Inspection on 06/11/07 for Derwent Residential Care Home

This inspection was carried out on 6th November 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 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

Derwent Residential Care Home 17/10/08

Derwent Residential Care Home 22/11/06

Derwent Residential Care Home 09/12/05

Derwent Residential Care Home 01/04/05

Derwent Residential Care Home 31/01/05

Derwent Residential Care Home 17/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Derwent Residential Care Home 38 Sedlescombe Road South St Leonards-on-sea East Sussex TN38 0TB Lead Inspector Caroline Johnson Key Unannounced Inspection 6th November 2007 09:30a 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 Derwent Residential Care Home DS0000041049.V346905.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. Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derwent Residential Care Home Address 38 Sedlescombe Road South St Leonards-on-sea East Sussex TN38 0TB 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) 01424 436044 01424 715409 derwent@cedarscaregroup.co.uk The Derwent Residential Care Ltd Denise King Care Home 34 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) 2. Dementia (DE) The maximum number of service users to be accommodated is 34. Date of last inspection 22nd November 2006 Brief Description of the Service: The Derwent Residential Care Home is a large detached house situated on the outskirts of St Leonards On Sea. It is registered to accommodate thirty-four older people. There is good access to St Leonards where there are a range of shops and services. All bedrooms have en-suite facilities. Communal space includes a dining room, large lounge area and a fully accessible well maintained garden to the rear of the property. The range of fees is £322-£382 per week as of 22/11/06. Additional charges are made for chiropody, hairdressing and other individual requirements. Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection process a site visit was carried out on 6 November 2007and the visit lasted from 09.30am until 5.10pm. During the inspection there was an opportunity to meet with the manager, deputy manager, cook and a member of care staff. In addition time was spent meeting with eight residents in private and with one visiting relative. A wide range of documentation was examined including a pre admission assessment for a recently admitted resident and two care plans. Records held in relation to quality assurance, staff recruitment, training, menus, fire records and health and safety were all examined. In addition a full tour of the building was carried out. In advance of the inspection the manager completed an AQAA (annual quality assurance assessment) and information from that document has also been included in this report. Since the last inspection of the home an extension has been built to the property comprising ten bedrooms, which are all ensuite, and an assisted bath/shower room. The lounge area has also been increased in size. In addition a new laundry and an office have been created. The garden area has also been improved and is now easily accessible to all residents regardless of disabilities. The category of residents that can be accommodated changed when the new extension was opened so the home can now admit residents with a dementia type illness. The change was mainly made so that the home could continue to care for some of the current residents that were experiencing some of the early signs of dementia. Prior to the inspection a range of survey and comment cards were sent to the home for distribution to residents, relatives and visiting professionals. Nine surveys were returned, one from a visiting professional, two from residents and the remainder were completed by relatives on behalf of residents. Overall comments received were very positive including, ‘haven’t seen any problems that need working on. All staff at the Derwent are very helpful and friendly’. ‘Tracy is a very good cook and food is varied. On the negative side, comments included ‘Often 1 or 2 activities a week. Residents could benefit from more stimulation’, ‘Regular requests but home have yet to install a line to have a new phone in the new extension. Staff try hard and are kind and helpful’, ‘the new extension with a different classification is a real challenge for them’. What the service does well: Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 6 The home is generally well maintained and decorated to a good standard. At least half of the staff team are trained to NVQ (National Vocational Qualification) level two or above. The home is continuing to develop their day activities and to ensure that residents are offered an activity on a daily basis. Staff spoken with stated that they feel well supported by the manager. All of the surveys returned referred to the food as being very good and residents spoken with during the inspection also stated the same. One resident stated that this is the home’s strongest point. What has improved since the last inspection? What they could do better: Eight requirements were made as a result of this inspection. Arrangements must be made for staff to receive training on a variety of topics to update their knowledge and skills. The frequency of supervision provided to staff must increase in line with the minimum standards. The home needs to continue with their plans to develop their quality assurance system. The proprietor must resume the practice of carrying out monthly reports on the running of the home. In relation to the building, the driveway must be more easily accessible, the carpet in the corridor on the ground floor of the main building must be replaced and the home must be adequately heated without the need for additional portable heaters. Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that they carry out a detailed assessment of needs prior to making a decision about whether they can accommodate a prospective resident. EVIDENCE: Pre assessment documentation was seen in relation to one resident who was recently admitted to the home. The manager had carried out an assessment whilst the resident was in hospital and the resident’s relatives had visited the home in advance of the move. There was detailed information in the assessment to provide guidance to staff on how the resident’s needs were to be met. Details of social history and preferred activities had yet to be assessed. Time was spent speaking with the resident about their move into Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 10 the home and they were very pleased with the process and with the care that is provided for them. They stated that they really liked their bedroom, ‘having family photos makes it feel more homely and the food is very good and staff very caring’. A relative spoken with stated that they visited a number of homes in the area and chose Derwent because it was clean and homely and had a good atmosphere. Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can feel confident that their care plans will include up to date information about their needs. However, with regard to one resident a risk assessment must be drawn up in relation to the management of diabetes. EVIDENCE: Two care plans were examined in detail. It was evident that they are reviewed and updated at regular intervals, although more recently in one of the care plans some of the monthly reviews had not been carried out. Advice to care staff was clear in most areas. A section is used to record each service user’s view of their care needs and another to record the staff view of the individual’s care needs. In one care plan where a resident has blood sugar readings taken there were records showing that regular readings were taken but the action to be taken by staff if the reading is too high or too low was not specified. Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 12 The manager advised that the company have set up a meeting to be held in January to discuss the issue of care planning in an attempt to make the format more user friendly. Staff observed in the course of their duties were courteous and residents all stated that the care they receive is very good. Records showed that residents attend a wide range of healthcare appointments as necessary to meet their individual needs. Residents’ weights are recorded on a monthly basis. If specialist advice or support is required to meet an individuals needs then arrangements are made for this to happen. A chiropodist visits the home every six weeks. One of the district nurses who periodically visits the home completed a comment card as part of the inspection process and comments included ‘I always enjoy visiting Derwent Residential Home because the staff always greet me and remember to do what is asked of them and are totally organised’. Medication is stored in two areas within the home. Storage on the ground floor was examined during this inspection and it was in order. Records seen detailing medication administered to residents were clear. A record is kept of all medication returned to the pharmacist and the record is signed and stamped by the pharmacist. Arrangements are to be made to ensure that all staff that need to, have received up to date training on medication. A local policy on the management of medicines has been introduced. Derwent Residential Care Home DS0000041049.V346905.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is working hard to develop their activity programme and to ensure that everyone is offered opportunities to participate in interesting and stimulating activities. EVIDENCE: A music and movement session was held on the morning of the inspection. This is a weekly session and a number of the residents spoken with stated that they enjoy this activity. Four of the residents were taken to the theatre the week prior to the inspection. A weekly bingo session is also held and there are plans to introduce a craft session. There are a number of board games and residents are encouraged to take part in these games. The selection of books available in the lounge has been updated and in addition to this there is also a mobile library that visits the home periodically. Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 14 One resident goes out independently to attend a number of clubs. A Communion service is held in the home once a month. A hairdresser visits weekly, and once a month there is a manicure service provided. A musician comes to the home every six weeks to provide entertainment. Residents’ individual likes and dislikes are recorded on their individual care plans. The manager advised that they have booked two adult choirs and two children’s choirs to provide entertainment during the festive season and the home is also hoping to arrange to take two groups of residents to the local pantomime. It was reported that as resident numbers increase, the intention is to appoint an activity co-ordinator to organise activities for the residents. To mark the opening of the new extension and garden, a garden party was held in September and residents and relatives were invited to attend. There were various stalls and a barbeque was also provided. Residents spoken with advised that it was a thoroughly enjoyable day and lots of photos were taken of the event. There is a four-week menu in place, which is varied and well balanced. The cook goes around the home on a daily basis and speaks with each resident to check if they are happy with the menu for the day. An alternative to the menu is always provided. Evening meals consist of a hot meal, sandwiches and/or soup. Specialist diets are catered for and at the time of inspection there were four residents on diabetic diets. A kitchen assistant also works with the cook and there are two shifts from 8am until 2pm and from 5pm until 7pm. Catering staff are trained in basic food hygiene. Residents spoken with during the inspection stated that the food is very good and surveys received prior to the inspection stated the same, one comment included ‘Tracy is a very good cook and food is varied. If I ask for anything she will always get it for us’. One resident stated that when they moved into the home they always accepted what was on the menu and didn’t want to trouble anyone by asking for an alternative but they have now realised that they can ask for an alternative and it is not too much trouble. Derwent Residential Care Home DS0000041049.V346905.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The procedures in place enable anyone wishing to make a complaint to do so. EVIDENCE: There is a detailed complaints procedure in place for staff and residents. Records showed that two complaints have been made since the last inspection of the home. The details of the complaints and the actions taken are clearly recorded. The outcome for one of the complaints could be recorded more clearly but it was acknowledged that the complainant had backed down and confirmed that they no longer wished to complain. The Commission has not received any complaints about this service. There is a suggestion/comments box that residents can use to raise any concerns or to highlight changes that they would like to see in the home. The manager and deputy manager attended the first part of a two-part course that would have enabled them to become trainers on the subject of adult protection and prevention of abuse. Unfortunately the second part of the course has not been held and it is now some time since the original course. The manager advised that they are now making arrangements for all staff to Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 16 receive training on the subject in the New Year. The subject is discussed with all new staff as part of their induction to the home and four staff received training on the subject of abuse in 2005. Derwent Residential Care Home DS0000041049.V346905.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is decorated to a good standard. The new assisted bath/shower room is a very good asset and will be of benefit to the residents accommodated. Plans to address the heating arrangements for the main house must be put in place and the carpet in the corridor on the ground floor must be replaced. EVIDENCE: Since the last inspection a new wing has been added to the property comprising ten bedrooms, which are all ensuite, and an assisted bath/shower room. The lounge area has been increased in size and seating is now arranged in small groups so that it is easier for residents to communicate with each Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 18 other. In addition a new laundry and an office have been created. The manager advised that the residents enjoyed watching the extension being built and one resident took photos of the extension at various stages of development. The garden area has also been improved and is now easily accessible to all residents regardless of disabilities. There is a choice of seating areas within the garden. Residents spoken with stated that they are looking forward to spending more time in the garden next summer. One relative advised that they have been waiting a long time to have a phone fitted to their relative’s bedroom in the new extension. The manager confirmed that there have been problems trying to resolve that matter but that these have now been resolved and it is hoped that the matter can be addressed speedily. As a result of the building works the front driveway has become uneven in places and the manager advised that the next priority is to reset the driveway. A hoist has been purchased for ground floor use only and it is currently used for one resident only. A maintenance person has been employed to work between the two homes owned by the proprietor in the area. Bedrooms in the main building are redecorated as and when they become vacant and all bedrooms seen were well maintained and were homely. Residents are encouraged to bring small items of furniture and photos/ornaments with them on admission so rooms reflect the individual tastes of the residents. On the ground floor in the main building the carpet in the corridor is worn and rucked in places. There are storage heaters in many rooms in the main part of the building. Additional portable heaters are provided to supplement the heating. Plans to upgrade the heating have been in place for a few years now and it is not clear when this is to happen. With the exception of one bedroom where there was a strong odour, all areas of the home seen were clean and free from odours. The manager advised that they are working hard to eliminate the odours from this one bedroom and will continue to do so. It was confirmed that in order to comply with the smoking laws they will be arranging to have a shelter built in the garden area to cater for any resident that smokes. Derwent Residential Care Home DS0000041049.V346905.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Emphasis on staff training and development needs to recommence to ensure that the staff team remain equipped to meet the needs of the residents. EVIDENCE: At the time of inspection there were twenty-one residents. Staffing levels consist of the manager plus three care staff in the morning until four pm and two carers in the evenings. The cook works nine to five and there is a kitchen assistant from five until seven. A review of staffing levels has recently been carried out and it has been agreed that the five to seven shift will be increased to four to nine or ten and the staff member will work in the kitchen between five and seven and as a carer for the remainder of the hours. As resident numbers increase the staffing levels will be kept under review. There are two carers to work a waking night duty. At the time of the inspection staff vacancies included a senior carer position, a full time housekeeper position and three waking nights a week shift. The manager advised that these positions have been advertised. Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 20 The category of residents that can be accommodated changed when the new extension was opened so the home can now admit residents with a dementia type illness. The change was mainly made so that the home could continue to care for some of the current residents that were showing some of the early signs of dementia. Eight of the staff team received training on the subject of dementia in 2007. Documentation held in relation to two staff appointed since the last inspection was seen. In both cases there was a detailed application form and two references had been obtained. The home keeps a record that they have checked identification but the copy of the identification is not always held on file. A criminal records bureau check is obtained. In relation to one staff member they had brought their old CRB that had been obtained in the past few months and the home had made arrangements to apply for a new CRB. However a pova first had not been obtained. The administrator made arrangements to deal with this on the day of inspection. Although records show that staff have attended some training in the past year there are still gaps in many areas. Nine staff received training on health and safety during 2007. The manager advised that the priorities for the New Year are in areas such as adult protection and prevention of abuse, moving and handling, first aid, infection control and fire safety. Records showed that five care staff have completed NVQ level two and one of these staff has also completed level three. A staff member spoken with stated that she has almost completed NVQ level two and is hoping to continue on to study for level three. The home’s induction package for new staff now complies with Skills for Care guidance. Derwent Residential Care Home DS0000041049.V346905.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to continue with their plans to develop their quality assurance system and to find a way of encouraging residents and relatives to be part of this process. Staff must receive regular supervision. The proprietor must formally document his visits to the service and the outcome. EVIDENCE: The manager has completed NVQ Level 4 and has several years experience in managing care homes. A staff member spoken with stated that she was very well supported and in particular she valued the support given to her in studying for her NVQ. Another staff member stated that she is supported in Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 22 her role by the manager, who she described as ‘very good’. Formal supervision sessions have not been held as regularly as on previous inspections but the manager advised that as the building works have now been completed this would free up more of her time to concentrate on management tasks. A staff member stated that although she has not had a formal supervision recently she felt confident that if she had a problem she could go to the manager and equally she felt that if the manager had a problem with her work this would have been dealt with. In relation to quality assurance the home are about to expand the current system to introduce auditing of current practices in an attempt to maintain and improve the quality of the care provided in the home. Audits will be carried out in relation to care planning, staff induction monitoring, catering, cleaning, health and safety and medication. The paperwork is now in place and the manager advised that the first audits would be carried out this month and monthly thereafter. They have recently sent out resident satisfaction questionnaires but to date they have only had a couple of replies. As a result of this they are hoping to revamp the questionnaire to seek the views of the residents on the quality of the care provided in the home. Another idea with the consent of individual residents is to introduce family consultation meetings. In addition to speaking with a relative during the inspection attempts were made to contact another two relatives following the inspection however this proved unsuccessful. Prior to the inspection a range of survey forms were sent to the home for distribution to residents, relatives and visiting professionals. Nine surveys were returned, one from a visiting professional, two from residents and the remainder were completed by relatives on behalf of residents. Overall comments received were very positive including, ‘haven’t seen any problems that need working on. All staff at the Derwent are very helpful and friendly’. ‘Tracy is a very good cook and food is varied. If I ask for anything she will always get it for us’, ‘Staff are friendly and helpful. Assess needs and changed care accordingly’, ‘family have always noticed how clean the rooms are when they visit. Mum been at the home for two years and we have been pleased with the care she has received. We feel she is as happy as she could be in her circumstances’. On the negative side comments included ‘Often one or two activities a week. Residents could benefit from more stimulation’, ‘Regular requests but home have yet to install a line to have a new phone in the new extension. Staff try hard and are kind and helpful’, ‘the new extension with a different classification is a real challenge for them’. It was reported that the proprietor visits the home on a regular basis to monitor how it is running. However, there are no reports of these visits kept in the home and the manager confirmed that she has not signed any reports. Within the past year the owner purchased another care home in the area and Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 23 has appointed an operations manager to provide support to both homes. Management meetings are now held on a regular basis. There is now an electrical certificate in place and a record is kept that all call points are monitored on a regular basis to ensure they are in working order. All portable appliances have been tested since the last inspection. A fire risk assessment has been carried out and as a result six door guards have been fitted. Another two door guards have yet to be fitted. More signage has also to be fitted and a fire extinguisher has to be put on a bracket. The manager advised that these tasks have been given to the maintenance staff for attention. Records showed that a Legionella assessment was carried out in June 2006 and the manager confirmed that an assessment has also been carried out this year. Derwent Residential Care Home DS0000041049.V346905.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 X 2 Derwent Residential Care Home DS0000041049.V346905.R01.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 OP7 Regulation 13(4c) Requirement In relation to one resident’s care plan a risk assessment must be drawn up detailing the action to be taken if the resident’s blood sugar reading is too high or too low. All staff must receive training on adult protection and prevention of abuse. In relation to the building: The driveway must be easily accessible to residents and visitors. Plans must be put in place to ensure that all parts of the building be adequately heated without the need for additional portable heaters. Carpets in the corridor of the main building ground floor must be replaced. Arrangements must be made for staff who have not yet received training to receive training in he following subjects Timescale for action 30/12/07 2. 3. OP18 OP19 13(6) 23(2b) 15/01/08 31/01/08 4. OP30 18(1ci) 29/02/08 Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 26 5. 6. OP33 OP33 24(1,2) 26(2,3,4) 7. 8. OP36 OP38 18(2) 23(4) First aid Moving and handling Food hygiene Medication The home must implement their new quality assurance system. The proprietor or a representative on his behalf must visit the home unannounced on a monthly basis and carry out a report on the conduct to the home. The report must be available for inspection. All staff must receive formal supervision on a regular basis. There must be an action plan in place detailing the work to be undertaken to address the recommendations of the recent fire risk assessment. 31/12/07 31/12/07 31/12/07 15/01/08 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 Derwent Residential Care Home DS0000041049.V346905.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Derwent Residential Care Home DS0000041049.V346905.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!