops should be administered after an individual has finished what they are doing and in private. There were gaps in the medication administration records on one day for three people. The manager gave a commitment to follow this up with the staff involved and audit the previous weeks medication packs. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 16 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 People living in the home are supported to maintain their independence, contact with important others and lifestyle, which enhances their quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People spoken with said that their visitors were made to feel welcome whenever they visited. The home supports people in their spiritual needs by the involvement of church ministers of varying denominations. There is an activities co-ordinator at the home and there is a regular programme of social activities. Since the last key inspection, the activities have increased from eight hours a week to fulltime. People spoken with told us that that the activities have improved and there is much more to do. One Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 17 person said, “ we play giant snakes and ladders and Bingo, it’s now suitable for all people of different abilities”. One person told us about a recent trip to the theatre and how much they had enjoyed it. Surveys from people told us that there are ‘always’ or ‘usually’ activities arranged by the home that they can take part in. There is a weekly timetable of activities and there are lots of photographs to show the different things that people have been doing. People spoken with said that they were free to come and go from the home as they pleased. They said that they made visits out to the shops, visited friends or family or other events in the community on their own if they were able or with the support of their relative or a member of staff. People spoken with and observed got up and spent their time how and where they chose. Some people choose to spend time in their bedrooms. The kitchen was well stocked with a variety of fresh and long-life foodstuffs. The cook was knowledgeable about the diets of the people at the home. We joined people for lunch, the atmosphere was relaxed and there were enough staff to serve the meal at a suitable pace. All meals were served hot and any support needed from staff was given discretely and sensitively. People spoken with and surveys told us that they generally enjoy the food and said there are always choices available. Two people commented that the food was not always to their liking and the menu could be repetitive. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 18 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 Complaints procedures make sure that peoples, relatives and representatives concerns and complaints are listened to and acted upon. A staff team who have a good knowledge of how to respond to any suspicion of abuse and to keep people safe from harm support the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy is in the service users guide. It does not give the commission’s correct contact details so complainants may not be aware where they can contact us with their concerns. From discussion with the manager and information provided in the AQAA, there have been three complaints in the last 12 months. There were records of the complaint, investigation and the outcome. People spoken with and surveys told us that they all knew whom they would talk to if they were unhappy or needed to complain. One person said, “If I’m not happy I talk to the manager”. Another person said, “I can talk to the owners but I find it best to put it in writing”. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 19 Staff spoken with and surveys told us that they know what to do if a service user or relative or friend has concerns about the home. Staff have attended training in the Protection of Vulnerable Adults (POVA) so that they are aware of the different ways vulnerable people are at risk of abuse, and would know how to respond. The whistle blowing policy needs to reviewed and include the correct contact details of the commission. This is so that staff know how to contact us with any concerns or allegations. There have been two adult protection investigations co-ordinated by the local authority since the last inspection. The providers co-operated fully and the allegations were unsubstantiated. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 20 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 adequate. The home is maintained and furnished so that people live in a homely and comfortable environment. Some unlabelled products and other products in people’s rooms may place them at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Communal areas of the home are comfortable, light and airy. Armchairs are comfortable and clean. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 21 A tour of the home was undertaken. A majority of the carpets and the decoration are generally in a suitable condition. However, the carpets in some of the corridors and the lounge are worn and will need replacing in the near future. The manager/owner said there is a programme and plan for the refurbishment of the home. The surveys from people living at the home show that the home is fresh and clean. However, there were a few bedrooms that had some unpleasant odours and one toilet was very stained. Personal rooms seen were nicely decorated and appropriately furnished. People are encouraged to bring their own belongings, personal items, and small pieces of furniture into the home. From information provided in the AQAA and records seen during the inspection, there are monitoring systems in place to make sure that the environment is safely maintained and managed. There is regular servicing of equipment and systems. In the bathrooms, there was liquid soap that had been decanted into bottles without a label describing what the product is. There was ‘steradent’ in some bedrooms and a bottle of surgical spirit in another. These products may present a risk to people, who are confused, if they are either taken by mistake or be flammable in the case of the surgical spirits. The laundry in the home is small, but sufficient to meet the needs of the people and the size of the home. The laundry room was seen to be organised and clean. Systems are in place to reduce the risk of infection. Disposable gloves, aprons and hand scrub are available and used by staff when handling soiled linen and when supporting people with personal care. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 22 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. The people living in the home are protected by robust recruitment practices and supported by a competent and managed staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection there were 24 people living at the home. One person was in hospital. The rotas for the last month including the week of the inspection were seen. Between 7.45am and 7pm, there are a minimum of four care staff on duty. Between 7pm and 9pm, there are three care staff on duty and between 9pm and 8pm there are two waking care staff. During the inspection, there were enough staff to meets the needs of the people living at the home. People spoken with and surveys told us that staff are ‘always’ or ‘usually’ available when they need them. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 23 People’s surveys show that staff listen and act on what people say. Comments included, ‘they all try and do what they can for me. There are always people around’. People spoke highly of the staff, they said, “staff are all very kind” and “I’m very satisfied with the staff they are all kind”. Three staff files were seen including the most recently recruited staff. Files included evidence of CRB (Criminal Records Bureau) checks and PoVA (Protection of Vulnerable Adults) checks for those staff that had started work at the home. All files seen also contained two references. The application form and reference request does not seek information about whether staff have been subject to disciplinary action. There is a staff induction in place. Staff induction is based on the Skills for Care induction standards. From the AQAA (Annual Quality Assurance Assessment) completed by the manager, the training programme and discussions with staff there is a training programme in place that focuses on mandatory training and the specific needs of the people living at the home. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 24 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, 37, 38 Quality in this outcome area is good. People benefit from living in a home that is managed by experienced providers, people’s views are sought about the service provision, and they are listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home told us that they felt confident about being cared for by a management team that they have known for a long time and liked the consistency. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 25 There were clear lines of accountability in the home; the management team comprises the manager/owner, deputy manager and senior carers. The manager/owner completed the AQQA (Annual Quality Assurance Assessment) and was able to demonstrate where they had improved the home over the last year and identify some areas for improvement. From information recorded on the AQAA, and the policies and procedures seen in the home, they have not been reviewed since 2005. There was a requirement made at the random inspection for the manager/owner to make Regulation 37 notifications. The manager/owner was able to tell us what notifications they had made. However, we were not able to verify this as no copies had been kept at the home. It is recommended that copies of Regulation 37 notifications are kept. The manager/owner took immediate action to seek the new information and format available from our website. The requirements issued at the last key and random inspections have now been met. During the visit staff appeared confident in their roles, the home was relaxed and people appeared at ease and comfortable. Staff spoken with commented positively about the management team, their job role and the people living at the home. The manager/owner told us that they do not manage or keep any monies for people living at the home. There is a quality assurance system in place. This includes surveys for people living at the home, relatives and professionals. Information provided before the inspection, by the manager in the AQAA (Annual Quality Assurance Assessment) shows that relevant Health and Safety checks and maintenance are being carried out at the home. A number of Health and Safety records were checked, including the fire safety log. These records showed that health and safety matters are well managed. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 26 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 X X 3 Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP10 Good Practice Recommendations Communal records should not include personal details but refer staff to look at the original record. This is to keep individuals records private and to meet the requirements of the data protection act. 2 OP9 Medications such as eye drops should be administered after an individual has finished what they are doing and in private. This so that people’s privacy and dignity is maintained and the administration of medications does not have a negative impact of their life style. Staff should sign the medication administration record when they administer any medication. This is to demonstrate that people are having their Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 28 3 OP9 4 OP16 medication as prescribed. Include the correct contact details for the commission in the complaints information. This is so that people know where they can contact us. The whistle blowing policy should be reviewed and include the correct contact details of the commission. This is so that staff know how to contact us with any concerns or allegations. Effective cleaning monitoring should be established so that unpleasant smells or stained toilets are reduced before they become obvious. This is so that people live in a clean and fresh environment. The risks of the use of ‘steradent’ and surgical spirit for people who are confused should be assessed. This is to minimise the risks to people, who are confused, if they are taken by mistake or spilt. Liquid soap that has been decanted into dispensers should be labelled. This is so that it is clear what the contents are and any risks can be identified and minimised. The application form and reference request should seek information about whether staff have been subject to disciplinary action. This is to make sure that staff are suitable to work with vulnerable people. 5 OP18 6 OP19 7 OP19 8 OP19 9 OP26 10 OP37 Copies of Regulation 37 notifications should be kept. This will provide an audit trail and enable the manager/owner to monitor significant events at the home. Danmor Lodge DS0000062426.V368166.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Danmor Lodge DS0000062426.V368166.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. 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. 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