Inspection on 13/07/06 for Donness Nursing Home

This inspection was carried out on 13th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Donness Nursing Home 14/07/09

Donness Nursing Home 20/08/08

Donness Nursing Home 03/09/07

Donness Nursing Home 14/09/05

Donness Nursing Home 07/04/05

Donness Nursing Home 15/11/04

Donness Nursing Home 05/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Donness Nursing Home 42 Atlantic Way Westward Ho ! Bideford Devon EX39 1JD Lead Inspector Victoria Stewart Key Unannounced Inspection 13th July 2006 9:45 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 Donness Nursing Home DS0000026712.V294564.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. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Donness Nursing Home Address 42 Atlantic Way Westward Ho ! Bideford Devon EX39 1JD 01237 474459 01237 479349 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) Mrs Yvonne Lesley Thelma Newton Mr Paul Christopher Newton, Mrs Esther Waldron Mrs Yvonne Lesley Thelma Newton Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To include a maximum of up to 3 named residents with a learning disability need who are under the age of 65 years The maximum number of persons accommodated at the home will remain at 34. 14th September 2005 Date of last inspection Brief Description of the Service: Donness Nursing Home is a privately owned home registered to provide nursing care for 34 service users who are over 65 years of age. Within the overall number of 34, the home can accommodate four people with a learning disability need under the age of 65 years. Donness is a detached, three storey property situated in the Westward Ho! area of Bideford. It occupies an elevated position and offers far ranging views to the nearby coastline. It has recently undergone modernisation with a new wing being built and modern facilities installed. All areas of the home can be accessed by one of the two passenger lifts. There is a selection of communal areas, which includes two dining rooms, three sitting rooms and a visitors lounge/quiet room. Accommodation comprises of four double rooms, and twenty-six single rooms, many of which have en-suite facilities There is a large sun balcony with lovely views, which extends from the sitting room to the front of the building. A direct bus route to and from Bideford is available. The cost of care at the time of the inspection was £485 to £530 per week. Chiropody, toiletries, newspapers/magazines, personal items, clothing and hairdressing are additional costs which are not included in the fees. The latest CSCI report is available at the home, with further copies available on request. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the planned inspection programme for the year 2006/7. An additional visit was been made to the home since the last inspection to investigate a complaint and communications have also taking place with the home and the CSCI regarding the staffing levels of the home. Two inspectors, Vickie Stewart and Susan Lyons, took 8 hours to complete the inspection. Brian Brown, the CSCI Pharmacist inspector assisted them for part of the day - he looked at the medicines in the home. The home was not full on the day of inspection, but the inspectors either spoke to or saw all of the residents there. It was difficult to obtain meaningful information from many of the residents, due to lack of verbal communication or the fact they were unable to understand what the inspectors were saying. Prior to the inspection, a number of information surveys were sent out. Seven out of sixteen sent to residents were returned; four out of eight sent to health or social care community based professionals were returned; five out of eight sent to relatives were returned and six out of twelve sent to care staff were returned. This report is written with information gained from the pre-inspection questionnaire completed by the home, by talking with residents, staff and management, by looking at a selection of records (including resident files, staff files, medication records, staff training records, quality assurance records, health and safety records, observation and by undertaking a tour of the building. The outcome of the inspection was fed back, discussed and agreed with the registered manager prior to the inspectors leaving the home. What the service does well: Care plans contain good information in enough detail to ensure that staff is all supporting residents in the same individual way. They are also being reviewed on a regular basis. A range of activities are provided on a regular basis, which include physical exercises, craftwork and games. Residents are able to choose when they wish to get up and go to bed and individual needs in relation to mealtimes are met. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 6 The house is pleasantly decorated with specialist equipment provided where it is needed. The home was clean and well maintained at the time of the inspection with a friendly and welcoming atmosphere. Staff have undertaken some specialist training in relation to learning disability and further training is planned for later in the year. What has improved since the last inspection? What they could do better: Prospective residents’ care needs must be assessed before they are admitted to the home, either by a health or social care professional or a trained staff member of the home, to ensure that their care needs can be fully met. The Service Users Guide needs to contain details of the range of needs of services offered by the home and the Statement of Purpose needs to contain all the information required about the services and facilities provided by the home. Whilst staff were considerate and respectful to residents, some aspects of privacy and dignity in the home need addressing and improving upon. Unsafe aspects of medication management must be addressed so that residents’ wellbeing is not at risk. Residents enjoy the food served, but aspects of choice of food, how it is served and staff assistance at mealtimes could be improved. The home must ensure that no member of staff works unsupervised until all the pre-employment information needed has been obtained - this needed immediate action. Records of residents’ money do not contain a receipt or signature when a relative brings in money and care needs to be taken to ensure that residents’ money held on their behalf is correct. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 7 There are generally good systems to ensure the health and safety matters are attended to, but further measures must be taken to fully protect residents and staff from unnecessary harm – one of which needed immediate action. 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. Donness Nursing Home DS0000026712.V294564.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 Donness Nursing Home DS0000026712.V294564.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): 1, 3, 4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides some information to prospective residents - but this does not include enough detail to allow them to make the choice about whether they wish to live at the home or not. The assessment information for some residents is poor and inconsistent potentially putting residents at risk and could result in needs not being met. EVIDENCE: The Statement of Purpose is in the form of a Quality Statement. However, this document needs to include all the information about the home and the services it provides which should be available to residents, relatives, placement officers etc. The Service Users Guide (SUG) was displayed in the hall and contained some useful information about the home. However, neither of these documents mentioned the fact that the home accommodates people who may Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 10 also have a learning disability need - four of whom may be under the age of sixty-five years. The two inspectors looked at eight resident care files overall, a mixture of those residents who older persons’ needs and those residents who have learning disability needs. Out of the four older persons’ care files, only one contained an appropriate assessment carried out by a health or social care professional, prior to living in the home, which included all the details necessary to begin to plan care. Out of the four files for residents with a learning disability need, only one had the necessary assessment completed. It was accepted that some of the other residents who have been living at the home for sometime might not have a copy of the shared assessment (health and social services assessment) due to the length of time they have been at the home. However, it was noted that two of these residents who have been admitted during the past twelve months, and were referred through a care manager, do not have such an assessment. Assessments, which have been completed by the home, do not give a clear picture of residents’ needs in all cases. If detailed assessments are not completed there is risk of a resident being admitted to the home whose care needs cannot fully be met. The home is currently accommodating eleven residents who have a learning disability need, four of which are under the age of sixty-five. Of those residents who were case tracked it was seen that the home is meeting their current needs. Some training has recently been introduced to the home concerning learning disability and although this was brief the home intends to continue with some more training. The inspectors were told that residents are able to come and visit the home prior to moving in and in some cases people have made more than one visit. Donness Nursing Home DS0000026712.V294564.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 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 adequate. This judgement has been made using available evidence including a visit to this service. There are good systems in place for informing staff about residents’ care needs - although a lack of detail in some care plans may lead to inconsistencies in care. Some aspects of the management of medication within the care home is poor and has the potential to place service users at risk of harm. Whilst staff ensure that some aspects of residents’ privacy and dignity needs are met – there are other areas that need improving. EVIDENCE: Seven residents care files were looked at. Although inconsistent in places in some residents’ files, these generally held some good information about how to meet residents’ individual care needs and included suitable risk assessments and psychological assessments (if necessary). Some files contained details of preferred residents’ activities. Information is also gained relating to the resident’s wishes following death. Other care files demonstrated good detail of Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 12 how residents’ needs are to be actually met, for example how to communicate, how many pillows a person likes and their preferred bedtime drinks. One staff member told the inspector how she recognised signs the resident made and understood what they indicated - it would be useful for these to be included in the care plan too. Resident and relative surveys returned confirmed that it was felt that all health needs were being well met. One relative commented that previous homes had been tried for his relative, but that they were unable to “cope with her needs and care was poor”. At Donness the relative was “happy and contented” and that the resident’s “physical and mental needs are being met”. Evidence was seen that residents are registered with a local GP and other health or social care professionals have been involved in the past where required. Surveys returned from community-based professionals were complimentary of the home. Specialist equipment is provided to maintain tissue viability for residents where necessary. Medication requiring refrigeration is stored in the domestic refrigerator located in the kitchen. No records are held to demonstrate that this medication has been stored in the range recommended by the manufacturer. The Medication Administration Records had very few gaps present for when medication had been given. However, for those medicines prescribed to be administered with a variable dose, many do not have records to indicate the amount actually given. Many of the hand written entries on the Medication Administration Record charts, although signed by two people, were not dated to indicate when the entry had been made. The medicines treatment room contained many out of date products for example blood glucose monitoring strips that were currently in use, urine testing strips and syringes. All medication is dispensed in the central medication room and then carried around the home to individual residents. Staff were able to tell the inspectors in their interviews how they promoted residents’ privacy and dignity when they are providing personal care. The inspectors saw that staff were seen to knock on bedroom doors before entering. However, some other issues of resident privacy and dignity are not addressed in the home; for example some of the toilet doors in the home do not contain appropriate locks/signs to indicate when they are in use and one inspector saw that residents were being disturbed whilst using the toilet and unnecessarily exposed. During the lunchtime meal, the inspectors felt that some residents, who required staff assistance, were being rushed to eat. Also after the meal staff washed residents’ hands and faces - whilst this practice was good, the inspector felt it could have been done more privately and more discreetly. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 good. This judgement has been made using the available evidence including a visit to this service. Residents are able to exercise some choice and control over their day-to-day lives where possible. The home offers a programme of social and recreational activities which residents enjoy. The home provides a welcoming and friendly approach at all times when relatives and friends visit. The diet offered is adequate – with menus being simple and meals palatable, but aspects of provision, choice and variety need improvement. EVIDENCE: Some of the residents’ interests were recorded on their individual care plans and the home provides specific staff to undertake activities in a group session. Activities in the home are varied and can be arranged for all the residents, some of the residents or individual residents. Staff said that they would like to take residents out more often but this was difficult due to staffing levels and lack of transport available. On the day of the inspection a planned quoits and Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 14 exercise activity was taking place in one of the lounges. Residents also have the opportunity to do craft work – with cards and boxes made which were seen. The inspectors were informed that staff do some sensory work with residents who are being nursed in bed. This information, however, was not in the care plan or recorded in the daily recording. One resident continues to go out to a social club, which he attended before living at the home. Visitors are able to visit when they wish and surveys confirmed they are always made to feel welcome at the home – one commented, “it would be very hard to find a better one”. Residents are able to choose which time they like to get up and the time they like to go to bed. It was good to see that a specific need in relation to meals for one resident was being met. The home had been through a difficult time recently, trying to find a suitable permanent replacement cook for the home. The menu plans provided by the home show basic food served. No choice is offered at lunchtime and tea is limited for example “tea – selection of sandwiches” or “hash browns with beans and jelly and fruit”. The main meal of the day shows no detail, for example “chicken, vegetables, potatoes”. Breakfast is “usual”. No menu display board was seen in the home. The inspectors were told that this is soon to be resolved with a new cook starting very soon. The inspectors saw lunch being served which appeared pleasant – although one resident’s looked “dried up” as it was served later than the others. One resident described the meals as “satisfying”, whilst another was asked if they liked the meals and the reply was – “definitely”. The inspectors’ felt that certain aspects of the care residents received at lunch could be improved upon (see NMS 10 for details). Care staff who commence work in the afternoon, start their shift early and work in the kitchen to help with lunchtime meals. The home employs hospitality carers whose roles it is to serve drinks, serve meals and help to feed residents. These members of staff work in the morning and in the afternoon. Staff commented that they would like to see a dishwasher installed in the kitchen which would enable them to do their jobs more efficiently. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 good. This judgement has been made using available evidence including a visit to this service. The home has a good complaints system with evidence that residents, relatives and professionals feel their views are listened to and acted upon. Residents are protected from abuse by staff, who understand the principles of adult protection and are aware of the procedures to take. EVIDENCE: The home has a suitable complaints policy, which is displayed in the home, although no mention that a complainant can contact the home at any time is written in it. No complaints were received on the day of inspection. One complaint had been received by the CSCI in November 2005 and had now been resolved following one requirement and one recommendation made by the CSCI to improve practice. A health/social care professional commented in one of their surveys that a complaint had been received about a resident at the home and that the home had dealt with it appropriately and the issue was now resolved. Resident and relative surveys confirmed that staff listened to them and they knew who to make a complaint to if needed. Staff interviews confirmed that they had a good awareness of adult protection issues and knew what to do if this occurred. Two training sessions had been planned for staff in the Protection of Vulnerable Adults; one was taking place on the afternoon of the inspection. Donness Nursing Home DS0000026712.V294564.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the benefit of living in a home that is generally safe, well maintained and homely EVIDENCE: At the time of the inspection the home was clean and well maintained. There is an attractive balcony for residents to sit on with views of the sea. A gazebo is provided which offers shade over the chairs. The home is decorated to a high standard with evidence of ongoing maintenance. Specialist equipment for pressure relief and to aid mobility is provided as well as specialist baths, rails around toilets and a shaft lift. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 17 During a tour of the premises, the inspectors noted that some of the toilet door locks were either broken or missing and were therefore unable to be locked to provide residents with privacy and dignity (see NMS 10 for details). The home has suitable laundry facilities. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff is sufficient to meet residents’ needs. Residents benefit from staff who receive the training necessary to allow them to do their jobs well. The staff recruitment procedures are generally good, but are not always robust enough to protect residents living at the home. EVIDENCE: Surveys completed by residents, residents and health/social care professionals describe staff as friendly, approachable, professional and caring. One resident said “taking everything into consideration, it is an excellent home with loving, caring staff” and another said “I like the staff and have a good relationship with all staff members”. Health/social care professionals described the “staff and management are always welcoming when visiting the home” and the home is “lovely, with lovely care and atmosphere”. The home was suitably staffed on the day of inspection. The majority of the team of care staff appear to be quite young and the inspectors felt they were caring and motivated. Staff commented that they would like more time to spend with residents. Two qualified Registered General Nurses (RGN) were in Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 19 charge of the home when the inspection commenced. The manager arrived at the home in the late morning/early afternoon. Four staff files were looked at. These all contained the information required but one file did not have a Criminal Records Bureau (CRB) check. This member of staff was working in the home unsupervised and an immediate requirement to stop this practice immediately was issued (until a satisfactory CRB has been received). The manager informed the inspectors that she did not know that this person was working unsupervised in the home. Staff have received some specialist training in relation to learning disability and some more is planned for the future. One new member of staff had recently received a suitable induction programme before undertaking NVQ training and this included training in fire, manual handling and abuse. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a good communication between staff, residents and the manager. Record keeping in the home is adequate, but improvements would mean that residents are fully safeguarded. Residents are involved in the running of the home, with some evidence that their views are sought. The practices relating to the health, safety and financial procedures of the home are adequate but need further improvement to prevent residents being placed at unnecessary risk. EVIDENCE: Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 21 The registered manager is a Registered General Nurse and almost completed the Registered Manager’s Award (RMA). She has owned and managed the care home for many years and staff surveys indicated that the majority of staff felt that the manager was approachable and listened to them. Questionnaires sent out to residents and visitors were looked at. These were very positive about the service and included views on subjects such as the quality of care, cleanliness, laundry and meals. Comments included “lovely, caring and friendly atmosphere”, “excellent all round care” and “wonderful nursing home with excellent care provided”. These questionnaires are sent out yearly with the last one returned in June 2006. The inspector was told that residents’ meetings are held every 12/16 weeks, but recent minutes of these meetings could not be found on the day of inspection. The last staff meeting was held recently when staff had the opportunity to help set the agenda. The records relating to residents’ monies were looked at. A record is maintained and receipts kept. Records showing the amounts of money deposited by relatives on behalf of residents showed that these are signed by staff members and no receipt given. Ways of improving this practice were discussed on the day of inspection. The amounts of money held were checked against records and it was noted that two residents’ monies were incorrect, showing a deficit in the actual amounts held than written in the records. During a tour of the premises, the inspectors noted that one of the resident’s bedroom doors (fire door) was wedged open and staff confirmed in their interviews that they know this practice is wrong but that it regularly happens. An immediate requirement was issued to stop this unsafe practice immediately. Staff mandatory training is undertaken including manual handling and fire. However, not all staff were able to attend the recent training and no further dates had been planned as yet to ensure all staff undertook this training. The inspectors found it difficult to check the staff training records as these are not held on a central record and are not always on staff’s files, for example details of recent fire training was written in the diary but no record of who attended. Servicing and maintenance of equipment is regularly undertaken. Fire records were checked and found to be satisfactory. Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 22 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 2 X 1 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1) c Sch 1 Requirement The registered person shall compile a statement as to the matters listed in Schedule 1. With regard to: • Ensuring that all prospective residents (and other interested parties) have access to the statement of purpose which details the facilities and services offered by the home, allowing them to make an informed decision about whether to live in the home or not. Timescale for action 13/09/06 Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 24 2. OP3 14 (1) a,b 3. OP9 13 (2) The registered person shall not 13/08/06 provide accommodation to a service user at the care home unless a suitably qualified person has assessed the needs of the service user; the registered person has obtained a copy of the assessment. With regard to: • Ensuring that all residents have a suitable assessment carried out by a recognised professional before they are admitted to the home - to ensure that the home can fully meet the individual needs The registered person shall make 31/08/06 arrangements for the safe keeping and safe administration of medicines in the care home. With regards to: • Ensuring that medication requiring refrigeration is stored within the temperature range as directed by the manufacturer • Ensuring that all medication and sterile products are removed after they have reached their expiry dates Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 25 4. OP10 12 (4) a 5. OP29 18 (2) 6. OP37 17 (2) Schedule 4 – a,b The registered person shall make 13/10/06 suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of the service users. With regard to: • Ensuring that residents are able to use the toilets in private without being disturbed and exposed • Ensuring that cleaning residents after lunchtime is carried out in a more dignified manner • Ensuring that those residents that require assistance at mealtimes are helped in a dignified manner and unhurried manner The registered person shall 13/07/06 ensure that persons working at the care home are appropriately supervised. With regard to: • Ensuring that all staff that have been employed to work at the care home have had all the necessary pre-employment checks carried out including a suitable Criminal Records Bureau check. Until that time all staff must be directly supervised when delivering personal care to any resident. The registered person shall 13/09/06 maintain in the care home the records specified in Schedule 4. With regard to: • Ensuring that accurate and up to date financial records are held for each individual resident in the home Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 26 7. OP38 13 (4) a,c The registered person shall 13/07/06 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. With regard to: • Ensuring that all fires doors are closed and not wedged open. If fire doors are to be kept open, then the appropriate and suitable equipment must be used to allow this 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 OP9 Good Practice Recommendations It is recommended that when an entry is hand written on to the Medicines Administration Record chart that this is signed and dated by the person making the entry and that it is then checked and countersigned by a second person. It is recommended that the menu, choice and variety of food served is reviewed and amended with resident involvement in the process. 2. OP15 Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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. Extracts may not be used or reproduced without the express permission of CSCI Donness Nursing Home DS0000026712.V294564.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!