CARE HOME ADULTS 18-65
Development Centre Dorincourt Dorincourt Oaklawn Road Leatherhead Surrey KT22 0BT Lead Inspector
Lisa Johnson Unannounced Inspection 15th May 2006 08:50 Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 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 Development Centre Dorincourt DS0000013626.V295582.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 Adults 18-65. 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. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Development Centre Dorincourt Address Dorincourt Oaklawn Road Leatherhead Surrey KT22 0BT 01372 841334 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) dominic.lodge@developmentcentre.org Queen Elizabeth`s Foundation To be confirmed Care Home 57 Category(ies) of Physical disability (57), Physical disability over registration, with number 65 years of age (1) of places Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 19-55 YEARS, up to one Service User may be aged OVER 65 YEARS 10th May 2005 Date of last inspection Brief Description of the Service: The Development Centre is a purpose built residential care home set the countryside in the outskirts of Leatherhead Surrey. The home offers accommodation to 57 people with physical disabilities, in the category of younger adult. The service has recently undergone a process of redevelopment of some of the buildings. The centre is continuing with its plans for redevelopment both physically and philosophically. Development Centre Dorincourt DS0000013626.V295582.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 key inspection carried out in 2006/2007. Mrs. L Johnson Regulation Inspector carried out the unannounced inspection, which took place over ten hours. Mr. S. Fleming the residential services manager represented the establishment. Since the previous inspection a number of management changes and arrangements have taken place. The residential services manager has submitted an application to the Commission for Social Care Inspection to be registered. For purpose of clarity the report will refer to the manager. A full tour of the premises was undertaken and care plans, staff files and policies and procedures were sampled. The inspector spoke to seven residents, six members of staff and the centres principle. Ten comment cards have been received from residents and one comment card was received from a relative. These comments are reflected in the report. The inspectors would like to thank the residents and staff for their hospitality and cooperation during this inspection. What the service does well:
There was an open, happy, relaxed and friendly atmosphere in the home. Good relationships were observed between staff and residents and it was pleasing to see staff and residents having their meals together. Staff had a good knowledge of the needs of residents. The home has made progress in ensuring that residents are involved in decision-making in the home and that they are supported to be as independent as possible. One individual said, “ I am going to be assisting in staff interviews, this is my home”. The service holds empowerment groups and one individual said, “Things are improving, I know what’s going on and I feel more empowered”. Another person told the inspector that he is going to be participating in the monthly quality visits. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 6 All written comment cards received confirm that residents know whom they can speak to if they are unhappy with their care. The home offers a range of recreational and educational activities both internally and externally and the inspector spoke to one individual who said,” I like drama best”. Some residents access local college and participate in work experience. What has improved since the last inspection? What they could do better:
Copies of contracts detailing the terms and conditions of the home must be maintained on individuals files. Further work is required in respect of care plans. The care planning system has been changed and individual plans are in the process of being fully completed. Some gaps were present where residents have not signed confirming their agreement to their plan. Plans sampled indicate that they are reviewed annually, but they should be reviewed more regularly to ensure they reflect any changing needs. The medication administration systems were examined and it was clear that a number of residents self medicate with no risk assessments having been completed. The homely remedies list must be updated and be agreed by the GP. The medication policy must be signed by all staff who administer medication and it is strongly recommended that where medication is
Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 7 handwritten on to the medicine card this should be checked and signed by two staff. During discussion with the manager it was discussed that some staff do not feel comfortable about administering one type of as required medication, which is prescribed for the treatment of repeated seizures. It is strongly recommended that this issue be discussed with the GP to look at alternatives to ensure that the needs of residents are met. The inspector spoke to three residents who said that there is lack of drivers on at weekends, which restricts the activities they can do. From comment cards received seven individuals confirm that the home sometimes provides suitable activities. The manager informed the inspector that this issue is being pursued. It was noted that this matter has not been met since the previous inspection. A further requirement was made this matter is addressed to ensure that residents are not restricted from attending activities they have preference for. The local safeguarding policy should be signed by staff to ensure that staff are aware of the procedures to safeguard residents from abuse. There is still some major outstanding refurbishment work, which has not been completed in Meadway and JAC units, and this requirement remains unmet. The bathrooms and toilets are in poor condition and there was an opening between two toilets that does not maintain privacy and dignity for residents. A broken light fitting was found in one sitting room. The corridors, kitchen and sitting room must be refurbished. The principle informed the inspector that she is meeting with surveyor in June. It was required that a refurbishment programme is submitted to the Commission for Social Care Inspection outlying the details for completion of this work to ensure that residents have a homely, comfortable and safe home to live in. During discussions with staff some concerns were expressed about the staffing levels and in particular the senior care staff cover. A comment card received from a relative indicates that there are not always sufficient numbers of staff on duty. The inspector sampled the rota, which indicated that on most days there are twelve staff on duty. However the rota did not clearly indicate who was in charge on each shift and their grades. A requirement was made that the staff numbers should be reviewed based on the guidance by the department of health to ensure that the appropriate numbers of staff supports resident’s needs. Comments were also raised from residents living in Woodfield flats that although they like to maintain their independence they would like to see staff a little more often for support and there have been occasional delays in response time to call bells. Therefore It is strongly recommended that the response time to call bells be monitored. The inspector was unable to access the staff personal files to examine the recruitment procedures. A requirement was made that arrangements must be in place for a key to be made available to ensure records are accessible to inspectors and that residents are protected by the homes recruitment policies and procedures. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 8 Two health and safety matters were identified, including wheelchairs being stored in the corridors in Meadway and records were not available to confirm that staff had received up-to-date training in fire prevention. Two requirements were made to ensure that these matters are actioned to ensure the health, welfare and safety of residents. 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. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. Individuals written contract/statement terms and conditions with the home were in place but were not available in resident’s files. EVIDENCE: An admission policy is in place and detailed pre-admission assessments are carried out before residents are admitted to the service and were sampled. Contracts were in place. However a requirement was made that these should be made available with individual’s files. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Further work is required to ensure that individual’s plans are completed. Residents are supported to make decisions about their lives. Residents are provided with opportunities to participate in the development of the home and its services. Further work is required to ensure that risk assessments are completed to ensure that residents are supported to be as independent as possible. EVIDENCE: Individual plans are in place and a new system has been implemented. The care planning system has changed and plans are in the process of being fully completed. One individual said that staff discuss his needs with him. However there were some gaps where residents have not signed confirming their agreement to their plan and risk assessments. A requirement was made that this is completed to ensure that residents are fully involved in the setting up of their plan. Plans sampled indicate that they are reviewed annually, but this should take place more frequently to ensure that they reflect any changing needs. Daily records were maintained with some maintained in the office and residents also keep some and clarification was needed in respect of this. One
Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 12 individual showed the inspector her daily notes and said that they had not been completed recently. During discussion with the manager it was discussed that the work undertaken by the life coaches with individuals should be included in the care plan. The home has made progress in supporting the resident’s decision making with the introduction of empowerment groups and regular forums. Some individual care plans sampled listed the likes and dislikes of individuals. Residents are supported to be as independent as possible and it was evident that equipment has been acquired for individuals for example, computers to assist communication and specialist aids. The inspector spoke to one individual who said,” I am going to be involved with interviewing new staff, its my home” and another person confirmed he is going to be participating in the monthly quality visit. Risk plans were completed covering a number of areas, however assessments had not been completed for individuals who self medicate. A requirement was made that these are completed to ensure that the health, welfare and safety of residents is protected. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14 15, 16 & 17 The home supports residents to maintain independent living skills. Individuals take part in fulfilling activities and participate in the local community. Residents engage in a range of leisure activities and are supported to exercise choice. One matter requires action. Residents are offered a well balanced diet EVIDENCE: Residents are given opportunities to participate in a range of recreational, educational and social activities both internally and externally based on individual preferences. During the inspection residents were busy attending activities for example art, cooking, music and IT. One individual stated, “My favourite activity is drama”. Another service user said, “I go shopping to Sainsbury’s”. A one to one life coach also supports residents and sessions were observed during the day and their role is to look at the future needs of individuals facilitate with daily living skills and they work closely with key workers. One life coach spoken to said she has supported residents to attend college and access work experience. Two residents spoken to go out independently to use the local shops and trips are organised for example to church, bowling and the pub. However three residents informed the inspector that there are not always drivers on at weekends for them to go out and participate in some activities. The manager
Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 14 said that he is looking at this matter. It was noted that that the original requirement for 06/11/05 was not met and a further requirement was made that this matter is addressed within the timescale set to ensure that residents are able to engage in their preferred activities. Residents maintain links with their families who can visit at any time. One individual had her own telephone and computer to maintain links. A comment received from a relative confirmed that they are made to feel welcome when they visit the home. Residents were observed to be moving around the home within the home with no restrictions. Residents were observed to have good relationships with staff and their privacy was respected. One individual said, “Staff knock on my door before entering”. Another resident said that “staff give you space”. A majority of comment cards received indicate that individual’s privacy is respected. There is a large dining room where residents can choose to eat if they so wish. The menu was sampled and choices are accommodated. The lunchtime meal was nutritious and well balanced. It was pleasing to see staff eating their meal with residents and who were observed to be supporting residents who required assistance with eating. Two individuals stated that the food is good and one person who is unable to communicate verbally raised her arm indicating, “Yes” when she was asked if she liked the meals. The homes chef informed the inspector that a food forum is being organised which residents will be able to participate in to express their views. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The health needs of residents are met and a range of specialist services is accessed to maximise individual’s independence. Further work is required to ensure that resident’s health, welfare and safety is protected by the homes medication policies and procedures. EVIDENCE: The home has a key worker system in place and residents are registered with a local GP and are supported by a range of health care professionals. For example district nurses, physiotherapy, occupational therapy and chiropody and records of health checks were maintained. During the inspection one individual had returned from a hospital appointment and was offered support from staff and the outcome of his appointment was recorded in his daily notes The medication administration systems were examined and photographs were in place. All medication administered was signed for and systems for disposal were in place. Medication was stored appropriately and a medication policy was available. However requirements were made in respect of the following matters; - A number of residents self medicate and risk assessments were not in place, the medication policy was not signed by staff, the homely remedies list must be updated and authorised by the GP and it was strongly recommended that where prescriptions are handwritten by staff this should be
Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 16 checked and signed by two people where possible. A discussion took place with the manager in respect of residents who are prescribed as required medication for repeated seizures and the inspector was informed that some staff do not feel comfortable administering this particular medication with regard to respecting residents dignity. It is strongly recommended that this issue be discussed with the G.P to ensure that the needs of residents are met. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is able to demonstrate that there is an accessible complaints procedure in place. Policies and procedures were in places that ensure that residents are protected from abuse however staff need to sign to confirm that they are aware of the procedures. EVIDENCE: The home has a complaints procedure in place that has been reviewed and complaints are responded to in a timely fashion. The Commission for Social Care Inspection has received two complaints one of which was investigated by the home and was dealt with appropriately. The inspector spoke to two residents who said that the manager was approachable and they felt able to raise concerns. During the inspection residents were seen going to the managers office to discuss issues and he was clearly responsive in his approach. From written comments received all residents confirmed that they aware of who they could speak to if they were unhappy about any aspects of their care. Records were maintained in respect of issues raised by individuals with documented outcomes. Since the previous inspection three issues were referred following the local authorities policy and procedures for safeguarding adults and one issue is currently ongoing. Procedures were in place for safeguarding adults including the local authority safeguarding adult’s procedure. Training records were sampled which concluded that staff are receiving up to date training in safeguarding adults. However a requirement was made that the procedures must be signed by staff to ensure that they are aware of the actions to follow to ensure that residents are protected from abuse. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Further work is required to complete the outstanding refurbishment work to ensure that residents have a homely and comfortable place to live. The home was able to demonstrate that it is clean and hygienic EVIDENCE: During a tour of the premises it was clear that substantial refurbishment is still required in Medway and JAC units, which does not create a homely atmosphere. The corridors should be repainted, the sitting room needs decorating carpets need replacing and the kitchen in Medway requires attention. The condition of the bathrooms and toilets are of concern as they are old and are in need of refurbishment. One toilet was seen to have a gap at the top, which does not maintain privacy and dignity for residents. It was concerning to note that the original requirement should have been met on 06/11/05. The inspector discussed this issue with the principle who explained the future plans and stated that she is having a meeting with a surveyor in June. A further requirement was made that the proposed refurbishment programme detailing the dates of completion of the outstanding work must be supplied to the Commission for Social Care Inspection to ensure that residents have a homely, comfortable and safe place to live. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 19 A further requirement was made that a light fitting in one sitting room is repaired. The inspector visited two independent flats with residents, which were homely and comfortable. The home was clean and hygienic including the main kitchen and the inspector was informed that new equipment has been ordered for this area. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 The staffing levels in the home require review to ensure that residents are supported by sufficient numbers of staff. The home must ensure all staff training is recorded on the schedule to ensure that resident’s health, welfare and safety are protected. A system for the availability of the key to access staff records must be implemented to ensure that residents are protected by the homes recruitment policies and procedures. EVIDENCE: Fifty-four percent of the staff team hold National Vocational Qualifications (level 2 or above). The training schedule was sampled which indicated that staff are receiving up to date mandatory training, epilepsy awareness, hydrocephalus awareness, peg feeding and future training has been arranged for first aid, confidentiality and visual awareness. The inspector was informed that fire prevention training has been undertaken, however this was not recorded on the training schedule to confirm this and all staff must receive training in infection control. This is to ensure that the health, welfare and safety of residents is protected. The staffing rota was examined which concluded that on most days twelve staff are on duty during the day. The inspector spoke to some staff in the home who expressed some concerns in respect of the present levels and in particular about the number of senior carers that are available on shifts. The duty rota did not record the grades of staff on duty. The inspector also spoke to three
Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 21 residents living in the flats who confirmed that they wanted to maintain their independence but would like to see staff visiting more often and two residents stated that there have been occasional delays in response to their call bells. A requirement was made that the staffing levels must be reviewed following the guidance recommended by the department of health. This is to ensure that residents are supported by sufficient numbers of staff and who have the appropriate skills to meet their assessed needs. It is also strongly recommended that the response time in responding to call bells be monitored. The inspector was unable to examine the staff personnel files as the personnel officer was away and it is required that the manager maintains a key. However the inspector was able to view a number of police checks, which have been completed for staff and volunteers. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 The manager has appropriate experience to manage the home and is able to demonstrate that he has implemented quality assurance systems. The home is able to demonstrate that the financial interests of residents are protected. Two health and safety issues must be addressed to ensure that the health, welfare and safety is protected. EVIDENCE: The manager has experience of working in care settings and has undertaken training and development. The manager has submitted an application to the Commission for Social Care Inspection to be registered. There was an open approach in the home and it was clear that the manager is accessible to residents who were relaxed in his company. One resident stated, “Its getting better here and I feel more empowered”. Staff meetings take place and notes were sampled. Three staff spoken to also confirmed that there have been some improvements and changes. The manager has introduced empowerment groups with positive feedback gained from residents. The home holds monthly forums, which are minuted
Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 23 and sampled by the inspector. The home is introducing monthly quality visits and one individual confirmed he was taking part in this process. Another resident said, “I am going to be interviewing staff and it’s my home”. The procedure for safeguarding resident’s finances was sampled. The manager has introduced a procedure and a book is maintained of monies kept in the safe and signed by residents and staff when taking money in and out. Due to a recent issue bankcards are maintained for safekeeping. There is facilities manager in post and health and safety checks were maintained including fire prevention. Records are in place for maintenance and equipment checks and adequate records were maintained in the kitchen. However wheelchairs obstructed a corridor kept there for storage and an immediate requirement was made that these were removed. A further requirement was made that the staff training record should include fire prevention, as this was not recorded. Development Centre Dorincourt DS0000013626.V295582.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 Adults 18-65 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 3 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 1 28 29 30 2 3 3 2 X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43
DS0000013626.V295582.R01.S.doc 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Development Centre Dorincourt Score 3 3 2 X 3 X 3 X 3 2 X
Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? 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. 2 Standard YA5 YA15 Regulation 17(2) Schedule 4 Requirement Timescale for action 15/06/06 15/06/06 2. 3. YA6 YA15 4 5 YA23 YA24 6 YA24 A copy of resident’s contracts must be supplied on individual files. 16(2)(m) Residents must not be restricted 18(1)(a,c) from accessing their chosen activities because of a lack of trained staff. (previous requirement 06/11/06 not met) 15(2)(a) Care plans must be agreed and signed by residents. 13(2) a) Risk assessments must be completed for all residents who self medicate. b) All staff must sign the policy and procedures for the administration of medication. c) The homely remedies list must be updated and authorised by the GP. 13(6) The local policy for safeguarding adults must be signed by all staff. 23(2)(b)(d) a) The open gap between the two toilets in medway must be attended to maintain privacy. b) The broken light fitting in the sitting room must be attended to. 23(2)(b)(d) The outstanding refurbishment
DS0000013626.V295582.R01.S.doc 15/07/06 22/05/06 15/06/06 22/05/06 30/06/06
Page 26 Development Centre Dorincourt Version 5.2 7 YA33 18(1)(a) 8 9 YA34 YA35 19 23(4)(d) 10 YA42 23(4)(b) work must be completed in Meadway and JAC units to include the bathrooms, painting of communal areas and kitchens. A plan for the refurbishment of the service must be submitted to the Commission for Social Care Inspection detailing the times for the completion of this work. (Previous requirement 06/11/05 not met). a) The registered person must review the staffing levels in the home based on the guidance by the department of health. b) The present staff rota must be reviewed to ensure that the shift leaders are highlighted. The registered person must ensure a key is available to access the staff personal files. a) The training record must include evidence that staff have received training in fire prevention. b) All staff must receive training in infection control. Wheelchairs must be stored appropriately ensuring that the corridors are free from obstructions. 15/06/06 05/06/06 15/06/06 15/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations It is strongly recommended that the manager discuss the issue in respect of prescribed as required medication for individuals with the GP.
DS0000013626.V295582.R01.S.doc Version 5.2 Page 27 Development Centre Dorincourt 2 3 YA20 YA33 It is strongly recommended that when prescriptions are transcribed by staff on the medication card this should be checked by two members of staff It is strongly recommended the call bell response times in the flats be monitored. Development Centre Dorincourt DS0000013626.V295582.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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