Inspection on 04/01/07 for Dormers

This inspection was carried out on 4th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dormers 31/10/05

Dormers 10/05/05

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 Vera Bulbeck Unannounced Inspection 10:15 4 January 2007 th 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 Dormers DS0000033582.V302555.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. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dormers Address Foxon Lane Caterham Surrey CR3 5SG 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) 01883 330927 Surrey County Council - Adults & Community Care Christine Whiting Care Home 47 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (33), Physical disability over 65 years of age (5) Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Accommodation and Services may be provided to named persons aged 60 - 65 years with the prior written agreement of the CSCI. 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. Respite Care may be provided to a maximum of 5 persons at the same time. 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. In addition to Service Users accommodated at the Home, Day Care may be provided on the Day Care Unit to a maximum of 7 persons. 31st October 2005 Date of last inspection Brief Description of the Service: Dormers is located in a quiet residential area close to local amenities. Care and accommodation is to provide older people some of whom have dementia. The home is operated by Surrey County Council and was purpose built in 1982. Accommodation 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 of single occupancy. Offices are situated on the ground floor. 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 DS0000033582.V302555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit to be undertaken by the Commission for Social Care Inspection for the year April 2006. The site visit was over a period of seven hours and thirty-five minutes. For details of how each standard was met please refer to the main body of the report. The site visit was unannounced, which meant that visitors, staff and residents were not aware of the visit prior to it commencing. The inspector had the opportunity to speak with a number of residents who live at the home. The majority were very complimentary about the home and staff. A full tour of the premises was undertaken. Two care plans were observed. There were a number of staff on duty including the registered manager, and deputy manager and there were thirty-one residents currently living in the home and three respite residents at the time of arrival by the inspector. A number of staff was spoken with during the visit. The inspector had the opportunity to speak with two relatives, comments were very positive about the home. Two comment cards were received completed by residents and comments were complimentary towards the home and staff. One resident had requested to speak with the inspector. However, on the day of the site visit the resident was not feeling well and refused to speak. Thirteen relatives completed the comment feedback cards and all felt the home was welcoming and were kept informed about important matters. One person stated that they were satisfied with the home and the care given, and another relative commented that they are not aware of the homes complaints procedure and did not have access to the inspection report. Another relative stated they felt residents were well cared for and had plenty to eat, food is good quality and the atmosphere in the home is relaxed and friendly. Mrs V Bulbeck, Lead Inspector for the service carried out the site visit. Mrs C Whiting the Registered Manager and the deputy manager Ms C Manners of the home was present. The home is registered for forty-seven places. The fees for the home are £546.79. The staff was observed to be courteous and the atmosphere within the home was relaxed and friendly. The inspector would like to thank the residents and staff for their co-operation and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A quality audit needs to be undertaken in the home on a regular monthly basis this needs to be carried out by the responsible individual or a representative. The last Regulation 26 report in the home was dated 29/11/06, and another report was faxed to the home on the day of the site visit which was dated 20/09/06, the report previous to this was 05/06/06. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 7 It would be highly recommended that management of the home check for any areas needing attention, are regularly maintained and a record be held on file. There is a maintenance book, which is well documented for smaller jobs around the home. It was also disappointing that a requirement regarding an action plan with timescales be completed regarding the redecorating of the home had not been met. 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 DS0000033582.V302555.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 Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is only admitted to the home following a needs assessment to ensure that the home can meet the resident’s identified needs. The home does not offer intermediate care. EVIDENCE: The home has a pre admission tool, which is used and was seen to be in place. However, at the time of the site visit it was noted that a resident had recently been admitted to the home and a pre assessment had been undertaken, on two occasions by the management of the home. The management of the home had admitted the resident on 29/12/06 with the information supplied by the hospital and care management. However, this information proved to be lacking in detail and the home found it necessary to contact the G.P, and on the day of the site visit a Consultant Geriatrician had been requested to see the resident, and it was noted that the resident had Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 10 been inappropriately placed, therefore the resident will be moved to a more suitable placement. This practice is unacceptable and will cause the resident and family some anxiety. However, the management of the home was not at fault for the process, due to not being provided with sufficient information. The management of the home to ensure in future all relevant documents are available before admitting any prospective resident. The home has provided a service users guide to all residents and relatives. A copy was seen on display in the main entrance hall. The management of the home to ensure the statement of purpose and the service users guide is reviewed on a regular basis to include any changes, and a copy should be provided to all residents. Relatives need to be provided with a copy particuarly, if a resident is unable to be involved with the care provided in the home. The home does not offer intermediate care. Dormers DS0000033582.V302555.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance are planned and were documented in care plans and discussion with a resident was evidently provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place. EVIDENCE: Two residents care plans were sampled and there was evidence that resident’s health, personal and social care needs had been identified and assessed. Care notes are well documented and detailed. A copy of the care plan is kept on each unit to enable staff to use as a working tool. A number of risk assessments have been updated for all residents living in the home. Medication records were found to be well documented and a list of staff signatures was recorded on the file. The returns book was observed and Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 12 controlled drugs were also checked, one resident was on controlled drugs and these records were found to be well documented with two signatures for administering medication as required. There was a photograph of the resident displayed on the MAR sheet record file. Medication is administered from blister packs and some from packs and bottles. Two members of staff are involved with the process. Storage facilities were appropriate. There are currently no residents who self medicate. Homely remedies are signed by the G.P and every three months there is an audit check by the local pharmacist. Fridge temperatures were recorded daily and the community nurse visits the home on a regular basis and undertakes injections and keeps a check on a resident who is diabetic. The residents spoken to confirmed that staff are respectful and knock on the door before entering. Observation by the inspector was residents and staff have a good rapport, residents are able to discuss with the staff any worries they may have and staff reassure residents, by supporting, explaining, and helping to clarify any problems and to ensure residents have a clear understanding. Dormers DS0000033582.V302555.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 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to maintain contact with family and friends. Meals are well balanced and varied with individual choices and preferences as well as special dietary needs catered for. EVIDENCE: The Majority of residents have contact with family and friends and those who do not have family or friends the inspector would advise an advocate is involved. The inspector was informed that an elaborate Christmas dinner was organised for the residents just before Christmas, and residents and staff commented how nice it was for all the residents to be together for the meal. It was also noted that a residents husband was invited to have Christmas day dinner with his wife and there were several birthday parties throughout the year with one resident reaching 100 years and two residents are over 100 years one being 103 years. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 14 The home also arranged a 60th wedding anniversary dinner for two with all the trimmings including a bottle of champagne. The inspector was informed the resident and her husband enjoyed the occasion. The meals served in the home were nutritional in content and well balanced. The chef controls the kitchen and undertakes the ordering and arranging menu planning. Menus are four weekly, but there are changes to the menu on a regular basis, this is mainly at residents request. The chef discusses with residents regarding the meals served. The daily menus are typed and each unit is provided with a copy of the meals served on the day. The chef informed the inspector on the day of the visit, there is a choice of meals and the majority of residents enjoy a roast dinner. Fish and chips are on the menu for Fridays. Cakes are baked on a daily basis and several resident’s confirmed the food is very good. There are two cooks working in the home who are aware of the resident’s likes and dislikes. At times agency staff cover a shift when the permanent staff are on a day off or annual leave. It was noted on occasions when agency staff are on duty the relevant records required by the Environmental Health Officer (EHO) are not completed. It was also noted that white coats or uniforms are not available for persons entering the kitchen. The inspector was informed if agency staff come to work in the kitchen they have to wear a blue plastic apron, this of course if they are not provided by the agency with a uniform. It was also not clear if the staff employed by the agency have the appropriate Food Hygiene training. There has been a recent inspection by the EHO on 19/12/06 and three requirements have been made. Management of the home informed the inspector these are being addressed. At the time of the site visit and discussion with the chef, this took place in the store cupboard where the records are kept, it was difficult to check the records in the confined space, and must be more difficult for the chef to work under these conditions when undertaking record keeping. The inspector was informed that he has been told he can use the office. However, the chef stated that would be difficult when undertaking the ordering for example, and he prefers to work on the worktops of the kitchen. Management of the home are going to review the possibility of rearranging the storerooms to enable the chef to have a place to store the records appropriately, and to have somewhere to complete the required paperwork. There is a dining area on each unit and the majority of residents are encouraged to eat meals in the dining room. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 15 There is a planned activity programme in the day centre and residents attend on a regular basis. Extra musical performers are invited to the home for example, before Christmas they performed a pantomime. An in house activity programme is organised by the staff and during the afternoon, time permitting staff spend time with the residents. The residents seem to spend a lot of their time chatting in the lounges, all appeared to be happy and those spoken to confirmed they were happy to be living in the home, and one resident stated the staff are very nice and helpful. Dormers DS0000033582.V302555.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 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 simple, clear and accessible complaints procedure, which includes timescales for the process. All required policies and procedures are in place to ensure that residents are safeguarded from harm or abuse. EVIDENCE: There have not been any recorded complaints in the home for some considerable time. All residents are provided with a copy of the complaints procedure, and copies are available on each unit notice board. The homes policies and procedures for the protection of vulnerable adults and a whistle blowing policy were in place and all staff has received the protection of vulnerable adults training except a new member of staff. Staff on duty confirmed they had undertaken this training and were aware of the procedures. However, some staff require updates to this training. The home has a copy of Surrey Multi Agency procedures. Residents are encouraged to vote and some have been registered for a postal vote. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible and safe with a pleasant and homely atmosphere. However, several areas around the home need to be redecorated. EVIDENCE: The home was found to be clean and tidy, there are two domestic’s who work on a part time basis. Staff undertakes some of the cleaning duties on a daily basis. Some of the residents like to be involved with the occasional job in their bedroom. The home has a nice homely touch and residents stated they enjoy living in the home. However, it was disappointing that a requirement was made at the time of the last inspection dated 31/10/05 for areas in the home particularly communal areas need to be redecorated. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 18 Areas around the home that require attention: One of the bathrooms on Primrose unit the lock was not working. Florescent light covers need cleaning. The surrounding paintwork in a bathroom on Lavender unit needs attention, and the loft hatch door needs attention. All the communal areas, hallways, corridors, dining areas, stairwells, lounges and some resident’s bedrooms need decorating as a priority. These areas were highlighted at the previous inspection and a requirement was made for an action plan with timescales of the areas to be redecorated. These areas are now in need of urgent attention. Laundry facilities within the home are appropriate to meet the needs of the residents. However, on the day of the site visit the laundry was full of clothes either needing washing or sorting. It was not clear when speaking with staff, which was supposed to be working in the laundry or why there was a considerable amount of washing. It was noted in one of the comments the home had received from the annual questionnaires sent out in December 2006 to relatives for completion, a relative had stated that clothes go missing in the home. The grounds are spacious and open and well maintained by the handyman/gardener. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff meets resident’s needs. The home has a comprehensive staff recruitment and training programme which, incorporates all areas needed to ensure, as far as reasonably possible, that residents are in safe hands at all times. However, details of all agency staff working in the home were not available. EVIDENCE: The staffing arrangements during each shift include seven staff in the morning, and seven care staff in the afternoon. There is four waking night staff on duty every night including a senior member of staff. The home has two domestic staff on a part time basis working in the home on a daily basis, and two chefs on a rota system who undertake the cooking. A number of agency staff are used on a regular basis, this is to cover areas of sickness by permanent members of staff. There are currently no staff vacancies in the home. Full recruitment procedures are being followed. All staff has been checked against the Criminal Records Bureau (CRB) before working in the home. Staff records were observed and found to be well documented, including contracts and terms and conditions. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 20 The inspector advised the management of the home that all agency staff working in the home must be fully vetted and details of each member of staff must be provided by the agency, including a recent photograph. All staff records must be available for inspection when requested. Training has been ongoing and the majority of staff has attended a number of training courses. A training plan has been produced and was generally up to date. However, the member of staff who maintains the training plan has been off sick and some training up dates are required to some staff. The home has 89 of staff with NVQ Level 2 and above. Training has been identified as a priority. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s, benefit from an open, positive and inclusive management style. The home has a monitoring system in place that is based on seeking the views of the residents. All policies, procedures and practices are in place. EVIDENCE: The registered manager is competent and qualified to manage the home, staff were complementary and stated they feel supported and the registered manager has an open door policy, staff stated they are able to speak with the manager at anytime. One member of staff stated the manager is very flexible with staff and has a great understanding. At the present time the registered manager is overseeing the management arrangements at another Surrey County Council (SCC) home and spends two Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 22 days a week in the home. On the other days she is on call for any other management duties that may arise. The post is in the process of being been advertised at the end of the month of January. However, it will be at least three months before a manager is in place in the other home. A questionnaire (Customer Care Satisfaction) is sent to all relatives on a yearly basis thirty-six sent out and twenty-seven questionnaires were returned on the last survey the majority stated they were satisfied with the care received. The registered manager informed the inspector, the majority of relatives manage resident’s finances. Surrey County Council (SCC) manages the finances of three residents. Resident’s personal allowances are paid directly to SCC, which is held in the main SCC bank account. It would appear that the three residents do not have their own bank or building society account the money is held centrally. The statement of accounts was seen and it was recorded two residents are able to sign for their money each week. The statement has all three residents on the same sheet including the amounts of money payable. This practice needs to be reviewed to ensure residents rights and privacy is respected at all times. A number of records were checked including the accident book and it was noted that the home evaluates the accidents and incidents in the home. These records are to ensure the appropriate staffing levels are maintained and to evaluate reasons for the number of falls. On the day of inspection it was noted that one accident in particular had not been included. All recorded accidents should be filed in the appropriate persons folder when completed, and should not be retained in the accident book. The certificate for the testing of Legionella was not available. Other certificates were in place these include the gas and portable appliances and a number of other areas had been checked. On Bluebell the dementia unit, whilst undertaking a tour of the premises, it was noted that cleaning materials were found under the kitchen sink in an unlocked cupboard. The registered manager immediately removed the items and went to speak with the agency member of staff who was on the unit at the time, and presumably left them in the cupboard. It was disappointing to note that Regulation 26 visits had not been undertaken on a regular monthly basis as required. The last recorded visit available in the home was on 29/11/06. A visit had been undertaken on 20/09/06 this report was faxed to the home at the time of the site visit. The previous visit was dated 05/06/06. Please send a copy of the monthly report to the inspector until further notice. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 23 Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 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 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23 Requirement An action plan must be completed with timescales for the home to be redecorated and a copy sent to the CSCI. (Timescale 09/12/05 not met). All communal areas in the home must be decorated. Management of the home to ensure full details of all agency staff working in the home are available. To ensure all cleaning materials are stored in a locked facility at all times. All staff to be aware of COSHH Regulations. Timescale for action 30/03/07 2 3 OP19 OP29 23 19 30/03/07 19/01/07 4 OP38 13 12/01/07 Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 26 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 3 4 Refer to Standard OP15 OP30 OP35 OP38 Good Practice Recommendations To consider an appropriate working area for the chef to undertake record keeping. Staff to receive updates to training. To review the financial arrangement for three residents. Regulation 26 visits must be undertaken monthly. Dormers DS0000033582.V302555.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office 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. 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