Inspection on 06/09/07 for Danmor Lodge

This inspection was carried out on 6th September 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 05/01/07

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 John Hurley Unannounced Inspection 6th September 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Danmor Lodge DS0000062426.V345755.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.V345755.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.V345755.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 as known to the CSCI within the category DE(E) may be accommodated. One person within the category MD and one person within the category DE(E) may be accommodated. 5th January 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 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. 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.V345755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of Danmor Lodge care home for the inspection year 2007/8. The inspection process followed the Commission for Social Care Inspection Inspecting for Better Lives methodology. The views of the people who use the service and people important to them were sought; where appropriate their comments are included in this report. The inspection lasted 6 hours. The inspector toured the building, spoke with the management and staff on duty and spoke privately with people who use the service on both an individual and group basis. They inspected a sample of the documentation relating to the individuals who reside at the home along with records relating to staff and other documents required by regulation. What the service does well: The feedback received from visitors said that they are always made to feel welcome. Feedback from those who receive the service indicates that staff make many efforts to make them feel comfortable. People who use the service and visitors confirm that visiting times at the home are unrestricted The people who use the service informed the inspector that they liked the food on offer, which they were informed was plentiful and offered choice. Meals are of a good standard and people have a choice about where they would like to eat their meals. They made comments like “the food is very nice”, “it’s good food here, and I appreciate it” and “I especially like the puddings and fish and chips”. People who use the service told the inspector that they are able to choose their own lifestyle within the home and make choices about how they wish to live. They confirmed that their individual preferences and routines are respected, for example, most have breakfast served in their own room by choice. The home employs activities organisers who come into the home to provide activities on a one to one as well as a group basis. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The registered manager and proprietor must ensure that: • substances hazardous to health are correctly stored in order to comply with current regulations and maintain the safety of those who live and work at the home. there is a recorded rationale and practice guidelines for the administration of medication via the per required needs route. all people who use the service have a detailed care plan which is reviewed on a monthly basis. all environmental risks are assessed and the identified action to minimize the risk is recorded and acted upon to minimize the risk of harm to people who use the service and staff. All staff treat the people who use the service with respect and dignity. • • • • It is further recommended that • • The registered manager monitors the temperature in the communal area to ensure that people who live at the home do not get too hot. All the recording in the home’s records is professional and treats all people with respect. 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.V345755.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. In general terms the initial assessments are adequate but lack detail that could put people at risk through inappropriate placements. EVIDENCE: The Registered Manager generally ensures that arrangements are made to carry out an assessment of need, which in the main is completed prior to any prospective individual moving into the home. Through discussion with the people who use the service and visiting relatives, the inspector established that prospective residents and their families are invited to visit the home prior to admission to establish if the home would suit their needs. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 9 The inspector sampled files relating to information about individuals living at the home and their pre admission assessments. One person who the inspector spoke with informed them that they had come into the home for a privately funded respite stay in January and was still waiting to go home. The inspector spoke with staff who confirmed that this individual had been taken in as a permanent resident acknowledging that the person had been told the initial stay was for respite. The assessment of need lacked detail and no written statement had been recorded stating that the home could met this persons needs. A number of the other files sampled did not fully illustrate the needs of those who subsequently took up residency or how these needs should be met. The home does not provide intermediate care. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 10 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. Care records do not provide sufficient detail to ensure that the resident’s health and personal needs are being fully and safely met. The home has systems in place for managing residents’ medicines but some aspects need improving to protect residents. Staff need to do more to be able to evidence that they treat residents with respect and dignity. EVIDENCE: The inspector sampled a number of files of individuals who reside at the home. In general terms the people who use the service care files contained much of the information required by regulation but lack detail. They did not contain evidence of robust monthly reviews and issues that affect the wellbeing of the individual did not appear to influence the care plans. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 11 A previous requirement to make proper provision for the health and welfare of the people who reside at the home remains unmet. One individual’s file was sampled as the accident book had indicated 9 falls in one month. The file did not contain a full assessment of these falls but action had been taken to address the issue. It appeared that most falls centred on the individual trying to mobilise out of bed. The action that was taken was to provide a mattress on the floor or to use cot sides. There was no evidence that other health care professionals had been involved in the decision to take these measures and there was little recorded to demonstrate that these measures had been adequately risk assessed. The file did not indicate how this person’s need was being met previously or up to the present day. There had been no monthly reviews of the care provided although the home had referred to a specialist for their opinion. The result of that assessment was the individual was inappropriately placed and required specialist help. The home could not evidence that action had been taken following this assessment to seek an alternative home and as a consequence the needs of this individual continued to be unmet. Another individual who had recently taken up residence was in a second floor room although the stated needs informed the inspector that the individual does not manage the stairs. The home has a condition on its registration that states that; “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”. The staff on duty confirmed that one individual would need assistance in the event of a fire. The file did not contain any risk assessment with regards to how this person would be evacuated from the building. Taking these points into account it would appear that there is a breach in the current conditions of registration. In a care plan it was recorded that a community psychiatric nurse (CPN) came in to carry out an assessment some months ago and prescribed medication. There was no recording relating to the outcome of this assessment or subsequent review as the care plan would have altered with the intervention and diagnoses by the CPN. The medication records were also sampled and a discussion held between the inspector and member of staff designated with the responsibility of medication practices within the care home. At the last inspection it was required that the registered manager ensure that a full audit trail is available and that a record of all medications held on the premises be kept. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 12 The inspector looked at the arrangements that had been made to address these issues. The inspector found some of the arrangements confusing and so tested out the systems in place that provided the audit trail. The simple test of counting the tablets held and looking at what was recorded as on the premises revealed that the arrangements are not robust as the record stated there should be 102 tablets of one preparation but the actual amount was 92. The inspector did note that all the medication sampled as being on the premises was recorded as such. The people who the inspector spoke with informed the inspector that they considered that the people who cared for them treated them with respect and dignity. They cited that staff knock on their doors before entering, their post is delivered unopened and that when they required personal assistance it was done in a discrete and respectful manner. These representations were made by the more able of the resident group. The inspector sat in the small lounge and talked with one individual before dinner. They heard staff comment to people who use the service to “go on down to the toilet and I will help change you in a minute” and “ come along now time for the toilet”. These comments undermine the dignity of those who use the service and so dispel some of the earlier representations made by other individuals who use the service. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pace of life appears to suit the individuals expectations and aspirations. The flexibility of the home enables people to maintain contact with their family and friends. The food is home cooked and appears to offer a balanced diet to the people who use the service. EVIDENCE: The inspector joined a small group of individuals for lunch and discussed the pace of life at the home. They confirmed that they could spend their time as they want to and that they are given choices. There are planned activities, which provide extra stimulation to the people who use the service. They are provided on a group or individual basis. These range from singing and bingo, gentle exercise, ball type games and outings. Several people told the inspector that they knew Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 14 what activities were taking place, some they liked others they did not. Given that the home provides two communal areas, those who choose not to participate do not have to. People’s records and the visitor’s book in the entrance hall demonstrate contact with family and friends as well as visits by professionals. Several people are able to go out of the home alone and others with their families and friends. The staff informed the inspector that individuals are encouraged to retain contact with the wider community as much as possible. The inspector toured the building and noted that many of the service users’ rooms were personalised with their own possessions. Those people requiring support during meal times were assisted in a dignified manner. Some people choose to have some of their meals in their own rooms, staff work hard to ensure that their wishes are met. The food that was served was of good quality and more was offered to those who wished for extra. The people who use the service confirmed that this was always the case. They further confirmed that the food is good, home cooked and plentiful. They informed the inspector that they are offered a choice and that staff knew what they liked and would make alternatives if the planned menu did not suit them. The dining room was pleasant with the tables attractively laid. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that is available to residents and staff. Residents are protected from the risk of harm. EVIDENCE: A clear complaints policy and procedure is in place and is displayed for residents and visitors. The people who use the service whom the inspector spoke with informed them that they felt able to complain and said they would have no concerns complaining to any staff member should they have need to. They felt that the staff are very approachable and will deal with any issues, no matter how minor, there and then if they could. The home keeps a record of any complaints made. There have been no issues recorded at the home, similarly there have been no complaints made directly to the regulator. Through conversation it was evident that the manager had a clear understanding of the local vulnerable adults procedure and how to implement the procedure in the event of receiving an allegation of abuse. The manager reported that the staff had received training in “Adult Protection”. The staff the Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 16 inspector spoke with were clear with regards to their duties and responsibilities. The complaints procedure was displayed and issued to new residents. The manager confirmed that a Protection of Vulnerable Adults check is performed prior to new employees starting work. The staff files confirmed this. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a good standard. There are sufficient communal areas and bathroom facilities to meet the needs of those who use the service. Individual rooms are personalised to reflect individual tastes. Staff need to be reminded of the need to ensure that soap and towels are not left in communal toilets which in turn may undermine infection control practices. EVIDENCE: The inspector toured the premises unaccompanied when they first entered the home inspecting a number of communal areas. They found that the home was Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 18 generally clean in all areas observed. It was noted that all toilet and bathrooms were found to be clean and hygienic, although it was noted that some areas were cleaner than others. The service user accommodation is provided over three floors. There is a passenger lift, assisted bathroom and call system available to people who use the service. They commented that call bells are answered promptly. People who live at the home are able to bring personal possessions with them. The rooms that were observed had been personalised with pictures, furniture and photographs. It was noted that not all wardrobes were fixed to the walls and no risk assessment was available to demonstrate that this was safe. It would be helpful if either of the aforementioned actions were taken to address this matter. There a two communal lounges and one dining room. One of the communal areas has a large glazed area in the ceiling and could be described as a conservatory. At the time of the inspection this area did not have any shading and was very hot. The doors to the outside area, which have a lock on, were open leading into the side garden which in turn leads on to the road through a set of gates approximately 3 meters away from the door. The communal areas are domestic in nature providing comfortable seating and dining facilities. The corridors are well illuminated with a number of prints on the walls. Whilst the home provides liquid soap and paper towels the inspector noted that in some communal bathrooms and toilets bars of soap and hand towels had been left in these areas. The registered manager informed the inspector that they had been left in there following a resident’s bath earlier. As bars of soap and towels may undermine infection practices in these areas more needs to be done to ensure a robust approach is taken. The cupboard, which contains cleaning products, was found to be open when the inspector toured the building. It was noted that a number of substances had been decanted into other containers which were not labelled contrary to the Control of Substances Hazardous to Health (COSHH) regulations. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team are knowledgeable with regards to the people who use the service needs. There are sufficient staff on the rota to meet the current needs of the people who live there. The employment procedures protect the people who use the service. EVIDENCE: People who use the service talked with as part of the inspection indicated that they felt their needs were met by the amount of staff on duty. The inspector talked with the staff on duty who were knowledgeable with regards to how to meet the assessed needs of the resident group. The people who use the service confirmed that the staff meet their individual needs in a way that suits them. They further commented that if they use the call system a member of staff will attend to them without too much delay. One person indicated that it can be busy in the mornings. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 20 The staff turnover continues to be low and staff provide good continuity of care. The manager ensures that opportunities to take up training are available. All staff spoken with had NVQ qualifications. The staff files that were sampled contained sufficient detail with which to establish the prospective employees suitability for the job; all requirements as set out in the National Minimum Standards are complied with. The inspector spoke with a member of staff who further confirmed that they had completed an application form, undertook a formal interview and had received an induction into the care home. Statutory training is well documented. The registered manager confirmed that all staff have received statutory training as and when required. The review of one resident’s file (as discussed in section 2 Health and Personal Care) 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. This needs to be addressed. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There needs to be development in the care management and review process to ensure that people’s needs are met at all times The staff group are formally supervised and their work appraised ensuring a consistent approach to meeting the needs of the people who use the service. The practices at the home do not consistently promote the dignity of the people who use the service. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 22 EVIDENCE: In general terms the residents said they felt confident about being cared for by a management team that they have known for a long time and liked the consistency. The management continue to have an understanding of the National Minimum Standards required and how they should be met, but more attention should be paid to their responsibilities with regards to ensuring all care plans are robust and fully illustrate people’s needs. They also need to ensure that where needs are unmet action is taken to address these shortfalls. Although action has been taken to address the requirements set at the last inspection a number of them have yet to be fully complied with. As with some of the care practices reported in section 2 Health and Personal Care some of the recording in the day to day staff handover diary was found to describe events in an unacceptable manner and in one case could be seen as harassment of another worker. This was pointed out to the registered manager who agreed to look at this issue. It would be helpful if the manager made arrangements to ensure that all recording in the home is closely monitored to ensure staff understand and record in a professional manner. The inspector spoke with the manager and designated person responsible for carrying out care needs assessments at some length over the course of the inspection. In the main the records relating to care plans are acceptable for those whose needs are less complex. However some issues identified the need for staff to be further trained in relation to carrying out full and comprehensive assessments and care plan generation to ensure that prospective residents enter a home that can meet their needs. This issue relates to the management and forward planning of the home. The feedback from the people who use the service confirmed that they felt a sense of belonging living at the home and gave examples of how staff do that little bit extra to help out. They informed the inspector that they can raise issues with the management, and can identify who the manager is. The staff the inspector spoke with confirmed that they have supervision on a regular basis. The records available further evidenced this. The inspector sampled a selection of health and safety records. The review of fire records showed regular tests of the fire equipment takes place and staff records demonstrated that staff have received fire training. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 23 As discussed throughout this report a number of Heath and Safety issues need to be improved upon in relation to COSHH and infection control Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 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 3 3 X 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X X X X 2 Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12 (1)(a) Requirement 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 and are reviewed monthly or sooner if significant events happen first.) Although some improvements have been made the previous timescale to have fully met this requirement (30/06/07) has passed. The Registered Person must make arrangements for the recording, handling and safe administration of medicines received in the care home including: Having an audit trail that is easy to follow and evidence of regular monitoring to ensure that medicines are given as prescribed. Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 26 Timescale for action 01/11/07 2 OP9 13 01/11/07 Although some improvements have been made the previous timescale to have fully met this requirement (30/06/07) has passed. 3 OP10 12(4)(a) The registered manager must ensure that all who use the service are treated with dignity and respect The registered person shall ensure that- 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 previous timescale to have met this requirement was 30/06/07 The responsible manager must establish and maintain a COSHH register and ensure that all substances identified on the register are kept in line with the COSHH legislation. 10/10/07 4 OP18 13(4)(c) 01/11/07 5 OP38 13(4)(C) 01/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Danmor Lodge DS0000062426.V345755.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!