Inspection on 14/08/07 for Dormers Wells Lodge

This inspection was carried out on 14th 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 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 Wells Lodge 23/03/09

Dormers Wells Lodge 24/10/06

Dormers Wells Lodge 04/05/06

Dormers Wells Lodge 08/11/05

Dormers Wells Lodge 15/04/05

Dormers Wells Lodge 13/10/04

Dormers Wells Lodge 19/04/04

Dormers Wells Lodge 24/11/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Dormers Wells Lodge Telford Road Southall Middlesex UB1 3JQ Lead Inspector Ms Jane Collisson Key Unannounced Inspection 10:00 14th August 2007 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 Wells Lodge DS0000027701.V337915.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 Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dormers Wells Lodge Address Telford Road Southall Middlesex UB1 3JQ 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) 0208-574-8400 0208 574 8401 Dormers Wells Lodge Limited Ms Blessing Tessy Oluku Care Home 45 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical Disability - Code P Dementia - Code DE The maximum number of service users who can be accommodated is: 45. 24th October 2006 2. Date of last inspection Brief Description of the Service: Dormers Wells Lodge is owned by Dormers Wells Lodge Ltd, which is a charitable trust and a non-profit making organisation. It is situated on a residential road in Southall, near to the Uxbridge Road, and is within easy reach of local amenities, including public transport. There is a parade of local shops nearby. The home has forty five single bedrooms. Twenty three of the rooms are located in a new dementia unit and twenty two are for frail older people. There are eight toilets, located throughout the home, and six bathrooms. There are two lifts to the first floor and a small stair lift on the ground floor between the older persons’ unit and the dining room. The dining room is large and can accommodate everyone for meals, entertainments and activities. The homes rear garden is attractive and well maintained with a pond, summerhouse, seating areas and raised flowerbeds. Paved areas around the garden allow easy access for people who are dependant on mobility aids. A shelter in the garden is provided for service users who smoke. The care team consists of the Registered Manager, Deputy Manager, five supervising staff and a team of care staff. There are domestic, laundry and catering staff, a finance manager, an administrative assistant and a handyman. The weekly fees, from the 1st April 2007, are £450-£500. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 14th August 2007 from 10.00am to 5.35pm and was carried out by two Inspectors. The inspection process took a total of fourteen hours. There were forty three residents in the home. The Inspectors toured the home and almost all of the residents were seen during the course of the inspection. The majority of people within the dementia unit were sitting in one lounge, with a small number preferring to use the first floor lounge to watch television. In the other unit, people were seen in the lounge, dining room and foyer with others preferring to remain in their bedrooms. The lunch time meal was observed, and the food sampled. Residents were positive about the meals that are provided. During the afternoon a keep fit session was held in the lounge, which is a twice weekly activity. The home also has an Activities Organiser on three afternoons a week. Entertainers also attend the home regularly. Documentation was examined, which included care plans, staff and training records, and maintenance records. The Registered Manager completed a PreInspection Questionnaire and Annual Quality Assurance Assessment and some of the information provided has been used in this inspection to assess the standards. The home has been without a Deputy Manager and this post was in the process of being advertised. There is a senior care worker on each shift and two of the senior care staff, together with care and ancillary staff, were met in the course of the day. The home would benefit from additional management cover, particularly since the introduction of the dementia unit. Because of the discrepancies in the medication found at the visit, the CSCI Pharmacy Inspector was requested to visit and did so on the 29th August to carry out an inspection of all of the medication administration. Her findings are the subject of a separate letter to the home but have been summarised in this report and the requirements have been included. Her overall judgement of the medication management in the home was “quite good”. An unannounced random visit had been carried out on the 21st June 2007, by two Inspectors. This was to look specifically at how the changes had been managed when the dementia unit was opened in May 2007. Information from that inspection has been incorporated into this report. CSCI surveys were sent to people living in the home and their relatives. Thirteen residents returned the surveys, eleven being supported by their key Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 6 workers to do so. Five were returned from relatives. The responses were generally positive. The findings from the surveys, and comments made during the inspection, have been included in the body of this report. Cultural and religious needs are met by regular visits to the home by local clergy, or with support from residents’ families. There is a provision for special diets for the Asian people in the home, which were observed. This inspection looked at all of the key National Minimum Standards. At the inspection in October 2006, fourteen requirements were made. There were five requirements made at the visit on 21st June 2007. Eighteen requirements have been made at this inspection, which included five made by the Pharmacy Inspector. Two requirements were repeated from the previous inspection as they were not fully met. What the service does well: What has improved since the last inspection? What they could do better: To enable prospective residents, and their representatives, to fully understand the services the home provides, the Statement of Purpose needs to be revised to take account of the changes to the home and reflect the facilities and services which are being provided, particularly for those with dementia. The assessment procedures for prospective residents need to take into account all of their needs, providing evidence that they can be met and demonstrate that their placement in the home, and the specific unit, is appropriate. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 7 It needs to be shown that the requirements of people being admitted are able to be met by the staffing levels, activities and environment of the unit to which they are admitted. The care plans, particularly those for people with dementia, need to demonstrate how the quality of life for the person can be enhanced. More evidence is needed that suitable activities and stimulating pastimes are being provided, particularly for people with dementia, and that sufficient staff, with the training and experience, are available to support them. A more robust system of risk assessment, particularly for falls, nutrition and manual handling, is required to ensure that every precaution, to minimise the risks, has been considered. A system of regular auditing of the care plans and associated documentation, by senior staff, is needed to ensure that important information is always recorded and reviewed. Sufficient bathrooms, with suitable equipment, need to be provided to meet the needs and preferences of the people in the home. The safety of the residents, and the staff, needs to be taken into consideration when deciding on the type of facility. An Action Plan is required to show when this will be achieved. The Registered Providers need to ensure that, in view of the frailty of the residents, covers are provided for the radiators in areas where people may be at risk. Sufficient staff need to be on duty, in all areas of the home, to provide for the assessed needs and support of the residents, which allows them the freedom of the home and garden. The fire risk assessment needs to be fully completed to take into account any specific difficulties or needs of individual residents. The frequency of equipment testing and servicing is also required to be included. To safeguard the residents, water temperatures must be kept at a safe and comfortable temperature. Action must be taken where water is deemed too hot or cold. On medication management, the Registered Manager needs to ensure that the systems are in place to record accurately, and to monitor, the medication brought to the home for people on respite. The home also needs to review its procedures for residents receiving respite care. Medication must be only be received in its original labelled packaging and recording must be strengthened to allow an audit trail to take place. The Medication Policy is required to be updated, with reference to current legislation. Risk assessments for self-medication must be signed and dated and regularly reviewed. The recording of Controlled Drugs, including running balances, must be improved. Trolleys must be secured to the wall with the available bolts. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 8 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. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 9 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 Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3, 4, 5 (NMS 6 does not apply) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with a Statement of Purpose, Service Users Guide and contract/terms and conditions which contain the basic information they require. There is a lack of evidence that the individual needs of people with dementia have been considered, and that the home has the expertise, staffing and environment to meet these. While assessments are carried out for prospective residents, more information regarding their needs, and how they will be met, would ensure that appropriate placements are made. EVIDENCE: Following the additional visit to the home on 21st June 2007, the Registered Manager had amended the Statement of Purpose and Service Users Guide to take account of the changes that have occurred since the registration of the dementia unit. These did not fully explain, however, how people in the unit are assisted to maintain their independence and participate in suitable activities, particularly those which provide stimulation. The Registered Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 11 Manager was asked to ensure that there is sufficient information in the documentation to show clearly how the needs of people with dementia are met, by the staffing, activities, training and the environment. There is, for instance, a lack of opportunity for people to use the garden regularly as there is no direct access from the ground floor lounge, where most people sit, although there is a door which could be utilised. People in the dementia unit only have access to the garden when accompanied by staff. Thought needs to be given to providing access to the garden for people to have exercise and fresh air and those people who are mobile should be offered a safe space in which to walk, unaccompanied if safe to do so. The information in the Statement of Purpose says that four people are on duty in the dementia unit during the day. However, this was not borne out by the rota copies that were seen. These showed that there are sometimes six people on duty until 10am but only five thereafter, throughout the home. Staff reported that they were one person short on the day of the inspection. The level of staff, when the application for the dementia unit was agreed, was higher. As the home is allocated over two floors, and has three separate lounges, there needs to be sufficient staff to provide cover in all of the lounges, and to carry out suitable activities and recreational opportunities. People are issued with contracts or terms and conditions as required and those replying to the Commission for Social Care Inspection surveys said that they had received their contracts. People have the opportunity to visit the home before making a decision about moving in. The Inspectors viewed five residents’ files to assess the pre-admission information gathered. The files had Social Services assessments that briefly outlined the residents’ needs, but two did not have pre-admission assessments which could be located and three had only a very brief assessment carried out by the home’s staff. This information, which needs to form the basis of the care plans, should be completed fully and the Registered Manager was asked to expand on the current form so that it can be evidenced that all of the needs of the people wishing to move into the home have been fully assessed. The additional visit made in June 2007 was specifically to look at the admissions to the dementia unit which had opened in May 2007. A number of the people who had been transferred to the unit did not have full assessments of need carried out by Social Services to determine whether they should be moved and, in some cases, their dementia has not been diagnosed by a health professional. There had been a lack of evidence of consultation regarding the moving of people to the dementia unit. The diagnosis made for some people was not dementia, but other mental health issues. It needs to be shown to have been agreed, following suitable assessments, that the dementia unit is appropriate for the person concerned and that their specific needs can be met. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 12 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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a detailed care plan but evidence is required that they or their representatives have been fully involved in these and that all of their choices and wishes have been considered. Risk assessments are carried out but do not cover all of the areas where people may be at risk, such as falls or poor nutrition. Better monitoring of medication is required to ensure that people are not put at risk. Residents are positive about the staff team and how they are treated. EVIDENCE: The Inspectors viewed sample of five residents’ files. A further seven files had been examined at the inspection in June 2007. Care plans were seen to be recorded in detail and covered areas such as personal and social needs. They described how much support the resident would need and where the resident could carry out tasks independently. The plans did not, however, include information on the residents’ preference for gender specific care and this is a re-stated recommendation. Residents have the right to request gender specific care and this was brought to the attention of the Registered Manager. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 13 Care plans did not always clearly evidence the involvement of the residents or their relatives in the development of the individual care plan. Members of staff need to take into account the residents’ views, or those of their representatives, and enable them to contribute their opinions. One Inspector was informed that a resident had a leg ulcer. However, the care plan had not been updated to reflect this change in need. This was brought to the attention of the Registered Manager and a re-stated requirement was made. The risk assessment for one person was examined which covered moving and handling risks. Nutritional risk assessments and a separate falls risk assessment had not been completed and, for one resident, the file contained no risk assessments. A re-stated requirement was made for risk assessments to be considered and completed where appropriate. Attention must be paid when assessing residents’ needs, as staff need to be mindful of potential and historical risks for each resident and care for the resident accordingly. It was confirmed that only on person has bed sides in place at night and a risk assessment was available. Samples of daily records were viewed and these outlined basic information for staff, such as what the resident ate, the activities they took part in and any personal care tasks carried out. The Registered Manager explained that not all of the annual reviews had been carried out for the people placed by one local authority. She had recently taken action to remind them of this and provided the evidence which showed that, of the twenty two people placed, thirteen had not had a review in the last year. The care plans for the people in the dementia unit have not been significantly changed and it is recommended that individualised, person-centred care plans are introduced in relation to their activities and the way in which their dementia affects their routines and abilities and how their support can be tailored to suit their specialist needs and improve their quality of life. The Inspectors did not find that staff were very aware of the way in which the support of people with dementia differs from that of a person able to direct their own support. One staff member indicated that the only difference in working in the dementia unit was that the work was “heavier”. This is a training issue which needs to be addressed. The Inspectors viewed medical appointment records. These record when a resident has seen a health professional and any treatment or outcome of the appointment. One resident’s file noted her weight, whilst another file had no record of weight. The Registered Manager and senior staff need ensure that system of regular monitoring of the care plans is undertaken in order to notice where there are shortfalls in recording. The majority of people responding to the Commission for Social Care Inspection surveys said that they “always” had Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 14 the medical support they needed and the remainder said that they “usually” did. The Inspectors viewed a sample of medication that was stored in the fridge. Temperatures of the fridge are taken on a daily basis and were within an appropriate range. Dates of opening were recorded onto the eye ointments. Different residents’ medications were stored in the same container and it is advisable to separate each resident’s medication to avoid confusion and errors occurring. A Monitored Dosage System is used by the home. However, the medication which had been received for a person on respite, was not maintained in good order. The Registered Manager and one of the senior support workers were unable to explain why some of the medications appeared not to have been given and which may have been PRN “as and when” medications. They were asked to obtain information from the person’s family, a matter of urgency, as to which medications were to be given. The Commission for Social Care Inspection’s Pharmacy Inspector was requested to visit the home to undertake an inspection of the medication administration and visited on the 29th August. Her overall judgement of the medication management was that it was “quite good”. She found that there was accurate recording of the administration of medication. She has provided a separate, detailed report to the home. A new trolley had been delivered at the first inspection and was in use when the Pharmacy Inspector attended. She has required that it is secured to the wall when not in use. She made a number of other requirements and recommendations. The requirements were in respect of the need for a new medication policy; risk assessments for people who self-medicate to be signed and reviewed regularly; the recording of Controlled Drugs to be improved. In respect of residents admitted for respite, a review of the procedures was required, to include the recording to be tightened so that an audit trail can be carried out. Medication is required to only be received in its original labelled packaging. It was recommended that the general practitioner/pharmacist is requested to label the medication with the full instructions. The Pharmacist also recommended that dividers, with photographs, are placed in between the Medication Administration Record sheets to minimise the risk of errors. People responding to the surveys said that they felt they were listened to by staff and that they acted, where necessary, to meet their needs. The majority said that staff were “always” or “usually” available. However, one person said that they were only “sometimes” available and another person felt that this was because staff were “very busy”. No concerns were raised with the Inspectors regarding dignity or privacy. It was noted in one lounge that screens are used when a person is being transferred to a wheelchair and staff said that this was to preserve her dignity. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 15 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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service have the opportunity to have visitors and maintain their friendships. Residents were positive about the variety of activities and entertainments which are offered. There was little evidence of specific and stimulating activities for people with dementia. A varied diet is provided, with cultural needs met. EVIDENCE: Staff informed the Inspectors that keep fit and bingo are the main group activities which take place and can cater for all of the people who wish to participate. Entertainers visit the home on a regular basis and these are advertised. In the feedback from the surveys, people said that they enjoyed the keep fit, bingo sessions and outings. There is an activities co-ordinator who works three afternoons a week and another person visits the home to provide the general exercise sessions twice a week. However, two residents spoken to said they attended keep fit as there was little else to do. The Inspectors viewed a list of activities and the entertainers who would be visiting the home over the forthcoming months. The weekend prior to the inspection, a barbecue had been held and a day trip to the coast was planned Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 16 two days after the inspection. The Inspectors were informed that sometimes outings are on offer but that, at the last minute, residents often refuse to attend. The Inspectors acknowledged that this can occur, but the home needs to look at ways to encourage people as it was evident that some of the more able people were looking for additional interests. Among the plans for improvement included in the Annual Quality Assurance Assessment was the acquisition of transport for the home. This could assist greatly in providing a range of outings, on a more spontaneous basis, which might improve the numbers attending. The Inspectors visited the new dementia unit, which had been open for three months. The majority of the residents were in the ground floor lounge, although there is another one available on the first floor. There is also a small quiet room but this was locked at the time of the inspection. This room had “bean bags” as the main seating. It is recommended that the room could be more usefully used, with small groups for instance, if the seating was more suitable. It would be suited for reminiscence work, for instance. It is recommended, also, that the room is left open so that people who may wish to walk around could find items such as books, photographs, puzzles and objects of interest which they may choose to look at spontaneously. There was no indication that specialist activities were available for those residents with dementia and no evidence that staff were aware of the ways to engage with those residents with different types of dementia. These concerns were raised with the Registered Manager and a requirement was made to consider how this standard may be better met. During the times that the ground floor dementia unit was visited, the television was on. There was little evidence that people were interested in this and some would have been too far away from the set to watch in comfort if they had wished to. Two of the people in the upstairs lounge said that they had made a positive choice to be there to watch the television. The Inspectors visited the kitchen. Samples of the menus were viewed and these provide residents with a choice of meals, including those for the Asian residents. The cook freshly prepares some of the desserts. The daily menu is now written on the whiteboards in the dining room. Menus provided on each table would be beneficial to those residents who might want to look through the meals being provided that day. The cook confirmed that if an alternative meal is requested then this is provided. The cook knew the residents with special dietary requirements and a list was seen in the kitchen of the residents’ specific likes and dislikes. This meets a requirement made previously. Cultural meals were also provided on a daily basis and the cook had provided a very special cultural diet to a person in the home on a temporary basis. The Inspectors sampled various items on the lunch and these were found to be satisfactory. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 17 Lunchtime was observed and staff assisted those residents appropriately who needed support to eat their meals. There is sufficient space for all of the people in the home to eat at one sitting and was seen to be relaxed and unhurried. The ethnicity of the residents is not fully reflected in the staff team and the Registered Manager said that she had not been able to recruit staff to provide this. However, she said that there are people who are able to communicate in the languages spoken by the Asian people living in the home. The religious needs of the people who do not require Christian worship to be provided are met by their families and clergy visit the home regularly to provide services and communion. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 18 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is supplied to everyone in the home and there is sufficient information for people to know how to make a complaint and evidence that people are aware of this. All staff have training to support them to safeguard the residents in their care. EVIDENCE: The Service Users Guide, which is placed in bedrooms, contains details of the complaints procedure. All but two of the eighteen people replying to the surveys said that they knew how to make a complaint. Families replying to the surveys said they know how to complain and said the home “always” or “usually” respond to any concerns they have. Meetings have been held with residents and families to encourage them to make their views known. Concerns raised regarding admissions to the dementia unit were addressed by an additional visit to the home in June 2007 by the Commission for Social Care Inspection Inspectors and have been referred to elsewhere in this report. Four complaints had been made since the last inspection, and these were answered satisfactorily within the stated timescales. There had been one potential safeguarding adults issue raised in the home in the last year but this was not taken further after investigation. All but one of the full staff team have received training in the protection of vulnerable adults in the last two years. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 19 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, 20, 21, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The communal areas provide sufficient choice in the dementia unit but are limited in the older person’s unit. Not all of the bathrooms are equipped for people who need supported facilities. Refurbishment work is being undertaken to improve the heating and hot water systems. Better use could be made of the garden facilities for people with dementia. EVIDENCE: Since the last inspection, the home has been divided into two units, one half of the home being for people with dementia and the remainder for frail, older people. The application for the dementia unit was approved by the Commission for Social Care Inspection and this was opened in May 2007. This provides, on two floors, two lounges and a “quiet” room in addition to the twenty three single bedrooms. There is a lift between the floors in each unit. The large dining room is used by all of the residents in the home for meals and recreation. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 20 There is no direct access to the garden from the dementia unit. The Registered Manager said that changes are being considered to create a conservatory off the dining room, which would have the effect of dividing the garden. However, this in not planned for the near future and thought must be given to how improvements can be made in the interim period. It is recommended that a fence is erected to provide a safe area for the people in the unit to walk, unaccompanied if it is safe to do so, and the door in the ground floor lounge used to provide access. Keypads have been placed on the doors of the dementia unit for security. Toilet doors have been painted yellow for easier identification. The home has a no-smoking policy and there is a shelter in the garden for those who wish to smoke. However, this necessitates some people having to be accompanied and it needs to be shown how the staffing levels support the residents who wish to smoke regularly. The twenty two people in the older persons’ unit have one lounge, which has room for around seventeen people to sit in comfort. The staff said that a number of residents prefer to stay in their bedrooms and therefore the lounge accommodation is sufficient at the present time. Residents are free to use the dining area but this does not have armchairs. It is recommended that the Registered Providers look at how sufficient communal accommodation is made available for all of the people in the older persons’ unit. The Dormers Wells Trust has a long-term plan for replacing the heating and hot water system, which dates from when the home was built. Work on the boiler system was being carried out this summer. Eventually, all of the radiators will be replaced but it was required that these were covered for safety until this is completed. However, a small number of radiators in communal areas and bathrooms were still uncovered and, to promote safety, these should be covered before the winter. The home has bathroom and toilet facilities throughout the home. Not all of the bathrooms have equipment and the Registered Manager said that there are plans to turn one into a shower room. With a total of forty five people in the home, the National Minimum Standards would be met by having all six bathrooms with assisted facilities and an action plan is required to show how this will be achieved within a reasonable timescale. The safety and preferences of the residents, and the safety of the staff, need to be taken into consideration when deciding on the type of facility. The home has a team of cleaners and all of the areas seen were found to be clean and odour-free. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 21 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels are insufficient to ensure that staff can be in all areas of the home, providing the appropriate level of support, particularly for those people who are less able. Staff have the opportunity to complete their induction and basic training, with regular refresher courses provided. The training is insufficient to provide person-centred care for those with dementia. EVIDENCE: The rota was viewed and did not show an increase in staffing levels from the inspection in October 2006, prior to the dementia unit being opened. The rota showed additional staff on duty at the busy time for personal care, between 6am-10am. However, some of the shifts then had only five staff in the home, including the supervisor who oversees the running of both units. There is a supervisor and two staff on the night shift. The rota is arranged to show the number of staff working on each floor, rather than on specific units, and staff confirmed that they work in all areas of the home. The proposed level of staffing was higher when the dementia application was agreed, which showed up to eight staff on the day shifts and four at night. The Inspectors did not feel that current staffing numbers could fully meet the needs of the residents and enable staff to carry out the tasks expected of them, such as providing activities. The Inspectors went to the first floor of the dementia unit where only a few residents spend time in the lounge area. Staff Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 22 do not base themselves here and instead, as the Registered Manager said, the more able residents are able to “keep a regular eye” on the less able residents. Sufficient staff must be on duty to provide cover for all areas of the home and residents should not be responsible for other residents’ support. Now that the dementia unit has been running for three months, and an evaluation can be undertaken, the Registered Manager must demonstrate that the staffing levels meet the residents’ needs in all areas of the home. There were two staff vacancies, in addition to the post of Deputy Manager that was being advertised. There were sufficient numbers of domestic staff working to maintain the cleanliness of the home. The Registered Manager provided a current matrix showing the staff training records. These provided evidence of the up-to-date manual handling training and the other basic training courses that staff had undertaken. While staff have all had basic dementia training there was found to be a need for more staff awareness of supporting people with dementia. This needs to be carried out as soon as possible, particularly for those who work more regularly in the unit. Of a permanent care staff team of twenty four, seven staff have National Vocational Qualifications. Two staff have Level 2 and five have Level 3. A further seven have commenced training, six at Level 2 and one at Level 3. Six of the staff have nursing qualifications gained abroad. A sample of four staff files was examined. While the recruitment records were generally satisfactory, one person who was recently recruited and working did not have a second reference, although it has been applied for. Staff induction records, which meet the “Skills for Care” standard, were seen. Because of the wait for Criminal Records Bureau disclosures, some staff were seen to undertake several days of induction training before they are employed. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 23 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home would benefit from additional management staff to support the development of the dementia unit. The views of residents and their families are sought regularly. There are robust procedures in place for managing residents’ money. Maintenance and servicing records are well maintained. EVIDENCE: The Registered Manager has a Level 5 National Vocational Qualification and has undertaken the Registered Managers Award. She has managed the home for three years and also undertakes training in manual handling for the staff team. The home has been unsuccessful in recruiting a Deputy Manager on a number of occasions, although the post was being advertised again during this inspection. With the changes which have occurred in the home, including the addition of a large dementia unit, the post of Deputy Manager would be a Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 24 valuable asset in providing support for the Registered Manager, who was found to be working long hours to provide the management cover that is needed. The Inspectors discussed with her that the dementia unit is in need of additional resources to ensure that the staff are working to provide the specialist support that is needed for this type of unit. The Registered Manager was seen to have taken disciplinary action, where required, with staff. This has included disciplinary action for medication errors. Regular supervision sessions and appraisals take place. The Registered Manager provided a report from May and June 2007 to show the results of surveys which had been undertaken with residents. Twenty seven surveys had been completed either independently or with the help of relatives and staff. The areas examined were care, food, staff, comfort, entertainment, complaints procedure and other services. The overall result of the survey had been “very good”. Apart from a comment about the laundry service being slow, there were limited specific comments and it is recommended that the quality monitoring is extended to include ways to develop the home and its services. Regular meetings are held with residents and families and the minutes for those of January and April 2007 were seen. Various members of the Dormers Wells Committee undertake the Regulation 26 monthly visits to the home and these are submitted to the Commission for Social Care Inspection, together with copies of the well produced monthly newsletter which provides information on activities and general news. The Inspector met with the Finance Manager and viewed a sample of residents’ finances. Residents are required to pay for additional services such as hairdressing, newspapers, purchasing clothes and any other personal items. The Finance Manager keeps receipts of all financial transactions, such as hairdressing and toiletry bills. The money counted was correct at the time of the inspection. The finances are audited three times a year and a report is made available twice a year. The Inspector viewed the most recent report and no errors or recommendations were noted. The Finance Manager, in some cases, has to request money from relatives, who might manage a resident’s personal monies. In these situations, the Finance Manager sends copies of the expenditure sheet along with a receipt of the outstanding balance to the person concerned, usually the relative. The Inspector was informed there are no problems in making these requests. Those residents staying in the home on a respite basis have their finances managed by the supervisor. Should a resident then become permanent, the finances, records and receipts are given to the Finance Manager. The respite residents’ monies were not checked on this occasion. Residents’ finances are counted and recorded on a regular basis and no errors have occurred. Where possible, residents are encouraged to manage their own finances. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 25 The Inspector viewed a sample of maintenance records. The Finance Manager keeps a record of all of the health and safety checks, noting when they were carried out, thus making it easy to monitor when maintenance checks are due. The portable appliance test, Legionella test and electrical test were all up to date. The Gas Safety record was recently out of date but as the home is having new boilers installed a requirement was not made on this occasion and will be checked at the next inspection. Fire drills had taken place on a regular basis and staff had received regular fire awareness training. The fire officer had visited in March 2007 and requirements that were made, such as producing a fire risk assessment, had been actioned by the home. The Inspector viewed the fire risk assessment, which is completed by an external ex-fire officer. This did not provide the detailed information, relevant to the home. Any additional risks, such as high dependency caused by poor mobility, dementia or other behaviour, or smoking, needs to be taken into consideration. The risk assessment also needs to specify the frequency with which servicing, maintenance, tests and drills are to be held. This shortfall was discussed with both the Finance Manager and Registered Manager. Checks on water temperatures have been made and it was noted that, for several months, the temperatures had been recorded as very low. Furthermore, as the maintenance person had been on leave since early July 2007, no other member of staff had checked the water temperatures. This was discussed with the Registered Manager and a requirement was made for water temperatures to be closely monitored and recorded and action taken where necessary. One tap was found not to be working when a check was made on the water temperatures in the bathrooms. Fridge and freezer temperatures had been taken in the kitchen and were within a satisfactory range. Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 26 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 xCHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X X X 2 3 STAFFING Standard No Score 27 2 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 3 X 2 Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 27 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. 2 Standard OP1 Regulation 4 (1), 6 (a) Requirement Timescale for action 01/11/07 2 OP3 14 (1) 3 OP4 4 (1), 18 (1)(a), 16(2)(n) 4 OP7 12 (1)(a) 15 (1) The Registered Manager must ensure that the Statement of Purpose is revised to take account of the changes to the home and reflects the facilities and services which are being provided. (Previous timescale of 30/06/07 not fully met) The Registered Manager must 01/10/07 ensure that the assessment procedures for prospective residents are shown to take all of their needs into account, providing evidence that they can be met and that their placement in the home, and the specific unit, is appropriate. The Registered Manager must 01/11/07 ensure that the specific needs of people who are admitted can be shown to be met by the staffing levels, activities and environment of the unit to which they are admitted. The Registered Manager must 01/11/07 ensure that care plans, particularly those for people with dementia, demonstrate how the quality of life for the person can DS0000027701.V337915.R01.S.doc Version 5.2 Dormers Wells Lodge Page 28 5 OP7 13 (4) b & c 6 OP7 15 (2) (b) 7 OP9 13 (2) 8 OP9 13(2) 9 OP9 13(2) 10 11 12 13 OP9 OP9 OP9 OP12 13(2) 13(2) 13(2) 18 (1)(c) (i), 4 (1) (a) be enhanced. The Registered Manager must ensure that all risk assessments for individual service users are in place to ensure precautions to minimise risks and promote safety, particularly for falls, nutrition and manual handling. (Previous timescale of 31/12/06 not fully met). The Registered Manager must ensure that there is a system of regular auditing of the care plans and associated documentation, by senior staff, to ensure that important information is always recorded and reviewed. The Registered Manager must ensure that systems are in place to record accurately and to monitor the medication brought to the home for people on respite. That the home updates its medication Policy with reference to current legislation. A copy should be sent to CSCI. That the home reviews its procedures for residents receiving respite care. Medication must be only be received in its original labelled packaging and recording must be tightened up on to allow an audit trail. Risk assessments for selfmedication must be signed and dated and regularly reviewed The recording of Controlled Drugs including running balances must be improved Trolleys must be secured to the wall with the available bolts. The Registered Manager must ensure that there are suitable activities and stimulating pastimes available, particularly for people with dementia, and DS0000027701.V337915.R01.S.doc 01/11/07 01/11/07 01/10/07 01/11/07 01/10/07 01/10/07 01/10/07 01/10/07 01/11/07 Dormers Wells Lodge Version 5.2 Page 29 14 OP21 23 (2) (j) 15 OP25 13 (4) a & c 16 OP27 18 (1) (a) 4 (1) 17 OP38 23 (4a) 18 OP38 13 (4) that staff have the training and experience, and are available in sufficient numbers, to support the residents with these. The Registered Providers must ensure that sufficient bathrooms, with suitable equipment, are provided to meet the needs and preferences of the people in the home. The safety and preferences of the residents, and the safety of the staff, need to be taken into consideration when deciding on the type of facility. An Action Plan is required to show when this will be achieved. The Registered Providers must ensure that, in view of the frailty of the residents, covers are provided for the radiators in areas where residents may be a risk. The Registered Manager must ensure that sufficient staff are on duty in all areas of the home to provide for the assessed needs and support for the residents which allows them the freedom of the home and garden. The Registered Manager must ensure that the fire risk assessment is completed. This must take into account any specific difficulties or needs of individual residents. The frequency of equipment testing and servicing is also required to be included. To safeguard the residents, water temperatures must be kept at a safe and comfortable temperature. Action must be taken where water is deemed too hot or cold. 01/12/07 01/11/07 01/11/07 01/11/07 01/10/07 Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 30 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 OP7 Good Practice Recommendations That a more person-centred approach is used when compiling care plans, taking into consideration the specific needs of people with dementia and how these are to be met. That the wishes of the residents with regard to personal care and same gender care is kept under review, so that people can express their preference once they have settled into the home. That the home requests dividers from the supplying pharmacist and includes these between each MAR with a photograph to prevent the risk of error. The GP/pharmacist should be requested to label medication with the full instructions and not use the instructions as directed. That better use is made of the small, quiet room to provide activities that people with dementia might enjoy and that the room remains open to provide them with an additional space to use for stimulation and exercise. That a fence is erected across the garden to provide a safe area for the people in the dementia unit to walk and the door in the ground floor lounge is used to provide access. That the Registered Providers look at how sufficient communal accommodation is made available for all of the people in the older persons’ unit. 2 OP10 3 4 5 OP9 OP9 OP12 6 7 OP20 OP20 Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Dormers Wells Lodge DS0000027701.V337915.R01.S.doc Version 5.2 Page 32 - 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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