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Inspection on 26/02/08 for Diamond House Care Home

Also see our care home review for Diamond House Care Home for more information

This inspection was carried out on 26th February 2008.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Diamond House Care Home Bennett Street Downham Market Norfolk PE38 9EJ Lead Inspector Mr Jerry Crehan Unannounced Inspection 26th February 2008 09:40 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 Diamond House Care Home DS0000065214.V360266.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. Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Diamond House Care Home Address Bennett Street Downham Market Norfolk PE38 9EJ 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) 01366 385100 01366 385600 diamondhouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Application In Progress Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42) of places Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18th April 2007 Brief Description of the Service: Diamond House is a care home providing residential care for up to 42 older people including service users with dementia. It is situated on the edge of the town of Downham Market and is within easy reach of local facilities including shops, pubs and other community facilities. Diamond House is purpose built with accommodation provided on two floors. Stairs and passenger shaft lift service floors. There are 38 single rooms and 2 shared rooms. There are patio and garden areas that are visible from a number of service users bedrooms. Diamond House is one of several homes in Norfolk owned by the proprietors. The range of weekly fees at the home is £275 to £550. Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use the service experience adequate quality outcomes. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. This report gives a brief overview of the service and current judgements for each outcome group. Before the inspection the manager of the service completed a lengthy questionnaire about the service. Sixteen comment cards were received from people who live at the service. Thirteen comment cards were received from relatives of people who use the service; nine comment cards were received from staff that work at the service. These reflected some positive views about the home and care provided there, however they also contained a negative theme concerning a lack of activity and stimulation for residents. There were positive comments about the service made by people spoken with at the time of the inspection visit. Records held by the Commission and previous inspection reports were checked. This key inspection comprised an unannounced visit to the home that took place over 7.5 hours on 26th February 2008. Opportunity was taken to tour the premises, look at care records and policies, and communicate with residents, care staff, and the manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. What the service does well: • • • • The individual needs of people using the service are assessed and understood in order that the service can be sure their needs will be met. People who use services receive good personal and physical healthcare. Staff seen were observed to be hard working and attentive in meeting the needs of people who use the service. Medication practices safeguard the health and welfare of people who use the service as sample audits were satisfactory and all medicines were accounted for. People who use the service have access to a good diet and meals that are well prepared. DS0000065214.V360266.R01.S.doc Version 5.2 Page 6 • Diamond House Care Home • People who use the service have access to an effective complaints procedure and are protected from abuse through staff awareness and training in protection. What has improved since the last inspection? • The home’s internal and external environment is safe and some areas benefit from improved decoration, maintenance and provision of equipment. The manager is commended for achieving a significantly improved ratio of NVQ trained staff (56 ) at the home. The manager ensured that the Commission’s comment cards for people who use the service and their relatives were properly promoted prior to the inspection visit. • • What they could do better: • The mental healthcare of residents with dementia is not fully supported by the home’s records and practice. The Proprietor must ensure that there are suitably qualified and competent and experienced persons responsible for dementia care delivery, and supervision, working at the care home. Social and life history work must be carried out by staff as this contributes to improving the care for residents as individuals and supports dementia care delivery. People who use the service are limited in what they can do to satisfy their social and recreational needs. Some parts of the home still lack a warm and homely feel. There is limited assistance available for care and otherwise attending to residents during mealtimes in the late afternoon and evening. The manager should ensure that the views of people who use the service are sought at all opportunities and included when making decisions that effect outcomes for people living at the home. • • • • • Diamond House Care Home DS0000065214.V360266.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. Diamond House Care Home DS0000065214.V360266.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 Diamond House Care Home DS0000065214.V360266.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): Standard 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents have their needs assessed, and access to all of the information they need about the service they may choose. EVIDENCE: The home has an assessment pro-forma (for pre-admission assessment) used by the manager or deputy when collecting information. The document is well designed to ascertain the level of support required by prospective residents. There is evidence of good assessment for new residents seen in their files. The sample of assessments seen covered a range of relevant areas such as an assessment of the physical and social needs of the resident, and a range of more detailed risk assessments such as nutrition, pressure ulcer, falls risk and moving and handling requirements. The information from these assessments had been collated into a ‘Pre admission draft care plan’. Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 10 The manager or other senior staff show people around and provide information about the service and facilities. Evidence of this was seen during the inspection visit. Diamond House Care Home DS0000065214.V360266.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): Standard 7, 8, 9, 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services receive good personal and physical healthcare. The mental healthcare of residents with dementia is not fully supported by the home’s records and practice. EVIDENCE: Each resident had an individual care plan and a sample of these were reviewed for residents accommodated on both floors of the home. Care plans seen included admission information that provides a brief profile of the resident, a diagnosis (where this was relevant) and a physical and social assessment. Care plans contained a range of other risk assessments such as general dependency, moving and handling, pressure ulcers, nutrition and falls. These indicate the specific risk and set out the measures taken to control risk. The manager stated that the comprehensive assessment of falls at the home undertaken last year with the support of community health professionals has helped to prevent falls. She indicated that the home’s environment is safer and Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 12 that care staff are better at supervising residents who are at risk when mobilising. Care plans for residents with dementia offer very little in the way of an individual view of the person and their needs, or a social or ‘life history’ of the person. The absence of this information compromises care staff’s ability to promote good social and emotional care, and does not support residents’ wellbeing (See Requirement 1). There were several examples of this including the following: A care plan seen for a resident whose assessment indicated that they enjoy walking up to half a mile a day made no mention of this and there was no evidence that the resident had been supported to continue this activity. A care plan was seen for a resident whose mental health is severely affected by their dementia in behaviour that challenges. This contained some good information for care staff about the fact that the resident had some challenging behaviour and when this was likely to occur. However, clear information was needed about what sort of challenging behaviours may be exhibited, what approach to take when these behaviours were exhibited, what this behaviour might mean. There was little in the way of stimulation available to this resident, their bedroom was odorous and drafty, and when visited in the early afternoon they were still in their nightclothes (See Requirement 2). There is evidence of access to health screening and involvement of community health professionals in resident’s care. There are records of professional visits to the home by G.P’s and Community Psychiatric Nurses. It is recommended that the home seek further advice from the continence advisor in managing continence for residents with dementia (See Recommendations). Comments from relatives of residents about the care at the home were generally very good. Comments received prior to the inspection visit included the following: ‘could not get better care’, ‘staff are kindness itself’ and ‘friendly atmosphere’. Staff seen were observed to be hard working and as attentive as they could be to the individual needs of the residents as they could have been despite the numerous demands on their time. The home was friendly and welcoming to its visitors throughout the day. There are suitable safe storage arrangements for medication. There were no residents responsible for their own medication at the time of the inspection visit. There were resident-identifying photographs alongside ‘medication administration records’ (MAR charts) to assist in the safe administration of medicines. The administration of painkilling medicines prescribed on a PRN (as required) basis at the discretion of members of care staff was considered. For these medicines it is recommended that there is good care plan guidance alongside MAR charts to ensure they are administered as appropriate (See Recommendations). Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 13 MAR charts noted were generally well kept and it was evident through records and sample audits that medicines have been administered in line with prescribed instructions. The residents spoken with during the visit stated that their right to privacy is respected at the home, and that their visitors are made welcome and can be seen in private (in their rooms) if they wish. Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have access to a good diet and meals that are well prepared. People who use the service are limited in what they can do to satisfy their social and recreational needs. EVIDENCE: There is a published programme of weekly activities at the home. The programme was made available in each resident’s bedroom, and in communal areas of the home. The activities on offer during the week of the inspection included light exercises, bingo, memory games and one to one sessions with the activities coordinator for those residents who are not able – or who do not wish to participate in group activities. There is organised entertainment brought into the home on a monthly basis, this is usually music based. The manager stated that two residents attend local social clubs and residents are invited to the Methodist church for harvest festival and other festivals. She stated that the home celebrates residents’ birthdays and other anniversaries. Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 15 There were generally poor responses from residents who commented on the provision of activities at the home. Two residents commented that activities ‘were excellent – now non existent’, and ‘we don’t have anything to do but watch TV, video or sleep - we miss our activities’. Responses from relatives were equally poor about the provision of activities and stimulation for residents. Comments received included ‘entertainments limited to TV, sleeping, Bingo’, ‘I don’t think there is enough to stimulate the patients and they sit around and watch the TV’ and ‘no stimulation – left in their room’. Care staff in their comment cards received by us prior to the inspection visit also raised this issue. Three of the nine comment cards received from staff indicated a view that more activities and entertainment needed to stimulate residents physically and with reminiscence. These are generally more negative responses than at previous inspections of the service (See Requirement 3). Staff and residents confirmed that visitors and relatives can attend the home at any time. There were several visitors to the home at the time of the inspection visit. The rooms seen on the day of the inspection visit are furnished and equipped to suit the service users daily lifestyle and reflect their personal choices and preferences. The lunch menu on the day of the inspection visit looked well prepared, substantial and well balanced as at previous inspections. The main lunch option was beef hot pot with mashed potatoes, green beans, sprouts and mixed vegetables. Pudding was apple crumble and custard. Some residents had evidently opted for alternative options, while others with special dietary requirements had their needs met also. Residents were complimentary about their lunch and the quality of meals and there were very few leftovers on people’s plates. One resident commented that their meals were ‘very good – I love my meals’. Most residents chose to take their meal in the main dining areas were they were supported by two to three care staff. Other residents preferred to take their meal in their own rooms where they receive support from care staff if they require. On the ground floor of the home this is proving very difficult, as there are two staff on duty to serve meals (to assist two residents who need support to eat) and to manage lunchtime medication. Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 16 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): Standards 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements for responding to the concerns and complaints of people who use the service are good. People who use the service are protected from abuse. EVIDENCE: The manager keeps a record of all complaints, though stated that no complaints had been received since the last inspection visit to the home. The home has a detailed complaints procedure and information on how to make complaints is detailed in the home’s guide for residents. The manager holds a monthly ‘surgery’ for resident’s relatives. Residents spoken with during the inspection visit stated that they would speak with the manager or carers if they had a concern or complaint. The manager had arranged for the majority of staff (19 out of 27 care staff) to undertake ‘Protection of Vulnerable Adults’ (POVA) training with further training on offer over coming months. The training programme is detailed, including identification of what abuse is, different kinds of abuse, the role of the carer in dealing with reported or witnessed abuse, and defining a vulnerable adult. Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment at the home is improving. It is safe, and reasonably well maintained though some areas should provide more comfort and convenience for people who use the service. EVIDENCE: A tour of the home’s environment was undertaken and there is evidence of ongoing redecoration of corridors, replacement of carpets and old divan style beds for new hospital type beds. An ‘activities lounge’ on the first floor is waiting for new carpeting before redecoration. Until then residents are not able to use this area. The manager stated that she has monies to provide appropriate items for this area such as sensory equipment. Bedrooms and bedding were improved; they looked more comfortable and were in reasonable repair. Planned redecoration of individual bedroom Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 18 accommodation is still needed to raise the general standard, the ‘warmth’ and ambience of the home’s environment. Some door handles on individual accommodation was faulty and bedroom doors could not be closed properly. This was brought to the manager’s attention during the visit for immediate attention. The exterior of the home was in a reasonable state of repair and there have been improvements to the garden areas at the front of the home, which are tidy and well kept. The enclosed garden to the rear of the home was reasonably maintained for the time of year and there is suitable seating available for residents. The internal and external environment is generally safe and accessible for residents and staff. Four of the thirteen comments from relatives of residents received prior to the inspection visit expressed concerns about the management of clothing and laundry generally. These concerns were shared with the manager during the inspection visit and commonly involve visiting relatives finding clothing belonging to other people in their relative’s wardrobes (See Recommendations). The hoist and other equipment was safely stored. The home was clean and tidy, though as stated above there were odorous areas. Diamond House Care Home DS0000065214.V360266.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): Standards 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are adequately trained and skilled. However, they are not consistently deployed in sufficient numbers to support the specialist needs of people who use the service. EVIDENCE: There were thirty-six residents accommodated at the time of the inspection visit. They were cared for by six care staff including senior care staff. Other staff included the manager, deputy manager, administrator, maintenance engineer, chef and kitchen assistant and three laundry/domestic staff. There was a total care staff compliment of twenty-seven. Staffing numbers and deployment continue to present a concern on the ground floor of the home. The two carers allocated to work on the ground floor of the home presents difficulties at mealtimes as indicated above in this report. However, there are difficulties at other times of the day also. Several residents need the assistance of two carers to assist them with transfers using the hoist or the stand aid. On occasions during the day this effectively leaves no carers for all other residents on the ground floor. The senior carer on duty has responsibility for administering medication to residents at several times during the day, thereby leaving their remaining colleague to manage all other care tasks. Staff will also be required to deal with visitors to the home including health professionals and resident’s relatives or friends, and from the late Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 20 afternoon onwards care staff are required to answer the telephone. The difficulty may be overcome through a different approach to staff deployment, or through the provision of an additional staff (See Requirement 4). From information provided by the manager and the proprietor there are 56 of care staff working at the home with NVQ 2 or NVQ3, and further care staff are currently undertaking the training. This ratio of NVQ trained staff exceeds the minimum 50 requirement, and the manager is commended for achieving this level. Sample staff files provided evidence that residents are protected by good recruitment practices. There have been improvements to the induction training and support available to staff. The manager with the support of senior staff is responsible for mentoring new staff through their induction to the home, and the training programme is in line with ‘Skills for Care’ requirements. Evidence of this was supported in records seen. Existing staff who have been employed within the last six months will also receive this improved induction training and support. Training records seen provide evidence of ongoing training and evaluation of learning signed off by manager, deputy manager or senior carer. A significant number of staff at the home have received specialist training in either dementia awareness or a more substantial training course developed by the Alzheimer’s Society. Care staff and other staff at the home have had access to a full range of mandatory training including health and safety, first aid, fire and infection control. Diamond House Care Home DS0000065214.V360266.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): Standards 31, 32, 33, 35, 36, 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is experienced to run the home. Management systems and management training should be further developed to measure success in meeting the aims and objectives of the home. EVIDENCE: The Manager has now been in post for 18 months and was previously the Deputy Manager of the service. She is currently in the process of applying to the Commission to be registered, and has recently successfully completed the ‘Registered Managers Award’ training programme. Further to issues described above with regard to deficits in the specialist mental healthcare delivered at the home for residents with dementia, the Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 22 manager and proprietor should allocate a person in charge of dementia care at the home. They should have an enhanced level of knowledge and training of dementia in order that they may properly supervise (and train) other staff (See Requirement 5). There is an on-call system at weekends for management advice and support. The system provides access to the manager or deputy, and to an area on call support system operated by the proprietor. It is recommended that the manager take charge of staff or team meetings periodically in order to use this forum to clearly communicate leadership, and management matters (See Recommendations). There are several processes at the home for monitoring the quality of the service it provides. There are systems in place that provide staff with formal supervision of their work and there are regular staff meetings. The Manager and the Proprietor carry out quality audits covering a range of topics, and they send monthly monitoring reports to the Commission. As indicated above, the manager holds monthly surgeries for resident’s relatives to raise issues they may have. It is still clear that a more formal quality assurance exercise that seeks the views of people who use the service, and others associated with it, has not been carried out. It is important that the views of residents and others are sought and used to inform any development or improvements to the service offered by the home, and more work is needed in this area (See Repeated Requirement 6). Relatives or appointees manage most residents’ financial affairs. Financial records reviewed were satisfactory and are evidently audited periodically for the protection of residents and staff. The home demonstrates generally good practices ensuring residents health, safety and welfare, however there are shortfalls in staff deployment, suitable activities and in supporting the care needs of residents with dementia through care practice and record keeping. Maintenance and fire records seen were satisfactory, and there are improvements to the home’s environment. There is relevant training for staff, with improved numbers of staff at the home who have had a range of mandatory training equipping them to safely carry out their respective roles. Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 23 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 3 X 2 Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement People who use the service must have a detailed care plan that reflects their needs to ensure that they receive the correct support to meet their needs. The manager must ensure that the home is conducted in a manner which respects the privacy and dignity of service users. People who use the service must be provided with facilities for recreation to suit their individual needs. The registered person must ensure that staff are deployed and working in such numbers as are appropriate for the health and welfare of residents. The manager must ensure that there are suitably qualified and competent and experienced persons responsible for dementia care delivery and supervision working at the care home. The manager must ensure that the views of people who use the service user sought and included when making decisions that DS0000065214.V360266.R01.S.doc Timescale for action 26/02/08 2. OP7 13(4)(a) 26/02/08 3. OP12 16(2)(n) 01/04/08 4. OP27 18(1)(a) 01/04/08 5. OP31 18(1)(a) 30/06/08 6. OP33 10(1) & 24(2) 30/06/08 Diamond House Care Home Version 5.2 Page 25 effect outcomes for people living at the home. This Requirement Is Repeated RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP9 Good Practice Recommendations It is recommended that the home seek further advice from the continence advisor in managing continence for residents with dementia. It is recommended that there is good care plan guidance for medication that can be administered on a PRN basis alongside MAR charts to ensure they are administered as appropriate. It is recommended that staff providing activities have access to appropriate training including reminiscence therapy. It is recommended that care staff play a more significant part in understanding and supporting residents to undertake leisure and social interests. This Recommendation Is Repeated It is recommended that the manager consider staggering the lunchtime, or making other arrangements in order that residents can be assured of getting the support they need by carers who are not under pressure to support others at the same time. It is recommended that the manager review the adequacy of the assistive technology available at the home to support residents, including hoists, as the home had one hoist with at least five residents on the ground and first floor using this for transfers. It is recommended that the systems for managing laundry be revised to ensure that residents own clothing is returned to them. It is recommended that the manager takes charge of staff or team meetings periodically in order to use this forum to clearly communicate leadership, and management matters. 3. 4. OP12 OP12 5. OP15 6. OP22 7. 8. OP26 OP32 Diamond House Care Home DS0000065214.V360266.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact 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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