Inspection on 05/01/07 for Danmor Lodge

This inspection was carried out on 5th January 2007.

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

Danmor Lodge 23/09/08

Danmor Lodge 06/09/07

Danmor Lodge 04/07/06

Danmor Lodge 03/11/05

Danmor Lodge 07/06/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Danmor Lodge 14 Alexandra Road Weymouth Dorset DT4 7QH Lead Inspector Alison Stone Unannounced Inspection 11.00a 5 and 19 of January 2007 th th 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.V316723.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.V316723.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.V316723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Two double rooms numbered 10 and 12. Only ambulant persons who are able to understand and react to emergency situations including evacuation of the premises may be located in rooms numbered 24, 25 and 26, on the second floor. One person within the category DE(E) may be accommodated. One person within the category MD may be accommodated. Date of last inspection 4th July 2006 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 service users over 65 years of age. Accommodation is on the ground, first and second floors; two passenger lifts and a ramp enables 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. Fees start at £375.00 per week. This information was given on the 5 January 2007. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of this care home by the Commission for Social Care inspection this year, the inspection year runs from 1 April 06 to 31 March 07. This was a key inspection. The key standards are identified in the main body of report in each outcome area. The manager of the home requested a second key inspection. The manager hoped a second key inspection would provide the reader with a full picture of the service provided at the home and note the improvements made since the last inspection. The inspection was carried out over two days. On the second day the CSCI specialist pharmacy inspector visited the home. The pharmacist inspector checked the medication policy and four residents’ medicines with the records to see if they were given as prescribed and recorded correctly. The inspector arrived on the first day at 11.00am and left at 7.30pm. During the visit, which lasted eight and a half hours, the inspector spoke with seven service users, the manager, the Responsible Individual the two deputy managers and members of staff. The inspector joined service users for lunch, undertook a tour of the premises, observed practice and looked at medication supplies. She inspected records relating to service users care, staffing and medication and other documentation relating to the running of the home. Preparation work included, reading, collation and analysis of surveys and comment cards and reviewing of the Pre Inspection Questionnaire sent to the manager prior to the inspection being completed. The Commission received 17 postal questionnaires from service users, eight comment cards from relatives/friends and seven from social and health care professionals, including two from GPs. The manager, the Responsible Individual and both deputy manager’s were present during the inspection. They provided the inspector with all the relevant information relating to the inspection and any necessary background information. Feedback was given to the manager and the responsible individual at the end of the first day of the inspection. Of the 38 National Minimum Standards, all 22 Key Standards and eight of the remaining 16 Standards were also assessed. The inspector would like to thank everybody who contributed towards the inspection process. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The manager has made some improvements since the last inspection in July 2006. There were six requirements and three recommendations made at the last inspection. Four requirements and one recommendation has been met since the last inspection. A further two requirements and have been partially met. Five requirements and five recommendations were made at this inspection. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 7 The home has improved in most of the areas identified in the last inspection, the areas that the inspector found improvements in are summarised in this section of the report. The manager has applied for a variation to ensure the home is registered to provide a service to all the people who live in the home. The homes practices are compliant with good fire safety management. Care plans had been developed to ensure they record all the necessary basic information and it was noted care plans had been regularly reviewed. What they could do better: Service users care plans need to be developed further to include all their health needs. Where the staff support service users with behaviour that can be challenging, a clear plan of care and risk assessment should be in place, guiding staff about positive and consistent ways of managing a person’s behaviour. Records of medicines received, monitoring of medication records and audit trails, and some aspects of medicines storage need improving. It is good practice to provide liquid soap and disposable hand towels, in communal bathrooms in line with good infection control practices. Staff need to have all the appropriate recruitment checks undertaken prior to the home employing them. Senior staff would benefit from formal training in the area of risk assessment and supervision. The management needs to continue to foster positive relationships between themselves and the placing social work team. The management of the home need to be aware of and show consideration to people around them when verbal outbursts are taking place. The home needs to further develop their quality assurance process. All events affecting a service user well being must be reported to the commission for social care inspection. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 8 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.V316723.R01.S.doc Version 5.2 Page 9 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.V316723.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service User Guide needs further development to ensure people are informed about all the services provided at Danmor Lodge. Service users can be confident the home can meet their care needs, because the home only takes referrals after people have been assessed by the social work team as suitable to live there. Service users and their families/representatives are actively encouraged to visit the home and spend time assessing the quality and suitability of the home’s facilities, before making a decision about whether they would want to live there. The home does not provide any intermediate care. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 11 EVIDENCE: In returned postal questionnaires service users commented that they were provided with enough information about the home before making a decision to move in. It was noted that there were copies of the Service Users Guide available in people’s bedrooms. However the current Service User’s Guide makes no reference to a day service the owner/manager is running from the home. The majority of service users who live at Danmor Lodge have been referred through the social work team so all have social work assessments in place. When a service user is referred to the home the manager/deputy also undertake their own assessment of people’s needs. The manager has now obtained a variation in the registration certificate to enable the home to provide a more specialist service to two people. The home can currently provide a service to one person with needs around dementia and one person with mental health needs. Both of the specialist beds are currently filled. Because these beds are filled the home is unable to offer a service to anyone else with specialist needs. It was noted that there was one other service user living at Danmor Lodge with a potential diagnosis of dementia, this diagnosis is currently being investigated. The manager needs to keep this situation under constant review to ensure the home can meet the service user needs. Service users said that they had been supported with visits to the home before making a choice about moving in. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. Each service user is provided with a plan of care, however care plans need further development so service users can be confident all their needs are included in their care plan. The home has systems in place to manage residents’ medication but some aspects need improving to safeguard their health and wellbeing. Service users can be confident that they will be treated with dignity and respect whilst living at the home. EVIDENCE: As part of the inspection four service user’s records were looked at. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 13 Generally care plans described the action staff were to take to meet a person’s needs although information was noted to be brief. Care plans reflected individual choices and people’s likes and dislikes. However care plans did not always include all service users needs, for instance one service user was on specific medication yet there was no mention of this on their care plan. Another service user was prescribed medication for constipation, however there wasn’t a care plan in place advising staff about this person’s needs in relation to their health needs. It was noted care plans had been reviewed monthly. Service user’s files demonstrated that they saw their GPs regularly and were supported to see the optician, chiropodist, and the dentist as required. Service users spoken to said they regularly saw their GP and other health professionals when they were unwell. Service users files did not demonstrate people were consistently weighed monthly. There was a clear medicines policy that reflected procedures in the home. One resident looked after their own medicines and had a lockable drawer to store them in. Staff trained and assessed as competent administer medicines. MAR charts, which the home prints, were countersigned to indicate that a second member of staff had checked them for accuracy to protect residents. The home had written confirmation of medication prescribed for residents but, for one medicine with a choice of dose according to symptoms, the dose on the MAR chart did not agree with the signed confirmation from the doctor. A few days later staff told me this had been corrected the same day following contact with the nurse but the nurse concerned could not recall this. There was no information in the care plan to guide staff deciding what dose to give, or record of monitoring symptoms. There was no audit trail for one resident’s medication, as staff had not recorded the quantities of medicines received. There were good records of administration for one medicine with frequent dose changes and the number of tablets remaining confirmed that it was given as prescribed and accurately recorded but for another medicine the records could not be verified as there was no recent stock balance. The home had started to set up a system to monitor medication audit trails and further advice on this was provided. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 14 Medicines were stored in locked cupboards and the home has arrangements to safely transport medicines. The temperature of the fridge was not monitored and there was no maximum and minimum thermometer for this. The Controlled Drugs (CD) cupboard does not comply with the misuse of drugs (safe custody) regulations 1973 and Temazepam was not stored in it. The inspector spent several hours observing service users in the home and made indirect observations of service users and staff interaction. Staff were noted to be chatting and regularly interacting with service users. Staff were noted to be polite and treated service users with respect. All the service users contacted as part of the inspection generally felt staff listened to their wishes. Service users were observed to be well dressed and smartly presented. People were noted to be wearing jewellery and dressed in clothes that reflected their individuality. Service users had nicely styled hair and were noted to be wearing their glasses. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 15 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. Service users have access to a lifestyle in the home that meets their interests and preferences. The home supports and encourages people’s social, religious and recreational interests. Service users are supported to maintain contact with family and friends. They are supported and encouraged to be part of the local community. Service users receive a well balanced diet and have a choice of where they would like to eat their meals. EVIDENCE: None of the service users who live at Danmor Lodge belong to an ethnic minority and/or a religious group outside that of the Christian faith. The manager supports existing service users to be active in their faith by arranging a variety of Christian events at the home, which are open to all. The home also celebrates Christian festivals like Easter, Harvest festival and Christmas. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 16 All the service users spoken to agreed that there were many activities offered at the home, including day trips. Two service users said that they really enjoyed going out into Weymouth. Service users spoken to as part of the inspection said there were always lots of activities over the Christmas period. The manager said that they had worked hard to provide a varied programme of activities over Christmas. Service users contacted as part of this inspection said they could choose whether to take part in the activities offered at the home. One service user commented that the home always ensures people have birthday parties that everyone is invited to. One staff member said that the owner/managers were very active in offering service users regular activities and go out of their way to accommodate people’s needs. The home encourages regular contact from service users family and friends. One relative spoken to said staff were always very friendly and welcoming to her. During the inspection it was observed that service users were encouraged to entertain their friends and relatives in the communal areas of the home. The facilities provided in service users rooms and the communal lounges offer people a pleasant, comfortably furnished environment to receive guests. One service user said that the manager has been very helpful to her, making sure she has lots to do during the day. She said the manager had helped organise her bus pass to enable her to travel around the local area independently. She also said that the manager arranged for her to go on regular holidays. The manager has two dogs, which she brings to work with her, service users spoken to said they liked having the dogs at the home. One mealtime was observed during the inspection. This was noted to be a pleasant social experience. Staff were seen to offer service users discreet support as required. Staff were observed to spend a long time gently encouraging one service user with a very poor appetite to eat. Service users were offered different choices of vegetables, drinks and puddings with their meals. It was noted that the chef was preparing a different meal for one person who had asked for an alternative to the meal on offer. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 17 The chef said he felt it was important to ensure that menus reflected meal choices people wanted. Discussion with the chef demonstrated he was aware of people’s different dietary requirements and caters for these in the menu choices. Danmor Lodge DS0000062426.V316723.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives cannot be confident that their complaints will be listened to and taken seriously. The home has a complaints process in place that supports’ the management of any complaints. Staff receive training in the area of Adult Protection, the manager was able to demonstrate that she had copies of the relevant polices and procedures in relation to Adult protection, to inform the home’s practice in this area. EVIDENCE: The manager said there had been two complaints since the last inspection, the review of these records showed that these had been appropriately investigated. Two people raising concerns about the home had contacted the Commission for Social Care Inspection prior to the inspection. These issues were discussed at length with both the manager and the Responsible Individual. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 19 The manager said she shared the concerns raised that a person may be inappropriately placed. She said that she is working closely with the health care professionals involved and keeps the service users care constant review. This second concern related to alleged unprofessional conduct by the responsible individual. This is the second time concerns in this area have been raised. A service user spoken to as part of the inspection said she had overheard the Responsible Individual using unprofessional language in the office, although this was never aimed at staff or service users. The Responsible Individual said he would take on board the issues raised. Service users contacted as part of the inspection process said that they knew how to make a complaint and felt confident to do so. There was one safe guarding Adult Protection referral made during the inspection period this was investigated by the social work team and the concern was unsubstantiated. The inspection of staff files indicated that staff had attended Adult protection training and were aware of the action they should take in the event of any concerns. Danmor Lodge DS0000062426.V316723.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, 20, 21, 23, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortably and nicely decorated home. Service users bedrooms are pleasantly decorated and furnished reflecting their personal tastes. The home provides service users with a clean, tidy and hygienic environment to live in. EVIDENCE: As part of the inspection a tour of the premises was undertaken. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 21 With the permission of the service users, three occupied bedrooms were looked at and a further empty bedroom was also looked at. The responsible individual said that a lot of building work has taken place in the home over the last 18 months. Part of the refurbishment work was to look at ways to make the home more accessible to the people who live there, this included the use of ramps, an assisted bath and providing a through floor passenger lift. It was noted that there is still building materials and debris in the grounds of the home, which distracts from it’s appeal. The responsible individual said that this would be moved shortly and certainly before the summer when the service users make use of the garden. Currently the owner/manager are also storing two boats in the grounds of the home, they said these too would be moved before the beginning of the summer. Service user’s bedrooms were nicely decorated and were noted to include furniture and fittings people had brought from their own homes. It was noted that there were many personal effects around service user’s bedrooms. In the case where bedrooms were shared, consideration had been given to each person’s individual needs and privacy. The manager said often double rooms are used by a husband and wife or sometimes a service user will pay extra to have a room to themselves. During the inspection the home was noted to be clean and tidy. The manager said that there are two domestic assistants employed at the home working various shifts covering a seven day period. It is their responsibility to ensure the home remains well maintained. They are also supported by housekeeping staff. One downstairs corridor area was noted to smell faintly of urine. Hand washing facilities in some communal bathrooms and toilets comprised of communal soap bars and towels. This does not promote good hygiene practices. Hand dryers and/or disposable paper towels would better support infection control practices. Danmor Lodge DS0000062426.V316723.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users can be confident that there is an adequate number of staff on duty to meet their needs. Further development of service users risk assessments would better support staff to meet the needs of service sues. Recruitment practices by the home ensure service users best interests are fully protected in this area. Staff are provided with training to enable them to be competent at their job and meet service users needs. EVIDENCE: Service users contacted as part of the inspection indicated that they felt their needs were met by the amount of staff on duty. None of the service users complained of having to wait long periods of time for assistance. Indirect observations by the inspector noted that staff readily provided assistance to service users as required. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 23 One staff member commented that on occasions such as meal times and in the afternoons they felt it was difficult to meet all service users needs immediately because it was such a busy time. However none of the service users contacted as part of the inspection felt staff were too busy to meet their needs. Nor did the inspector observe service users waiting an unduly long period of time for staff assistance. The owners/mangers also offer a day service to two people, once a week on different days. This is in addition to providing a service to the people who live there. To ensure all service users’ needs are adequately cared for the manager must ensure staffing levels reflect the amount of people they are providing a service to, including any day service. Currently the home has a number of vacancies, so staffing levels are such that they are able to cater for the needs of people who use the day care service as well as the ‘residents’. However the manager needs to keep this situation under review. The review of one service user’s file indicated that the risk assessment in place did not meet all their needs nor did it provide staff with adequate guidance on how to mange the person’s behaviour. Two files indicated staff had been appropriately recruited and all the necessary checks had been obtained prior to staff being employed. Staff files reviewed indicate that staff were supported with an induction programme, which included all the necessary mandatory courses like, food hygiene, health and safety, fire training, first aid, manual handling and protection of vulnerable adults. As well as mandatory training it was noted staff were also provided with specialist training. Both of the deputy managers had been supported with management training, which included brief supervision training. The manager said that it was her intention to provide the deputies with dedicated supervision training. It was noted the deputies had their National Vocational Qualification at Level 3. At the last inspection it was recommended that the deputy managers undertake formal risk assessment training, the manager was unable to demonstrate that this had taken place, she said risk assessment training was included in the NVQ qualification. However the NVQ qualification does not provide staff with formal risk assessment training. Danmor Lodge DS0000062426.V316723.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, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users benefit from having a consistent manager and management team. Occasionally the discord and unbecoming language emanating from the office could have a detrimental affect on service users and visitors. Service users would benefit from the development of a quality assurance system, to inform them about the quality of care they can expect to receive living at Danmor Lodge. Staff supervision is not consistently implemented to an adequate level to ensure staff performance is regularly monitored. Service users health and safety is generally maintained by good management practices relating to the implementation of health and safety measures. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 25 EVIDENCE: Service users said they felt confident about being cared for by a management team that they have known for a long time and liked the consistency of a stable management team. Returned postal comment cards from three care managers commented that the manager and her husband were not always welcoming towards them. The manager and Responsible Individual are aware of these comments and said that they are working to address this perception. It was noted that the manager and responsible individual were generally helpful and supportive of the inspection process. However on occasions, during the inspection the Responsible Individual was noted to deal with problems in a way where he found it difficult to manage his emotional responses. This led to outbursts which service users could clearly overhear. The home has taken on board the issues raised at the last inspection about developing a quality assurance system that involves all stakeholders and has sent out quality related questionnaires to professionals, service users and staff asking for their views on the service provided. This has yet to be developed into a formal quality assurance process that generates an annual report. The manager said that this is being developed and when completed they will send a copy of the annual report to the Commission for Social Care Inspection. The home has polices and procedures in place relating to the management of service users finances and currently the home does not act as anyone’s appointee. The review of staff files indicated staff were not consistently supervised every other month. The inspector sampled a selection of health and safety records. The review of fire records showed regular tests of the fire equipment take place and staff records demonstrated that staff have received fire training. The home has employed a consultant who has completed a fire risk assessment in line with the new fire regulations, the manager said that they and are waiting for the completed risk assessment to be returned to them. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 26 The home has regular visits from the environmental health officer. The chef said that there were no issues of concern raised at the last inspection. It was noted that there was an up to date portable appliance testing certificate in place, along with the appropriate five-year hard wiring check. It was also noted that there was an up to date gas landlord certificate in place as well as regular services on the passenger lift. Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 27 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 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 X 18 3 3 2 3 X 3 3 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 3 2 Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 4(1)(b) Requirement The registered person shall compile in relation to the care hoe a written service statement (in these Regulations referred to as “the statement of purpose”), which shall consist of (b) a statement as to the facilities and services, which are to be provided by the registered person for service users. (This refers to ensuring that the Service Users Guide details all the service provided at Danmor Lodge, including the day care provision.) The registered person shall ensure that the care home is conducted so as (a) to promote and make proper provision for the health and welfare of service users. (This relates to ensuring service users care plans include all their health needs.) Amended to demonstrate this requirement was partially met. The Registered Person must make arrangements for the recording, handling and safe administration of medicines DS0000062426.V316723.R01.S.doc Timescale for action 30/06/07 2. OP8 12 (1)(a) 30/06/07 3. OP9 13 30/06/07 Danmor Lodge Version 5.2 Page 29 4. OP18 13(4)(c) 5. OP26 16(1)(j) 6. OP33 24(1)(a) (b)(2)(1) (3) received in the care home including: a) Keeping a record of all medicines received. b) Having an audit trail that is easy to follow and evidence of regular monitoring to ensure that medicines are given as prescribed. The registered person shall 30/06/07 ensure that-(c) unnecessary risks to the health or safety of service users are identified and as far as possible eliminated. (This relates to ensuring the all risks identified to staff and service users are appropriately assessed and a management plan is developed.) The registered manager must 30/06/07 ensure after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. (This refers to the hand washing and drying facilities within the communal toilets and bathrooms.) (1) The registered person shall 30/06/07 establish and maintain a system for- (a) reviewing at appropriate intervals; and (b) improving, the quality of care provided at the care home, including the quality of nursing where nursing is provided at the care home. (2) The registered person shall supply to the commission a report in any respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service users. (3) The system referred to in paragraph (1) shall provide for consultation with service users DS0000062426.V316723.R01.S.doc Version 5.2 Page 30 Danmor Lodge and their representatives. (This refers to developing a quality assurance system that generates an annual report; a copy of this report then needs to be forwarded to CSCI.) 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. Refer to Standard OP7 OP9 Good Practice Recommendations It is recommended that staff undertaking risk assessments receive formal training. This recommendation is made for the second time. The home should follow guidance from the Royal Pharmaceutical Society including: a) Having clear instructions in the care plan when the dose of medication is adjusted to control symptoms, and records of monitoring of symptoms. b) Monitoring the maximum and minimum temperature of the medicines fridge daily when in use. c) Storing Controlled Drugs (CDs), including Temazepam, in a CD cupboard and keeping a record of the current stock balance. It recommended that the manager keep staffing levels under review to ensure the numbers of staff reflect the fact that the home provides a day service. It is recommend that staff responsible for supervision of staff are trained in this area. It is recommended that the manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3. 4. 5. OP29 OP30 OP32 Danmor Lodge DS0000062426.V316723.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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. 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