Inspection on 21/08/07 for Donnington House

This inspection was carried out on 21st August 2007.

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 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

Donnington House 11/02/10

Donnington House 14/12/09

Donnington House 18/11/09

Donnington House 26/06/06

Donnington House 21/09/05

Donnington House 03/05/05

Donnington House 14/10/04

Donnington House 09/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Donnington House 47 Atlantic Way Westward Ho! Bideford Devon EX39 1JD Lead Inspector Andy Towse Unannounced Inspection 10:00 21 August 2007 st 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 Donnington House DS0000053386.V333447.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. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Donnington House Address 47 Atlantic Way Westward Ho! Bideford Devon EX39 1JD 01237 475001 01237 424540 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) WWW.stone-haven.co.uk Stonehaven (Healthcare) Ltd Mrs Jennifer Mary Burrows Care Home 36 Category(ies) of Dementia (36), Old age, not falling within any registration, with number other category (36), Physical disability (36) of places Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Donnington House is a large detached property situated in the seaside resort of Westward Ho! It has recently been extended and has increased its registration to 36 older adults who may also have dementia or physical disability. The accommodation is on three floors. There is access between the floors by stairs, chairlift and a passenger lift. The majority of residents are accommodated in single occupancy rooms but there are two bedrooms which have shared occupancy. Fees charged range from £274 to £395 per week. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. It took place over two days. Information contained in this report was obtained from surveys forwarded to residents and staff prior to the inspection and by a Quality Assessment compiled by the registered manager. This information was complemented by that obtained during the inspection. This included a site visit and a tour of the premises, discussion with the registered manager, residents and staff and inspection of policies, procedures and other records held at the home, including those records relating to residents. What the service does well: What has improved since the last inspection? The home has been considerably extended since the last inspection. As well as additional bedrooms this has resulted in improvements to the physical Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 6 environment such as the installation of a passenger lift and an improved chair lift. What they could do better: 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. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 7 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 Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 8 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): ,5 and 6 Quality in this outcome area is good Donnington House operates an appropriate admissions process which ensures that only people whose needs can be met are admitted to the home. The home encourages potential residents and/or their relatives to visit the home as part of the admissions process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The admissions process was discussed with the registered manager, following which the files of three residents were inspected. There was also a discussion Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 9 with the residents about their experience of being admitted to Donnington House. Two residents who were case tracked had previously lived in other residential care homes. In one instance a relative of the prospective resident had visited Donnington House in order to see whether in her opinion it would meet her relative’s needs. The registered manager of Donnington House had also visited the prospective resident at her place of residence to carry out an assessment regarding whether Donnington House would be a suitable residence for this person and whether it would meet her needs. In another instance, several residents were relocated from another care home. The prospective residents were to be allocated newly built rooms in the extension of the home and were invited to a coffee morning. Although at that time the prospective residents were not able to see their rooms due to ongoing building work, they were able to see parts of the home and were also able to meet the staff and the owners of the home. The registered manager had spent a day in the prospective residents’ previous home during which time she was able to meet the residents and assess their needs. Relatives were also invited to be present during this period of assessment so that they could contribute any relevant information. In addition to carrying out these assessments, the files were also seen to contain other information such as photocopies of care plans which had been compiled by the previous home as well as other information supplied by social services and healthcare professionals. The manager was also able to show details of having seen a potential resident, received, information from him/her from the Social Services Department, and from this information and visit, conclude that this person’s needs could not be adequately met by Donnington House. Donnington House does not offer intermediate care. Donnington House DS0000053386.V333447.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 ,9 and 10 Quality in this outcome area is good. Residents have care plans which outline their personal, health and social care needs. Inspection of residents’ files show that they have regular access to the services of healthcare professionals The home operates an appropriate system of medication administration. Whilst the privacy and dignity of residents appears generally to be respected, observation showed this to not always be the case. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 11 The files of three residents were case tracked. All of the files contained care plans. The records relating to a recently admitted resident were seen to contain a care plan which included sections covering clinical care, physiotherapy, dental and optical needs, medication, activities and falls. The file also contained a Mental Capacity Assessment and in this instance a risk assessment relating to the resident’s capacity to self medicate, which had been signed by the resident. This and the other care plans inspected were reviewed monthly. Whilst the files of residents contained older care plans, they also now contained care plans which were common to all homes run by the ‘Stonehaven Company’ and which were referred to in the previous inspection. Entries on this file showed regular contact with healthcare professionals demonstrating that staff were observant regarding this resident’s changing medical needs. Entries showed that residents had annual eye tests and medication reviews, the latter carried out by the resident’s general practitioner. Other entries showed nurses giving advice regarding potential pressure sores, residents having blood tests and the registered manager, in discussion spoke about her intention to seek the advice of the incontinence nurse adviser regarding the needs of one specific resident. Files were seen to contain risk assessments which were regularly reviewed. Where residents had the capacity they were seen to have signed their care plans. The home has a written medication policy. This is reviewed by the registered manager. It contains a policy regarding the use of homely remedies which has been discussed with the general practitioner. Medication was seen to be kept securely. Whilst medication was seen to be placed in pots prior to it being administered, it was seen that the staff member who placed the medication in the pots also administered it. The reason given for the placing of medication in pots was that the medication trolley was too large to go into the lounge. The recording of the administration of medication was seen to be carried out correctly. Staff who administer medication have received Medication administration training. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 12 Residents spoken to said that staff respected their privacy. Staff, in conversation were able to give practical examples of how they ensured that residents’ privacy and dignity were respected. However, whilst some staff were seen to knock on bedroom doors before entering, whilst we were sat with one person in his/her room, a staff member did enter without the courtesy of first knocking on the door. During the course of the inspection it was seen that the toilets in the lounge area did not have locks. Locks to toilet doors are necessary to enure that residents have privacy. The absence of locks was pointed out to the registered manager, who, by the end of the inspection had ensured that locks had been fitted to these doors. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. The home arranges activities which reflect what the residents want. The home ensures that visitors are made welcome and residents can maintain links with the local community. Meals reflect choices expressed by residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In conversation residents said that they had the choice of when to get up, go to bed and where to go within the home. One resident still drives a car and goes wherever he/she wishes. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 14 During the inspection a resident was seen being taken out by a friend to an event in the community. The same resident was said to attend other events in the community accompanied by family members. Two other residents attend the local Whist Club with family and friends and some also attend the British Legion. Residents confirmed that they could receive visitors at any time. One spoke about a relative visiting and that visitors could come ‘when they want’ and that staff ‘always asked if they want a cup of tea.’ Another referred to a relative who had visited the previous day and who had been made welcome by the staff. Residents’ care plans contained sections which referred to their interests and the home’s ‘Statement of Purpose’ refers to the home offering those resident there a variety of activities in which to participate. In April 2007 the home sent out a questionnaire to residents relating to activities which they would like to see introduced into the home. Suggestions made were the commencement of a gardening club, a film club, a family quiz, flower pressing and more opportunities relating to cooking, such as cake decorating. Currently the home offers activities such as colouring, ball games, bingo, art and skittles. Since the questionnaire some residents have participated in cake decoration but, due to ongoing building work, the gardening club has yet to start. Every week residents also are visited by a pets as therapy (P.A.T.) dog and external entertainers, such as a musician are sometimes available. Residents spoken to said that they were satisfied with the activities available at the home. They also liked to spend time on their own doing such things as puzzles from books they owned, or, in another instance, listen to audio tapes of books of their choice. With regard to the spiritual needs of residents, Holy Communion is available. Residents are encouraged to bring with them any articles of sentimental value which they can then use to personalise their rooms. Wherever possible residents are encouraged to manage their own finances and retain their own autonomy. This was evidenced by one resident who still drives her own car. Residents were seen to be having their meals in relaxed surroundings and eating in a leisurely manner. There was a choice of both main and sweet courses. In March 2007, the residents had been given the opportunity to comment on the meals and express their preferences in a ‘Food Questionnaire’. Of the 23 residents living at the home, 22 had replied. These responses included suggestions about what different foods could be added to the menu. These Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 15 included lasagne, curry and pigs’ trotters. Whilst the curry has been tried and will be added to the monthly menu, the home is still trying to locate a source of pigs’ trotters. Three residents spoken to said that they enjoyed the food available at the home. One said that the food at the home was ‘very, very good’ and then referred to there being a choice, with especial reference to what was available at breakfast time. Donnington House DS0000053386.V333447.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): 16 and 18 Quality in this outcome area is good. Residents are protected by the home’s complaints procedure and a staff group who are knowledgeable about what constitutes abuse and what to do if they suspect that it is occurring. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Donnington House has a written complaints procedure. It contains information regarding the timescales for the completion of investigations and also details of who to contact when making a complaint. It also states the right of any complainant to contact the Commission for Social Care Inspection at any time during the complaints process. Copies of the complaints procedure are displayed in various places around the home to ensure that visitors and residents are aware of its existence. Copies have also been placed on the doors of every resident’s bedroom. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 17 The home also has a ‘Whistle-Blowing Policy’. This policy offers protection to staff who complain or raise concerns about abuse or poor practice within the home. The registered manager is aware of the Protection of Vulnerable Adults (POVA) register and the need to safeguard residents by putting forward for inclusion on it, the names of any staff who are considered unsuitable to work with vulnerable adults. As part of the home’s training programme, all staff received training relating to the protection of vulnerable adults in 2006. Training relating to abuse is also covered in the ‘Skills for Care’ training which staff undergo. Residents spoken to were confident in approaching the manager if they had any concerns or wished to make a complaint. In addition to this, a ‘Suggestions Book’ has been placed on each floor into which residents or any interested parties are free to make comment. At the time of the inspection there were no entries in either of these books. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. The home is undergoing considerable development. This has been manage managed in such a way as to minimise the inconvenience to residents. The resultant environment, when work has been completed, will meet the needs of those who live there, providing that the existing lower ground floor is brought up to the same standard as the areas of the home which have just been built. EVIDENCE: Since the last inspection the home has been re-registered to accommodate a further ten residents. This has meant that considerable building work, both Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 19 internal and external to the premises has, and is continuing to take place. The manager described the actions she had undertaken to ensure the health and safety of residents during this time, and also how she had ensured that the building work was as unobtrusive as it could be for residents. In discussion the residents said that they had not been too inconvenienced by the building work. The home now accommodates 35 residents. The ten new bedrooms are all on the ground floor and have ensuite facilities. The building work has also lead to an additional lounge being installed, extra toilets and an upgrading of some toilet and bathing areas into easily accessible and useful wet rooms. The two tier chairlift to the upstairs rooms has been replaced by a new one and a passenger lift now links the first floor with the one below it. A considerable amount of redecoration has accompanied the extension. The downstairs of the property, where the majority of residents are less able remains unaltered by the extension work and refurbishment. This part of the home still retains the ‘tired’ look referred to in the previous inspection report. There was also a malodour and the landing carpet is still old and stained. The registered manager said that it is her intention to have this area of the home brought up to the same standard as the upper floors and the extension, however, whilst building work is in progress she was deferring replacement of carpets. To ensure that the carpets were kept in an hygienic state she has it professionally cleaned each month. The communal area on the lower level has been improved by the enlargement of the conservatory area and a grant has been obtained which we were informed, would be used to ensure that the lower ground floor was upgraded to the same standard as the rest of the premises. The laundry area remains, as in previous reports, a separate room with washable walls and a water proof floor and adequate to meet the needs of the current residents. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 and 30 Quality in this outcome area is good. Staff numbers are adequate to meet the needs of residents Residents benefit from a workforce which receives ongoing training and development Residents are protected by the home’s robust recruitment procedure. The home offers its staff an appropriate induction. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Rotas were shown and there was discussion between the registered manager, staff and residents regarding staffing levels in the home. Rotas showed that at peak times during the day there were three staff on duty on the lower ground floor which accommodates up sixteen residents and three staff on the ground and upper floor which accommodates a maximum of twenty residents. The staff numbers did not include those of the registered manager. Night cover is Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 21 supplied by two wakeful night care assistants, with the support, if necessary of a third staff member who is rostered to sleep in on the premises. Rotas are arranged to afford an overlap of workers between shifts to facilitate the exchange of information between shifts. Staff were asked if they considered that the staffing levels were sufficient to meet the needs of those who lived there. They confirmed that they considered that they were. The home has acomitment to staff attending NVQ training courses. Whilst two of the staff are NVQ assessors, the home still uses a local college for its NVQ training needs. Currently the home has a staff group comprising 23 care staff of whom 11 have NVQ 2 or above qualifications with the majority of the remaining staff either on NVQ training courses or preparing to commence such training. In addition to NVQ training, some staff have attended training relating to dementia which was arranged through a local college. This assists staff in understanding and meeting the needs of residents who have dementia. Other staff are scheduled to attend courses relating to working with people who have dementia. In addition to the above training staff also attend the statutory training such as Moving and Handling and Fire Safety. The files of recently recruited staff were inspected. All were seen to contain police checks, two appropriate references and required documents to verify the identity of the staff concerned. These records also showed that no staff had commenced work at the home until the registered manager had obtained letters to show that the potential staff had not had their names placed on the Protection of Vulnerable Adults (POVA) register. Anyone whose name has been placed on this register is regarded as unsuitable to work with vulnerable adults and would therefore be unsuitable to be employed in a care home. Staff files contained information which showed that all new staff now undergo an induction programme. Senior staff are responsible for working through and ensuring the new staff successfully complete their induction. The induction is a recognised induction programme, compiled by Skills For Care, and serve to ensure that staff are acquainted with the necessary knowledge and skills to work with people receiving care. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35, 36 and 38 Quality in this outcome area is good. The registered manager has the experience and qualifications expected of someone managing a residential care home. The use of quality assurance questionnaires ensures that the views of residents and stakeholders can be taken into consideration regarding the development of the service. The homes’ policies and procedures safeguard residents’ finances Whilst the home offers it’s staff supervision, improved recording would ensure that it’s frequency could be more easily monitored. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 23 Residents health and safety is safeguarded by the home’s policies, procedures, staff training and maintenance of equipment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has completed her Registered Manager’s Award and holds an NVQ 4 qualification. She has been manger of Donnington House for over four years and has previous experience of working with elderly people in a residential care environment. She has also attended training events to ensure that she is aware of changing legislation or other issues relating to the running of a acre home. An example of this was her recent attendance on a course relating to the ‘Mental Capacity Act’. The home has an ongoing quality assurance system. As one of a number of homes run by the same group, it receives regular visits by an employee of the company whose remit is to inspect the home and advise on any issues relating to good practice or the National Minimum Standards. The home submits weekly, monthly, quarterly, bi-annual and annual reports tt the main office regarding the running of the home. Questionnaires are also submitted to residents regarding issues relating to the care they receive. Examples of these, concerning menus and activities have been referred to previously in this report. Responses to these questionnaires are used by the registered manager in ensuring that the running of the home reflects the views of residents. In addition to questionnaires being forwarded to residents, questionnaires are also forwarded to other stakeholders such as relataives and general practitioners. Wherever possible residents take responsaibility for their own finances, or their relatives assume this responsibility. In instances where this is not possible the home operates a system which protects residents. Staff within the home receive supervision. The registered manager and deputy manager supervise designated staff. Whilst the supervision takes place, records were insufficient to confirm the regularity with which it took place. Random inspection of records made available at the time of the inspection showed that the home is run in a way which protects the health and safety of those who work and reside there. Examples of this were certificates showing the safety of electrical installations within the home, the testing of fire safety equipment and staff having training regharding moving and handling, food hygiene and fire safety. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 24 Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 25 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 3 X X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP10 OP36 Good Practice Recommendations The registered manager should ensure that all staff realise the importance of ensuring that residents maintain their privacy and dignity. Improved recording regarding supervision would ensure that it’s frequency could be more easily determined. Donnington House DS0000053386.V333447.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Donnington House DS0000053386.V333447.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. 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