Inspection on 20/08/07 for Dapplemere

This inspection was carried out on 20th August 2007.

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

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

Other inspections for this house

Dapplemere 03/01/07

Dapplemere 22/05/06

Dapplemere 26/01/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Dapplemere Shepherd`s Lane Chorleywood Hertfordshire WD3 5HA Lead Inspector Mrs Jan Sheppard Key Unannounced Inspection 20th August 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 Dapplemere DS0000064417.V344566.R02.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. Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dapplemere Address Shepherd`s Lane Chorleywood Hertfordshire WD3 5HA 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) 01923 282119 F/P 01923 282119 matron@dapplemere.co.uk Pressbeau Ltd Manager in post but not yet registered Care Home 22 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (15), Terminally ill over 65 years of places of age (7) Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user can be accommodated in the dementia category. This condition will be removed if the named person leaves the home permanently for any reason. 3rd January 2007 Date of last inspection Brief Description of the Service: Dapplemere is a two storey period house to which a modern single storey extension has been added. The extension provides seven places. All bedrooms are now for single occupancy and some have en-suite facilities. The home has a lift. As the original building is constructed on several levels residents accommodated in this area are required to have a degree of mobility. The home is located in a rural setting a short drive of a junction for the M25 and Chorleywood railway station. The Statement of Purpose and Service Users Guide provide good information about the home for referring social workers and prospective clients. A copy of the most recent CSCI inspection report is available. The current fees range from £ 525 to £650 plus where appropriate the amount of the Registered Nursing Component granted. Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day when one inspector spent seven and a half hours visiting the home speaking with the homes Manager with staff, residents and with some visitors. A tour of the premises was made and an examination and spot-checking of records was undertaken. All the key standards were assessed during this inspection. The one requirement made at the last inspection, concerning the registration of the then Manager was not met as she left Dapplemere shortly after that last inspection. The application for registration by the current manager who commenced her duties on 12th June 2007 is in process. The comments in this report reflect the findings made during that visit and also take account of information sent periodically to the Commission by the Manager along with other information provided by resident’s relatives and stakeholders in the home. On the day of this inspection the home was found to have a well-ordered and homely atmosphere where staff and residents were seen to be interacting positively together. Pre – inspection comments received from residents and relatives spoke very positively about the care delivered at Dapplemere. What the service does well: What has improved since the last inspection? On her arrival at the home some ten weeks ago the new manager identified a range of aspects of the service that she judged needed improvement. These included some refresher training courses for the staff, revised recording procedures to fully evidence the care actually delivered and the purchase of new equipment to ensure the safety and well being of the residents. Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 6 Since the last inspection a number of works of refurbishment have been completed in the home including the installation of a lift, the laying of new carpeting throughout the hall and passageways, works of redecoration and new soft furnishings provided in several of the residents bedrooms along with the provision of hoists special beds and other equipment provided following individual needs assessments by an occupational therapist. Building works are about to commence on an extension to the home to provide four further single bedrooms all with en suite facilities. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dapplemere DS0000064417.V344566.R02.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 Dapplemere DS0000064417.V344566.R02.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. Standard 6 does not apply to this home. People who use this service experience good quality outcomes in this area, this judgement has been made using all available evidence including a visit to the service. The home provides sufficient information about the services it offers to enable prospective residents and their relatives to make an informed choice. A comprehensive assessment is carried out in order to establish the needs of individual residents prior to them moving into the home. EVIDENCE: The Manager makes a visit to the prospective resident in their home or other setting to assess their health and social care needs, to judge their compatibility with the other residents and to assess whether the home could meet these needs. Admissions to the home are not agreed until this has been done and the prospective resident and where appropriate their relatives also have had an Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 9 opportunity to visit the home. If at all possible prospective residents are also invited to spend a day in the home viewing the vacant room and meeting and sharing a meal with the other residents. One recently admitted resident reported to the inspector that their admission to the home had been handled very sensitively and at a pace that they could accept. The paper work pertaining to recent admissions evidenced that the policies and procedures are followed correctly and that all prospective residents have the required information about the home including the Statement of Terms and Conditions and the Service Users Guide. The care needs of new residents are regularly reassessed and a formal review of their placement undertaken after six weeks residency. Dapplemere DS0000064417.V344566.R02.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 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to the service. Good quality care plans are maintained for each resident to enable staff to provide care appropriately as identified. Residents have prompt access to medical services whenever these are needed to meet their needs. Residents are given every opportunity and encouragement to make as many decisions about their own lives, as it is safely possible for them to do. The medication storage and administration system is robust and gives good protection to the residents. EVIDENCE: The health and personal care needs of the residents are met following an assessment of their individual needs and with due reference to them retaining their respect and dignity. The residents care plans are individually focused and provide an up to date record of their needs how these may be changing and Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 11 how they will continue to be appropriately met. Since arriving at the home the new manager has reviewed all the care plans; she has reintroduced a resident key worker system and has established new recording procedures for food and fluid intake recording, weight monitoring, turning records and pressure wound care. Monthly reviews are made of all care plans and where a residents needs may be quickly changing more frequent reviews will be undertaken. A more formal review will be held every six months and residents and where they wish relatives also are encouraged to attend and to sign the plans. The manager explained that the company’s new Operations Manager is assisting her to look at the format and arrangement of the care plans their content detail and how this information could be rearranged so that recent information can be more easily accessible and that all this can be presented in a more person centred format. Little or nothing of the social history of the residents could be seen recorded on the care plans, which the inspector spotchecked. Since the last inspection the home has notified the CSCI of two instances of pressure wounds both these concerning new residents who were admitted to the home from hospital with pre- existing wounds. The records showed the good awareness of the home about this aspect of care and evidenced that the Tissue Viability Nursing service was promptly involved, that the GP made regular visits, nutritional supplements were given and special supportive mattresses and other equipment were supplied. The progress of this treatment was regularly recorded. Aids and equipment are provided for all residents to meet their individually assessed care needs. Since the last inspection a number of new hoists and other mobility equipment have been purchased. The care records evidenced that residents have regular access to doctors the community nursing service, specialist Consultants, chiropodists, opticians dentists and to a hairdressing service. All the residents were observed to be wearing smartly laundered clothing and to have a well looked after appearance. Residents confirmed that their laundry service is prompt and efficient. Personal care was seen during this inspection to be being delivered to the residents in a kind and understanding manner by staff that clearly understood the care needed both physical and emotional. A member of staff was seen to reassuringly intervene with one resident who became somewhat anxious about what they should be doing and this being done in a manner which promoted their independence and feeling of well being. There have been no changes to the medication administration system since the last inspection. A monitored dosage system (MDS) is used supplied by a local pharmacy. Only trained nurses administer the medication. Records of Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 12 medication entering and leaving the home are checked in and out with appropriate records kept. The administration recording records (MAR) were accurately kept with no omissions. The Manager discussed with the Inspector how her regular audits of these records should best be recorded. The home has the appropriate storage facilities and arrangements in place for the administration of controlled drugs. The records relating to controlled medication being administered in the home on the day of this inspection were checked and were accurately maintained. No resident currently selfadministers their medication but protocols are in place for if any individual admitted to the home and assessed as able to self medicate wished to do so. Dapplemere DS0000064417.V344566.R02.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 and 15. People using this service experience an adequate outcome in this area. This judgement has been made using a range of evidence including a visit to the service. The diverse social and activity needs of the residents are now better supported but further improvements could be made in this area to meet resident’s individual requirements and expectations. The residents receive a good dietary outcome ; a healthy diet of freshly prepared good quality food is always available and residents are regularly consulted as to their choices. EVIDENCE: Since her appointment the new manager has reviewed the range of activities that the home offers and found them to be somewhat limited. She has also recognised that the activities are not linked to individual needs interests and preferences. Following the review of each resident’s activity wishes and interests these are now being formally recorded in their care plans. A number of immediate changes have already been introduced but the manager Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 14 recognises that further developments are needed with the activity programme. On the afternoon of this inspection an outside activity organiser visited the home to run an exercise class, which was clearly enjoyed by some residents. Many of the residents at Dapplemere are fortunate in having relatives and friends living nearby who visit often and take them out. During this inspection a constant steam of visitors was seen and those spoken with were all positive about the home and the manner in which care was delivered. Appropriate refreshments were offered and one visitor whose relative is very sick and who is currently visiting daily told the inspector that the kindness and understanding of the staff and the offer of lunch was much appreciated. The home provides good quality freshly cooked food according to a pre set menu. The majority of the residents said that the standard of the food was good that they enjoyed their meals and that there was always sufficient , that it was attractively presented and served at the right temperature. However one or two residents commented that the menu was on some days somewhat limited. Another resident commented that they know the cooks very well and that they often come to talk and consult with them. On the day of this inspection the dessert offered two different dishes made using blackberries that the cook had gathered whilst on a county walk the previous day were much commented on. The cook discussed with the inspector the ways in which she is trying to improve the variety of meals for a resident on a wheat free diet. A birthday tea was being prepared for one resident with the whole home joining in. The serving of lunch was observed in the dining room around a very large dining table this was seen to be a relaxed and social occasion where a glass of wine was being enjoyed by some and where staff individually waited on the residents. However it was noted that not all of the residents were entirely comfortable sitting on the dining chairs with no arms. A number of residents eating on individual tray tables in the small lounge were seen to have their meals delivered already plated and that no social interaction existed between them whilst eating although staff were seen to be appropriately helping them and to have good individual interaction. The quality of the meal times for these residents was discussed with the manager and should be reviewed. The manager said that staff are currently carrying out an audit of all residents food likes and dislikes to ensure that their needs and wishes can be better met. Dapplemere DS0000064417.V344566.R02.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 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Policies and procedures are in place to protect residents from abuse, neglect and self harm. EVIDENCE: A comprehensive complaints policy and procedure is in place and is well publicised in the home and to the residents. There have been no complaints since the last inspection. The home has received a number of complimentary letters from relatives. One resident told the inspector “ I have nothing to complain about but if I had I would speak first with the Manager”. The home follows the Hertfordshire County Council inter- agency safeguarding adult’s procedure (adult protection) a copy of which is kept in the office. Staff spoken with were familiar with issues relating to safeguarding adults and confirmed that they had undertaken training about this. The subject of the protection of vulnerable adults and whistle blowing is covered during the induction of new staff. The Manager said that she plans additional refresher training on this subject for later in the year for all staff. Since the last inspection a disclosure concerning abusive practice made by a newly admitted Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 16 resident concerning her previous residential home was properly and promptly dealt with by Dapplemere. Dapplemere DS0000064417.V344566.R02.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 and 26. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to the service. The service offers a homely physical environment, which is comfortable and subject to regular maintenance and on going works of improvement. A number of areas where further improvements are needed were identified to eliminate any risks and ensure the safety of the residents. EVIDENCE: Dapplemere is a home in two parts; the main home is a two story period house to which a modern single story extension was added approximately twenty years ago. On to this a two-story extension providing four en-suite rooms is about to be built. This will provide twenty-two single rooms many with en-suite facilities. On the day of this inspection the home was clean fresh and odour free. The bedrooms were attractively decorated, well personalised and Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 18 appropriately equipped to meet the individual needs of the residents. However despite the recent installation of a lift several of the bedrooms in the original old building are, because of steps and slopes, are not suitable for residents who have poor mobility or those who need to use equipment to assist their mobility. The home has one assisted bathroom and one shower room. The manager said that the bathroom is to be refurbished as part of the building programme. It currently has a very shabby appearance and the bath needs to be replaced with one of a design which will fully meet the needs of the residents and which can be operated by the staff without risking potential injury to them. Improvements needed to the furnishings in the shower room were discussed with the manager to provide a welcoming and private environment for residents taking a shower. To facilitate the building works the laundry room has already been relocated to a spacious and well-equipped porta-cabin in the garden. All the homes linen is laundered on site and the residents commented favourably on this service. The manager has yet to review the fire precaution arrangements for this building. There are no toilet or washing facilities dedicated for staff use; staff commented critically about this. The kitchen which has an overall tired and worn appearance requires various works of improvement to ensure that health and safety standards are maintained: - There is a hole in the ceiling; there are gaps in areas around some of the recently refitted plugs; The area where a boiler was recently removed has yet to be retiled and the flooring levelled; the fly screens are damaged and do not give adequate protection; the kitchen has no hot air extraction system; the cook said that she manages to keep cool by opening a window but as the kitchen is immediately adjacent to the road this practice could give rise to health risks. A number of radiators around the home were found not to have low surface temperature covers and these could potentially put the residents at risk of accidental scalding. Dapplemere DS0000064417.V344566.R02.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 and 30. People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to the service. Experienced and qualified nurses and care workers who are appropriately trained to meet the needs of the residents staff the home. Staff were confident of their knowledge of the needs of the residents and feel well supported in their work. The recruitment policies and practice ensure that the residents are in safe hands and are protected. EVIDENCE: On the day of this inspection the home was fully staffed; the number of staff on duty matched the planned rota and appeared to be sufficient to meet the needs of the residents. Residents’ comments confirmed that there are always sufficient staff and that they are very kind and helpful. The new manager commented on the stability and long service of many of the staff who had worked at the home for years. She said that agency staff are never used but explained that she intended to recruit more bank staff so as to give more flexibility with rota planning. The rotas evidenced that both the waking staff on duty at night are qualified. Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 20 Staff told the inspector that they had good training opportunities. The home currently employs five registered nurses and fifteen carers several of whom work part time. The number of care workers holding NVQ level 2 qualifications exceeds the 50 minimum required and further staff are currently studying for this qualification. Individual staff training needs are determined following their supervision and are planned to fit in with the objectives as set at their annual appraisal. Since her arrival at Dapplemere the new manager has arranged refresher training on Moving and Handling techniques, fire Awareness procedures and a seminar on after death care was delivered by a firm of local undertakers. The managers training plan for the rest of the year includes courses on Infection Control in September, Prevention of Pressure Sores in October, Continence Care in November, Fire Safety in December and courses on POVA, Stoma Care and Parkinsons Care in the new year. One recently appointed staff member confirmed that she had commenced her induction-training course very promptly and her records evidenced this. A spot check of staff files made during this inspection evidenced that all have had a CRB and POVA check carried out. Two new staff files were examined and these evidenced that their recruitment procedures had been carried out correctly. Dapplemere DS0000064417.V344566.R02.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): 31,33,35 and 38. People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to the service. The home has effective management that ensures that the changing needs of the residents are met and that the home is meeting its aims and objectives. The quality assurance system ensures that the views of the residents and their families underpin all self-monitoring, review and development of the home. Appropriate records for the health and safety of the residents and staff are maintained in the home and staff follow the homes policies and procedures. EVIDENCE: The home is well run in accordance with the principles set out in the Statement of Purpose ensuring that the home is run in the best interests of its residents. Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 22 The new manager is a qualified nurse and has had many years experience of managing residential and nursing services and a specialist dementia care unit in another residential setting. She appears to have settled very quickly into her job at Dapplemere and discussed with the inspector her assessment (after ten weeks) of the needs of the service, what actions to meet these needs she has already taken and the plans for the others. She is shortly to register for a place on the Registered Managers Award Course and has commenced her application to the Commission for registration as manager. During the inspection it was seen that the manager was setting the tone for the home was providing strong leadership to the staff team and was enjoying good relationships with the residents. Her calm and kindly manner was reflected by other staff and positively commented upon by residents and relatives alike. Her open approach to staff management and her encouragement to them to contribute comments and suggestions concerning the running of the home were evidenced in the staff meeting minutes. Staff spoken with during the inspection said that they felt well supported by the manager who was approachable and that she spent time on the floor assisting with the residents. A concern raised by one staff member to the inspector before the inspection had then been discussed directly with the manager and dealt with before this inspection day. The health safety and welfare of the residents are promoted and protected by the good record keeping of the service. Spot checks were made of various records including Fire testing, Accident recording, Risk assessments and Water Temperatures and these were well maintained there by ensuring the health safety and welfare of the service users. Records evidenced that staff are appropriately supervised and that a programme for annual appraisal is in place. The manager confirmed that she is well supported by the company managers from whom she received regular visits. The company carries out regular service audits of the home and Regulation 26 monitoring visits are made and reports of these are maintained. A system for quality assurance in the home, which includes annual surveys of residents and their families, is undertaken. The annual report concerning the company’s findings following this survey is not currently sent to the Commission as required. Through out this inspection the manager demonstrated a good awareness of current good practice national trends and recent developments in the service. She appeared to have a good understanding of equality and diversity issues and a grasp of the complexity and varying strands of these issues. Renovation and extension building works to the home are to commence shortly, this will provide twenty two single bedrooms. The manager discussed Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 23 with the inspector the plan for these works and how any disruption for the residents will be accommodated. She agreed to send a copy of this plan to the Commission for information. To ensure every ones safety it is important that the risk assessments for the building and for the residents are kept up to date during the changes of this building programme. Dapplemere DS0000064417.V344566.R02.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 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 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 3 x 3 x 3 x x 3 Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13(4)(a) & (c) & 23(2)(p) 23(2)(b) Requirement Radiators must be assessed for any risks they present to the people who use the service and action taken to minimise any identified risk. The kitchen must be maintained in good repair so as not to present a health hazard e.g. the hole in the ceiling repaired, gaps around the plug sockets filled, the floor retiled around the boiler, the fly screen replaced and a heat extraction system installed. The activity programmes must fully meet the needs of all the residents to ensure their engagement, inclusion and satisfaction. The bathroom must be maintained in good repair and have the appropriate equipment so as not to present a hazard to residents or staff. Timescale for action 31/10/07 2 OP19 31/12/07 3 OP12 16(2)(m) & (n) 30/11/07 4 OP19 23(2)(b) 31/01/08 Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 26 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 Dapplemere DS0000064417.V344566.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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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