Inspection on 10/05/05 for Dormers

This inspection was carried out on 10th May 2005.

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

Dormers 04/01/07

Dormers 31/10/05

Dormers 13/12/04

Dormers 07/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Dormers Foxon Lane Caterham Surrey CR3 5SG Lead Inspector Ms S Magnier Unannounced 10 May 2005 08.20 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 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. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dormers Address Foxon Lane, Caterham, Surrey, CR3 5SG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01883 330927 Surrey County Council - Adults & Community Care Christine Whiting CRG Care Home 47 Category(ies) of DE(E) Dementia - over 65, 20 registration, with number MD(E) Mental Disorder - over 65, 6 of places OP Old Age, 33 PD(E) Physical Disability - over 65, 5 Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Accommodation and Services may be provided to named persons aged 6065 years with the prior written agreement of the CSCI. 2. Intermediate Care may be provided to One Service User on Rose Unit the remaining beds on Rose Unit will only be used for Respite Care. 3. Respitwe Care may be provided to a maximum of 5 persons at the same time. 4. Bluebell Unit will be used exclusively for Dementia Care. A maximum of 6 Service Users with Dementia may be cared for in other parts of the Home. 5. In addition to Service Users accommodation at the Home, Day Care may be provided on the Day Care Unit to a maximum of 7 persons. Date of last inspection 13 December 2004 Brief Description of the Service: Dormers is located in a quiet residential area close to local amenities. Care and accomodation is to provide older people some of whom have dementia. The home is operated by Surrey County Council and was purpose built in 1982. Accomodation is arranged in 6 units at ground and first floor level. Each unit has its own bathroom and toilet facilities and a communal lounge/dining area. All bedrooms are single. Offices are situated o the ground floor and first floors. All floors are accessed by means of a shaft lift. The main kitchen is located on the ground floor. In addition, part of each communal area is also equipped as a kitchenette. The home has ample off street parking and an enclosed garden. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours during the early morning and afternoon. A large proportion of residents and staff were spoken with during the day including the Registered and Deputy Manager. Care plans, risk assessments and other records were seen and a tour of the premises was undertaken. What the service does well: What has improved since the last inspection? 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. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 7 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 standard(s) 1,2,3,4, The home has clear information for residents to make an informed choice regarding their stay at the home. EVIDENCE: The Inspector sampled the resident’s statement of terms and conditions of their stay, which were found to be adequate. The service user guide and the homes statement of purpose were sampled and were clear, comprehensive and available to residents and their significant others. There was evidence that full assessments of resident’s needs had been undertaken, by suitably qualified staff trained prior to a person moving into the home. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 8 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 standard(s) 7,8,10, The home continues to meet the health and personal care needs of the residents through a comprehensive care planning system. EVIDENCE: The home has made strenuous efforts to improve and develop the residents care plans. Each plan contains a comprehensive and detailed account of all the needs of the residents and is complemented by a risk assessment. Daily records are documented by care staff in each resident’s personal care record. Each resident also has a personal file, which is kept securely. The inspector sampled the records of a resident who moved the home five months earlier and a full care plan had not been documented. The Manager advised that this should have been attended according to the homes policy in six weeks. A requirement has been made that all residents have a full documented care plan in order to ensure that all their needs are met. Several care plans sampled had not been reviewed and updated. A requirement has been made that all staff must update care plans each month to ensure that the residents needs are being fully met and changing needs are identified. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 9 Feedback from residents about the home included the following: ‘I’m very happy with my care, they’re wonderful workers, where would I be without them, they like their work’ ‘They look after me well’ ‘I had a chest infection and they brought the doctor in for me’ ‘I see the chiropodist and the optician’ ‘The hairdresser comes and I have my hair done every two weeks.’ Feedback on written comment cards indicated that some resident’s felt their privacy was not respected at all times and that other residents came into their private space. It is recommended that the Registered Manager look’s into this concern. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 10 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 standard(s) 12,13,14,15 The home is a busy and happy environment offering stimulation, support and ensuring that residents maintain social contacts. EVIDENCE: Several residents were seen to move around the home freely and also using the public telephone area and reading daily newspapers, which are delivered to the home. A mobile library and shop for confectionary and other small items are also available to residents. One resident was supported by staff to the small internal lobby area to have a cigarette. One resident told the inspector ‘I’m very happy with the home, if I could change anything I would get in the car and go for a drive’. Other comments included ‘My nephew and nieces come in and see me every weekends,’ and the ‘Priest visits each week to give Holy Communion’; ‘ my wife becomes much more articulate and clear speaking when staying here and I am very impressed with the care’. All the comment cards sent to the inspector said that the home offers suitable activities with one resident requesting that staff take them swimming. The meal times of breakfast and lunch were observed and the meals were prepared and served by staff to a high standard. Each table was thoughtfully Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 11 presented with condiments, napkins and homely tableware including on each table a printed menu. Staff supervising the meal times offered choice, support, promoted resident’s independence and meals were served in a quiet and unobtrusive manner. The residents spoken with complimented the staff and the Chef who they said took time to speak with them individually to ask them what their meal/food preferences were and also to make sure that the meals were alright. Two comment cards from the residents stated that they only sometimes liked the food. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 12 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 standard(s) 16 The home has a clear, appropriate complaints procedure. The procedure could be made more accessible to residents and visitors. EVIDENCE: The home has received no complaints. The complaints procedure was sampled as concise and clear. Despite the complaints procedure being available in the home one comment card from a visitor to the home stated that they did not know how to make a complaint. A recommendation has been made that the Managers place a copy of the complaints procedure in the separate communal areas of the home to ensure that residents and other people visiting the home have access to the procedure. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 13 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 standard(s) 19,20,21,22,23,24,25,26 The areas of the home seen during the inspection were clean comfortable and offered a safe homely environment for the residents. EVIDENCE: The home was clean and bright. The resident’s bedrooms reflect their own lifestyle and preferences, which include their furniture including beds, chairs, bedding and ornaments including photographs of loved ones. Several residents had televisions, radios, music centres and their own telephones. Throughout the home Braille signage was available to residents with impaired vision. The housekeeping staff stated that they like their jobs and for some it was convenient with living locally. Staff were aware of the Control of Substances Hazardous to Health guidance and the storage areas throughout the home for the housekeeping equipment were orderly and well managed. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 14 The hairdressing room was well equipped and a recommendation has been made that the room is decorated and more clearly defined as a hairdressing area in order to offer the residents additional change of environment and stimulation. Two of the hairdressers working in the home have achieved NVQ in hairdressing. Several bathrooms throughout the home have been redecorated and offer a less clinical environment for residents when bathing. The equipment used to support residents with bathing had been regularly serviced to ensure safety. It is recommended that the toilet areas within the home be decorated to make them less clinical and more homely for the residents. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 The home must continue to develop a robust recruitment and selection process and ensure that all staff are receive training appropriate to the work they have to perform. EVIDENCE: The home has recruited a new Receptionist who has developed a newsletter for the residents. This was viewed as bright, informative and offered articles of interest of topical subjects, local history news, and special events of interest e.g. the meaning of Easter in differing cultures and the Royal wedding. The staff files indicated that staff job descriptions were out of date and did not reflect the current duties being carried out by staff. The Managers advised the inspector that Surrey County Council were still holding meetings regarding the updating of the job descriptions for all staff. It is recommended that this be achieved as soon as possible. All staff CRB’s were sampled by the inspector. The home does not currently have an Induction plan for Agency staff. The inspector and the Managers discussed a way in which this requirement could be achieved within the timescales set. One staff file sampled needed to be updated to include the staff members current job description, title and to indicate that a documented selection process e.g. interview had taken place. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 16 The training records sampled were difficult to track the staff training to ensure that all training needs had been met. A requirement has been made that all staff working in the home including Agency staff have received training adequate to the work they are to perform and training records are available in the home. The Managers told the inspector that the home would be undertaking Dementia training with an external provider who has already completed assessments of the home. This is a positive development with regard to staff support and provision for residents with dementia. The Inspector sampled the chiropodist file and noted that no certificate of insurance was available. A requirement has been made that is obtained to ensure the safety and well-being of the residents. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 The management and administration of the home is both professional and robust. EVIDENCE: The management of the home is effective, orderly and stable. The Managers have made a concerted effort to supervise staff and the senior care staff ‘review’ the performance of the care assistants. The Managers expressed concern as they are aware that the regulations of staff supervision is not currently being met and a requirement has been made that they continue to be proactive in the support of staff needs and performance. The Inspector discussed the possibility of reviewing the format of the supervision record in order that time management issues could be addressed. The Manager audits all incidents, including falls sustained by residents. These are discussed at the team meetings and this was observed to be good practice. The inspector has requested the monthly audit to be sent routinely to CSCI. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 18 The management of the home ensure that the health and safety of residents is paramount and sound procedure e.g. the testing of water temperatures recorded prior to residents having a bath are in place. A requirement has been made that the rusting radiator cover in the hairdresser’s room be replaced. The inspector noted a staff member walk down corridor with an uncovered commode pan. A requirement has been made that all staff must be mindful of control of infection and maintain the dignity and respect of residents. Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 3 3 x x 2 x 2 Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15.(1)(2)( a)(d) Requirement The Registered Persons must ensure that all residents have a full documented care plan in order to ensure that their needs are met. The Registered Persons must ensure that all care plans are reviewed and residents notified of any revision. The Registered Persons must ensure that all staff receive adequate supervision of their work. The registered Persons must ensure that Agency staff receive structured induction training. The Registered Persons must ensure that all staff files reflect the current job description, title of the staff member and evidence that a documented selection process e.g. interview had taken place. The Registered Persons must ensure that all staff, (including Agency) recieve training appropriate to the work they are to perform. The Registered Persons must obtain a current certificate of insurance from the chiropodist Timescale for action 13.5.05 2. 7 15.(2)(b)( c) 18.(2)(a) 10.6.05 3. 36 10.8.05 4. 5. 30 30 18.(1)(c(i ) 17.(2) Schedule 4 10.8.05 10.8.05 6. 30 18.(1)(c(i 10.8.05 7. 30 7,9, & 19 Schedule 2.5 & 9 24.5.05 Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 21 who visits the home. 8. 38 23(2)(d) The Registered Providers must ensure that the rusting radiator cover in the hairdressers room must be replaced. The Registered Provider must ensure that the home is conducted in a manner that respects the privacy and dignity of residents. 10.8.05 9. 38 13.(3) 12.(4)(a) 13.5.05 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 10 Good Practice Recommendations Comment cards indicated that some resident’s felt their privacy was not respected at all times and that other residents came into their private space. It is recommended that the Registered Manager looks into this concern. A recommendation has been made that the Managers place a copy of the complaints procedure in the separate communal areas of the home to ensure that residents and other people visiting the home have access to the procedure. The hairdressing room is decorated and more clearly defined as a hairdressing area in order to offer the residents additional change of environment and stimulation. Several toilet areas throughout the home should be decorated to offer a less clinical environment for residents. It is recommended that the revision of staff job descriptions be achieved as soon as possible. 2. 16 3. 20 4. 5. 25 29 Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Dormers H58_s33582_Dormers_v225861_090505_stage 4.doc Version 1.30 Page 23 - 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. 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