Inspection on 22/06/06 for Dolphin View

This inspection was carried out on 22nd June 2006.

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

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

Other inspections for this house

Dolphin View 14/11/08

Dolphin View 16/11/06

Dolphin View 25/11/05

Dolphin View 18/07/05

Dolphin View 02/12/04

Dolphin View 14/06/04

Dolphin View 10/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Dolphin View Harbour Road Amble Morpeth Northumberland NE65 0AP Lead Inspector Mrs Irene Bowater Key Unannounced Inspection 22nd June 2006 09:30 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 Dolphin View DS0000000510.V290780.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. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dolphin View Address Harbour Road Amble Morpeth Northumberland NE65 0AP 01665 - 713339 01665 713223 dolphinviewhome@fshc.co.uk 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) Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) Mrs Susan Davison Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Four named service users are known to be outside category OP. One is category MD(E), one LD(E) and two PD. Should any of the named service users leave the home, the Commission for Social Care Inspection must be notified immediately, at which time these places will revert to the category OP. 25th November 2005 Date of last inspection Brief Description of the Service: Dolphin View is a purpose built care home with nursing situated on the edge of the harbour in Amble Northumberland. The home is over two floors, which are accessed by stairs and a passenger lift. Currently all the rooms are for single occupancy. None of the bedrooms have ensuite facilities, however each bedroom has a hand washbasin. There are bathrooms, showers and toilets close to residents’ bedrooms and all communal areas. Specialist baths and toilets are provided for residents with disabilities. There are lounges on both floors with the dining room situated on the first floor. There is access to a garden area to the front of the home, which affords views across the bay and harbour area. Car parking is provided to the rear of the building. The fee rate start from £332.94 up to £400.78 plus the Registered Nursing Care contribution, which is set nationally. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over two separate days at different times. This was because of serious concerns, which were found on the first day, and which resulted in the inspection being stopped, in order for the home and company to take immediate action, as there was lack of hot water, assisted bathing facilities, fire and food hygiene training, not enough hoist slings and staffing difficulties in the evenings. The company responded in writing to the immediate requirements issued within the agreed timescales. Given the serious concerns raised at the first visit by two inspectors, the Infection Control Nurse from the Health Protection Agency accompanied the inspector on the second day of inspection. The findings have been shared with the home and have been incorporated into the report. A further unannounced visit took place to complete the inspection and to ensure the appropriate action was being implemented by the home. The home has been subject to two additional unannounced visits since the last inspection. This resulted in an Enforcement Notice being issued in April 2006. The Company have responded to the issues raised and have complied with the Notice within timescales. They continue to work with CSCI and other Agencies. Over the two inspection days tours of the premises took place, residents and staff were spoken with on both occasions. Care records and other records were inspected on both days. Discussions were also held with the company representatives for the home on both occasions. What the service does well: The staff have all the necessary information before any resident moves into the home to ensure they can meet their needs. The care plans are detailed regarding the health and personal care needs of individual residents. There is good communication with other professionals to ensure residents health care needs are met. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 6 Staff make sure residents maintain their dignity and right to privacy when delivering personal care. Resident’s rights and preferences about who assists them is taken into account at all times. The staff were able to discuss individual residents care needs. Visitors are made welcome and there are good links with the local community. Staff encourage residents to bring personal items with them to make their rooms individualised. Comments from the residents and relatives were positive about the staff and the care they gave. Six relative and visitor Comment Cards were returned to the Commission. Comments included, “I am very pleased and satisfied with the way my relative is treated,” “I am very grateful for the way the staff look after my relative for me”. “The staff are wonderful and must be the homes greatest asset”. No completed surveys were returned from the residents. The home benefits from a core of staff that have worked at the home for some considerable time. What has improved since the last inspection? What they could do better: Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 7 The staff need to develop the social activities to improve the quality of life of residents living in the home. Further reviews of the menus are needed to make sure all meals are varied and nutritious. Further training for staff is needed so that they can continue to improve the lives of the residents living in the home. The concerns and complaints from residents must be acted upon without delay. The consultation with residents and their representatives’ needs to improve so that they feel their concerns are listened to at all times. One comment card said, “the bathroom was always running out of hot water and the residents bath had to be delayed or cancelled.” Residents voiced great concerns on the first day of inspection about the lack of hot water and bathing. A review of infection control procedures is needed to make sure staff and residents are safe at all times. All maintenance problems must be reported to the right people so repairs can be carried out. The systems to enable residents to receive interest on their money need to be resolved. A planned replacement programme for bedroom furniture is needed. Health and Safety issues must be reviewed to keep residents and staff as safe as possible. All of the requirements from this report need to be met within the timescales. 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. Dolphin View DS0000000510.V290780.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 Dolphin View DS0000000510.V290780.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 is not applicable The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The admission assessments ensure the residents care needs will be met. EVIDENCE: Five care plans were inspected and showed that the manager carries out comprehensive assessments before any resident is admitted to the home. The care managers and the nurse’s assessments were also available. These records form the basis of the care planning process for the resident. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The care planning system provides staff with the information they need to meet resident’s assessed needs. The health needs of residents are currently being met. There is interagency working. The systems for the administration of medicines are currently safe and consistent. Personal support is currently promoting residents right to privacy and dignity. EVIDENCE: Each resident has a care plan, which is based on the admission assessment. The care plans inspected were well kept with the information clearly recorded. Six care plans were inspected and found to contain relevant risk assessments for the prevention of falls, pressure sore and wound care, moving and Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 11 assisting, catheter care, continence promotion, nutrition and mental health status. Risk assessments were available for the safe use of bedrails. Monthly health observations including weights are recorded and any changes acted upon. Care plans also refer to family visits, phone calls and social activities. The residents have access to all NHS facilities. There are regular visits from GP’s and other health professionals including dentists, opticians and chiropody services. There are appropriate pressure reliving devices available to support the staff and residents in daily activities. Advice is sought from tissue viability specialists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. The home has comprehensive medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. The nurse in charge confirmed that there were only two residents who have night sedation. Staff were observed to work hard to make sure residents rights to privacy and dignity was respected when giving personal care. The residents and staff have formed good relationships with each other with the interaction being professional, friendly and based on mutual regard. There is easy access to a payphone and residents can have a phone in their own room. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Social activities currently do not provide stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. Residents are supported to make choices and take control over their lives. The evening meals do not offer a healthy and balanced diet for residents. EVIDENCE: The activities organiser is currently off sick, which means that the daily activities both within and outside the home are not frequent. Residents said they missed being busy and were looking forward to going out and about again. One relative expressed his concern that there was no television in the upstairs lounge. The residents said they had a television in the downstairs lounge or in Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 13 their own rooms and liked to sit quietly or chat to each other without the television on all day. One resident said that she liked to sit and read her paper and watch the sea. Several of the residents spent time in their own rooms watching television or reading. One resident said she kept herself busy tidying her room and going into the town. The residents said that their visitors are always made welcome, could visit at any time and in private. Residents are able to manage their own finances for as long as possible. Information and advice is available about finding advocates if necessary. People are able to bring their own possessions with them from home such as furnishings and keep sakes. This has made their own rooms individualised and reflective of their lifestyles. Since the last inspection the registered manager has carried out a food survey. This has found out what residents likes and dislikes are for all meals. The teatime menu has been reviewed and some improvements have been made. The teatime menu still needs to look at providing a variety of cooked foods. Three evenings there is soup and sandwiches, two evenings there is a cold buffet, two evenings is a light cooked meal and every evening there are cakes or scones. There is a choice of continental or cooked breakfast and there are alternatives available for the main meal, which is served at lunchtime. On the day of inspection there was a choice of lasagne or cheese flan with tinned tomatoes and mashed potato and the dessert was rice pudding or yoghurt. Cold drinks were given throughout the meal. The dining room is large and pleasantly decorated. Tables were appropriately set and staff gave assistance when necessary in a sensitive manner. Several of the residents had their meal served to them in their own room. Residents spoken to said they “get plenty to eat and “the meals are nice. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The complaints procedures are clear. Residents are not confident that their views are always listened to or acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: The home has comprehensive policies and procedures available which set out how and to whom complaints may be made. The procedure is displayed on the notice board.The complaints records were clear, with actions and outcomes recorded. There have been no recorded complaints since the last inspection. On the first day of the inspection residents and staff about lack of hot water, lack of available bathing facilities, lack of staff in the afternoons and a lack of slings for staff to safely move residents who were immobile raised numerous complaints. The registered manager is on long term sick and the Inspector requested that the Regional Manager came to the home to discuss and resolve the serious concerns raised. Both the Regional Manager and the Responsible Individual came to the home and all the complaints discussed. Four immediate requirements were made and a plan covering all the areas to be actioned was received the following day. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 15 The inspection was stopped and was completed six days later. All of the immediate requirements had been met and the inspection completed. There are policies and procedures in place for Adult Protection. The staff have received in house training about how to deal with alleged abuse in the last twelve months and this training is ongoing. There have been no referrals in the last year. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. There has been some investment in the home, which continues to improve the conditions for the people who live there. There are still some requirements that have the potential to place residents at risk. EVIDENCE: The location and layout of the home is suitable for the needs of the residents. The home has had an ongoing redecoration and refurbishment, which has greatly improved the appearance of the home. Residents have access to safe outside garden areas, which have views across the bay and harbour. All of the lounges and dining rooms have been tastefully decorated and refurbished. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 17 All of the residents said the home was a lovely place to live. The home is a smoke free area. Since the inspection of 25 November 2005 when a Warning Letter was issued and a further inspection on the 3 April 2006 when a Statutory Enforcement Notice was issued a detailed inspection of the premises was undertaken. All of the requirements from the Enforcement Notice have been met. Bedside lights have been fitted, an assisted bathing facility has been provided on the first floor and adequate laundry facilities have been provided. None of the bedrooms have an en-suite facility. There are toilets, bathrooms and shower rooms close to all resident areas. On the first day of the inspection the staff said that the assisted bath downstairs was not being used as the handset was broken. The newly installed assisted bath upstairs was not in use as there was a problem with the hot water supply and the shower room flooring upstairs still floods. Residents also complained about the lack of hot water to wash with and that on some occasions they were unable to have a bath as there was either no hot water or there was no bath for them to use. The bathroom upstairs was cluttered with equipment and bathrooms with domestic baths are used as storage. One bathroom was full of old televisions, air mattresses, wardrobes, wheelchairs and other equipment. An immediate requirement was issued to the Regional Manager to make sure that there were sufficient bathing and showering facilities for residents to use on both floors and to repair the heating and plumbing system to make sure there was enough hot water at all times in the home. The Responsible Individual responded immediately and gave written confirmation the next day that there were sufficient assisted baths and showers in use and that new pumps had been installed to the hot water system. A second inspection visit confirmed that all the requirements had been met. Residents were delighted to have hot water and were again enjoying regular baths. Staff were also able to wash their hands effectively. The staff said there were not enough hoist slings for residents who were immobile. There was only one for upstairs and one for downstairs. Four were being used exclusively for residents who have infections, two of whom share one. An immediate requirement was issued. On the second inspection day there was evidence that there was sufficient moving and handling equipment, including hoist slings for the staff to use. The residents all have a single bedroom. The rooms vary in size and all were pleasantly decorated. Residents have been encouraged to bring small items with them making their own rooms highly individualised and reflecting individual lifestyles and preferences. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 18 The vanity units and other bedroom furniture are showing signs of wear and tear and have not been replaced. All of the bedrooms have been fitted with suitable bedside lights. The refurbishment of the laundry has been completed. There is now a soiled and clean area with sufficient room for ironing and storing of some linen. The walls and flooring are easy to clean and there is access to a hand wash sink. Although there are soiled linen skips, items of soiled laundry were lying on the floor waiting to be washed. A sluice disinfector has been fitted in the first floor sluice. Given the serious concerns raised about the lack of hot water the Infection Control Nurse from the Heath Protection Agency accompanied the Inspector on the second inspection day. The sink in the original side of the laundry has an overflow water drain discharging into it and this sink should not be used for hand washing. The staff are physically washing out soiled commode pots with toilet brushes. The staff had not been trained on how to use the disinfector properly and were using the open sluice hopper to flush out soiled commode pots. The downstairs sluice was particularly smelly and currently the staff are flushing contaminated fluids down the open hopper and then transferring soiled containers upstairs to be sterilised. Many of the bins did not have lids nor were they foot operated. These concerns were discussed with the Responsible Individual at the time of inspection and it was confirmed that further Infection Control training would be sourced, guidelines on how to use the disinfector would be given to staff and appropriate waste bins have been purchased. Dolphin View DS0000000510.V290780.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The lack of a fully trained staff team has had a detrimental impact on the quality of care provision in the home. Improvements taking place with staff training and records will ensure residents are protected from harm. EVIDENCE: The home staffs the home according to the Company’s staffing grid. The staffing levels for the current number of residents are: 1 qualified nurse at all times. 5 care staff in the morning 4 care staff in the afternoon and evening 3 care staff at night. The registered manager staggers the timing of shifts during the day. There have been some staff shortages, which the home tries to cover with agency staff. The registered manager is currently on sick leave. The staff confirmed that in the afternoons and early evening they had to prepare the tea and wash up afterwards. This meant that there were not enough staff to care for the residents needs. Staff were untrained in food Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 20 hygiene and were carrying out food preparation tasks in the same clothing that they were carrying out care duties. This was brought to the attention of both the Regional Manager and the Responsible Individual and an Immediate Requirement was issued to make sure there were sufficient care and kitchen staff employed who were appropriately trained. The Responsible Individual responded the next day with an action plan, which confirmed that additional hours had been provided for kitchen staff, a training programme had been started and protective clothing had been issued for staff working in the kitchen. Evidence of the improvements were seen on the second inspection day. Eight of the staff have NVQ level 2 or above. Only 36 of care staff have this qualification. Five staff started foundation training in June 2006. Five personal records were inspected. All had Criminal Record Bureau checks, contract of employment, proof of identity and induction. One record did not have a Criminal Record Bureau check and another record only had one reference. There are staff training files and there is a training and development programme. These records were poorly kept and there was little evidence to show that training had taken place on a regular basis. The Fire training records were not available on the first day of inspection and it was confirmed that staff had not received the training at the required times. Staff had not received moving and handling training. Following discussions with the Regional Manager and the Responsible Individual immediate requirements were issued to provide fire training and food hygiene training within specified times. A second visit to complete the inspection found that the staff had received the training and moving and handling training was taking place. Five staff had received first aid training in May 2006. Dolphin View DS0000000510.V290780.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. There has been no consistent leadership or guidance to ensure residents receive quality care. There is some evidence to show that views of residents and their representatives are sought and acted upon. Residents personal accounts are not managed to ensure their best interests are protected. Staff do not receive supervision from management. This can affect the welfare of residents. There have been poor health and safety practices, which pose potential risks to residents, staff and visitors. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has a registered manager who has been in post for some time. She is a first level registered nurse who has completed the Registered Managers Award. The manager is currently on long term sick and this has had an impact on the general management and administration of the home. Staff were unclear about their responsibilities when anything goes wrong or who would tell the appropriate person. These issues were discussed with the Responsible Individual who now visits the home daily and has placed a senior manager at the home three days a week. The registered manager has carried out survey about the home and especially the food provision. The results are published and some improvements have been made. The Regional Manager visits monthly and produces a report, which is made available to the Commission. Before the registered manager went off sick regular resident, relative and staff meetings were held. Residents’ personal allowances are held in a central non-interest bearing account. The Company is planning to change the system to enable residents whose money is building up to get interest on their own money. This has not yet happened. The home maintains detailed records of all transactions with cross-referenced receipts. Supervision and appraisal records were not readily available and those inspected were not up to date. Staff had not received up to date training in safe working practices especially in food hygiene and certificated fire training. Staff have not received in house fire instruction, drills and food hygiene at the appropriate intervals. An immediate requirement was issued to the home to ensure that staff are trained by 29 June 2006. The outstanding requirement was addressed by that date. Accident recording and reporting is in place and the manager has completed monthly audits. The staff said they could not put water in the hot food trolley as it leaks. This makes the trolley very hot and the said they had received some burns. They also said that the soup burns, as the trolley has no water in it. The staff have no recorded any burns or scalds in the staff accident book. In house maintenance records were up to date. The records show that there have been faults on the thermostatic mixing valves on the bath taps for over one year. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 23 All utility contracts were available and up to date. Doors including the laundry door were held open by chocks, footstools and metal door holders. The downstairs lounge door did not fit properly into the rebate. Dolphin View DS0000000510.V290780.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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 2 2 X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 2 X 2 Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 12(2) 16(2) Requirement Timescale for action 31/08/06 2. OP15 12(2)(3) 16 (2)(4) 3 OP19 16 23 4. OP21 23 The registered persons must ensure that residents are given opportunities for stimulation through leisure and recreational activities in and outside the home which suits their needs, preferences and capacities The registered persons must 31/08/06 ensure that the teatime menu provides in adequate quantities suitable, wholesome and nutritious food, which is varied and properly prepared and available at such time as may reasonably be required by the residents. Timescale 01/03/06 not met. The registered persons must 31/08/06 ensure that a refurbishment and replacement plan is implemented and followed with records kept. The registered persons must 31/08/06 ensure that there are assisted bathing and showering facilities at all times in a ratio of 1facility to 8 residents. The obsolete, broken equipment must be removed from the unused bathrooms. DS0000000510.V290780.R01.S.doc Version 5.2 Dolphin View Page 26 5. OP22 16,23 6. 7. OP24 OP25 16,23 13 8. OP26 13,16 9. OP26 13,16 10. OP28 18 11. OP29 7,9,19 12. OP30 12,18 The registered persons must ensure that suitable hoists and slings are available at all times to meet residents needs. The registered persons must continue the replacement of bedroom furniture. The registered persons must ensure that thermostatic mixing valves are fitted and operational to provide water close to 43 C. The registered persons must ensure that sluices are locked when not in use. Suitable procedures must be in place for cleaning and disinfecting all contaminated commodes. The registered persons must ensure staff are trained in infection control policies and procedures to minimise the spread of infection. The staff must ensure that all spillages are dealt with appropriately and ensure contaminated materials are not transferred from one floor to another. A second sluice disinfector must be provided. The open sliuce hoppers must be removed and replaved with suiatble sinks. The sink in the soiled area of the laundry must not be used for hand washing. The registered persons must provide suitable linen bins in the laundry. The registered persons must ensure that 50 of care staff are trained to NVQ level 2 or equivalent. The registered persons must audit all staff files to ensure recruitment policies are being followed. The registered persons must DS0000000510.V290780.R01.S.doc 31/08/06 31/08/06 01/10/06 31/08/06 30/09/06 01/12/06 01/09/06 31/08/06 Page 27 Dolphin View Version 5.2 13. OP31 14. OP35 15. OP36 16. OP38 implement a training and development programme to ensure staff are able to meet the changing and assessed needs of residents. 10, 12, 38 The Responsible Individual must inform the Commission of the length or expected length of the registered managers absence. 17,20 The registered persons must ensure that any interest accrued on residents money is paid into their individual account. 18 The registered persons must ensure that staff receives formal supervision at least six times a year with records kept. 13,23 The registered persons must ensure that wooden chocks are not used to hold open bedroom doors. Advice must be sought from the Fire Officer. The hot food trolley must be repaired or replaced. The lounge door must be refitted. 31/08/06 31/08/06 01/10/06 31/08/06 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 OP36 Good Practice Recommendations The registered manager should consider delegating some of the supervision sessions to other senior staff. Dolphin View DS0000000510.V290780.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 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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