Inspection on 15/04/05 for Dormers Wells Lodge

This inspection was carried out on 15th April 2005.

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 14/08/07

Dormers Wells Lodge 24/10/06

Dormers Wells Lodge 04/05/06

Dormers Wells Lodge 08/11/05

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Dormers Wells Lodge Telford Road Southall Middlesex UB1 3JQ Lead Inspector Ms Jane Collisson Key Unannounced Inspection 15th April 2008 09:30 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.V362079.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.V362079.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 manager@dwlodge.co.uk 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.V362079.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. 19th February 2008 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. Two lifts serve the first floor and there is 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 2008, are £460 to £535 in the dementia unit. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We carried out this unannounced inspection on the 15th April from 9.30am to 6.30pm and it was undertaken by two Inspectors. The inspection process took a total of nine hours. The Manager was present. We toured the home and met the majority of the people living in the home in the course of the day. During the morning, most of the people spent their time in the lounges and bingo was available, after lunch, in the main dining room. This is part of a regular programme of activities. A small number of people were seen in their bedrooms and some were spoken to in private. Several people had visitors and one was met on this inspection. People, particularly those living in the residential unit, discussed with us the food provided, activities and how they found life in the home. The Manager provided us with the completed Commission for Social Care Inspection’s Annual Quality Assurance Assessment at the last key inspection in August 2007. This included statistical information about the home, its residents and staff, how the home is managed and its future plans as at June 2007. On this inspection, we examined a range of documentation, including care plans, medication, staff and training records, maintenance and finance records. The staff handover meeting, between the early and late shifts, was attended. We met a number of staff during the inspection, including three of the supervisors. One supervisor works on each shift to oversee the staff team and manage the home in the absence of the Manager. A new Administrator had recently been recruited, whose duties will include overseeing the health and safety maintenance. There are a number of Asian residents in the home and a daily Asian menu is provided. One of the residents commented that the Asian food is “very good”. Religious needs are met by visits to the home by local clergy, or with support from residents’ families or friends if they wish to go to places of worship outside of the home. We had carried out an additional unannounced visit to the home on the 19th February 2008 to check on the progress of the requirements made in August Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 6 2007. An Immediate Requirement was made in respect of the medication and a second visit was made on the 26th February 2008 to check that the requirement had been completed. The observations from that visit have been incorporated into this report where this is appropriate. We looked at all of the key National Minimum Standards at this inspection. At the inspection in August 2007, fourteen requirements were made. There were additional requirements made at the random inspection in February 2008 and these have all been assessed at this inspection. A total of fifteen have been made arising from this inspection and eight of these have been carried forward. The Registered Providers need to ensure that the Manager is supported to meet these requirements within the timescales given. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose needs to reflect the staffing levels actually in place. A more thorough assessment procedure is needed for prospective residents, which demonstrates that their needs are taken into account. It must be ensured 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. A more person centred style of care plan would be of benefit, which can be used as a working document to demonstrate how the quality of life for the person can be enhanced. The risk assessments need to be revised to ensure that all of the assessments for individual service users are in place and precautions to minimise risks and promote safety, particularly for falls, bathing, nutrition and manual handling, are in place. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 7 The medication procedures still require improvement. In particular, it must be demonstrated that accurate monitoring takes place and the Registered Manager must ensure that this is carried out. All medication needs to be recorded upon being received with a clear audit trail of administration and disposal. Staff who administer medication need to be shown to be competent to do so and to be working in accordance with the policies and procedures of the home. In the ground floor dementia lounge, the exit to the garden may be a trip hazard and needs to be levelled for safety, or a ramp installed. There remains a lack of suitable activities and stimulating pastimes for those people in the dementia unit. Staff need to be available, in sufficient numbers and with the appropriate training, to provide this. There should be 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. Incidents which may affect the wellbeing of the people living in the home must be reported to the Commission for Social Care Inspection at the time of the event and to the London Borough of Ealing’s safeguarding coordinator, where this is appropriate. It has been an outstanding requirement that, in view of the frailty of the residents, covers are provided for the radiators in areas where residents may be a risk. This was required to be met by 1st November 2007 and has not been completed. The fire risk assessment is in need of completion to meet the current legislation and must take into account any specific difficulties or needs of individual residents. The home has not met the National Minimum Standard of having 50 of the staff trained in National Vocational Qualifications at Level 2 or above. An Action Plan to show how this can be achieved within a reasonable timescale is required. 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.V362079.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 Wells Lodge DS0000027701.V362079.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 (6 is not relevant to the home). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has developed a Statement of Purpose and Service Users Guide, which provides basic information about the service and the specialist care the home offers. The Guide is made available to individuals in a standard format. The admission procedures for new people are not particularly personalised and need to show the individual needs, concerns and wishes of the prospective resident and their families. EVIDENCE: People living in the home have a copy of the Statement of Purpose and Service Users Guide to keep in their bedrooms. We were provided with copies of the documentation, which was updated in February 2008. It was a requirement at the last inspection that the needs of the people moving into the home can be shown to be met by staffing levels, activities and the environment to which they are admitted. The staffing levels shown in the Statement of Purpose did not fully explain how each of the units is staffed. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 10 Two of the staff employed are only on duty until 10.00am and so the number available in each unit is not throughout the day. This needs to be clarified in the Statement of Purpose and to be shown that the staffing levels are sufficient to meet the aims and objectives of the home. The people living in the dementia unit are able to access the regular activities held in the dining room each afternoon. However, we found that there are no specific programmes for the people in the dementia unit which would help to promote and retain the skills they may have. A more stimulating atmosphere could be beneficial to a number of the people that we met. We examined six of the records of people living in the home and found that the Local Authority had provided the necessary assessments when people are referred to the home. The assessments carried out by the home’s staff, to ascertain whether the person’s needs can be met, were found to be quite brief and the sample seen were not dated or signed. A more thorough assessment would be of benefit, particularly for people being considered for admission to the dementia unit. It was not demonstrated that a range of equality and diversity issues are discussed during the assessment process. Dormers Wells Lodge DS0000027701.V362079.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. 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. This judgement has been made using available evidence including a visit to this service. Each person has a care plan but the practice of involving residents in the development and review of the plan is variable and not in evidence. The care plans are not always person centred and were not seen to be used as working documents or provide evidence of improvements to the quality of life. Medication systems do not always follow good practice or safe practice guidelines and have needed action to improve. There is a lack of understanding of the safe handling of medication. Personal care preferences may not always be respected. EVIDENCE: We examined six of the records for people living in the home. The care plans are detailed in most respects, and some information on people’s personal preferences are recorded. However, we found that the care plans for people with dementia were not sufficient person-centred. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 12 It is not shown, in an easy format, how each person’s life can be enhanced by the activities and facilities that are available, or might be introduced to suit the individual person. We found at the inspection in February 2008, in the sample of files we examined, that the health needs of the people were not always recorded satisfactorily. Records of visits from the general practitioners and others were not always evident. The records checked on this inspection were satisfactory. At the staff handover meeting that was attended, there was an emphasis on passing on information regarding physical health needs. Discussions about the ways in which social and emotional needs can be met would be helpful in encouraging further activities in the dementia unit. At the last key inspection we had made a requirement in respect of the risk assessments. These needed to be completed to show that all of the potential risks are identified, what is in place to ensure the safety of the person and the staff assisting them, and how the risks can be reduced. In February 2008, we found that the risk assessments were still in need of improvement. Although risks had been identified, there was insufficient information to show how any potential risks would be minimised. The care plans and risk assessments needed to be monitored for accuracy and to ensure that risk reduction plans are clear. A new risk assessment had been added to those already in place, and some of these had been completed. However, the previous assessments were still in the files. We discussed with the Manager that, whatever system is used, there needs to be a clear risk assessment for each identified area, which shows how the staff manage the risks. The safeguards for the person and the staff team need to be included in this. For instance, the use of the most suitable equipment to bath or shower people should be identified so risks can be reduced. This needs to be discussed with the person concerned, or their representatives, to see if their individual preferences are also being met. If they cannot be met, then this needs to be recorded. We checked a sample of the medication and its administration. A stock check had been carried out the Friday before this inspection but two medications were found to have three tablets too many in stock. The Manager was asked to check the medication with us. Although she felt it was an error resulting from the wrong totals being brought forward to the Medication Administration Record sheet, the errors should have then been picked up on the two stock checks that were recorded. The medication for a person on respite had not all been recorded upon the Medication Administration Record sheet. The supervisor on duty said that it was not recorded as the person had been admitted from home and not the hospital. The Manager was advised that a previous requirement had been made in respect of all respite medication being recorded when brought into the home. This was from the June 2007 inspection. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 13 We found at the February 2008 inspection that it was necessary to issue an Immediate Requirement. This was for all of the medications to be checked within 48 hours to ensure that all of the people living in the home were receiving the correct medication. We found some medications that had not been carried forward when the Medication Administration Record sheets had been changed. Staff said that the medications had been given, but these had clearly not been checked against the Medication Administration Record sheet, or signed for, as they did not appear on the record. A medication packet had the name of the person for whom it was prescribed crossed out and the first name of a resident handwritten on it. It was not possible to know whether it had been dispensed but two tablets appeared to have been given without being signed for. Neither of the supervisory staff on duty could show us evidence to demonstrate if either medication had ceased and, if it had not, how the mistakes occurred. A return visit was made to the home to check on the Immediate Requirement, where it was found that staff had signed retrospectively for the medication that had not been recorded on the Medication Administration Record sheets. They were reminded that medication should only be signed for at the time it is administered, having been checked against the Medication Administration Record sheet for accuracy. We felt that the storage of the non-blister packed medication, in baskets and mixed together, could be improved. We strongly recommend that the medication for each person is stored separately, preferably in individual containers. The fridge where medication is stored has the temperature taken on a daily basis. Appropriate medication was stored in the fridge. We are concerned about the need to have made requirements at several of the home’s inspections regarding medication administration and monitoring. The records provided by the home about training indicated that the two of the senior staff who dispense medication had training in 2006 and the other is not recorded. The staff who receive, administer and dispose of medication must be made aware of their responsibilities in keeping accurate records and regular training would support this. It has been a requirement that the Manager has systems in place to ensure that regular and accurate monitoring takes place and this is repeated. Those people who wish to stay in their bedrooms have this right respected. We observed that staff treated a person with dementia appropriately when personal care was to be provided. Those people who are able to direct their own care were satisfied with the care provided but one person said that cross gender care had been offered for personal care, when she had stated her preference for female care only. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 14 Dormers Wells Lodge DS0000027701.V362079.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. There is planned activities programme but this may not always met the needs of people with dementia. Most people say the food in the home is of satisfactory quality and suits their needs. It meets the dietary and cultural needs of people who use the service and choices are available. People who have concerns about the amount of food, and the way it is served, do not feel that their concerns are addressed. EVIDENCE: All of the people living in the home have the opportunity to join in the Activities Programme which takes place in the afternoon, in the dining room. On the afternoon of the inspection, people were able to participate in bingo. Other activities include exercises and music. There are regular entertainers visiting the home and five minibuses have been arranged for outings between April and August. A colourful monthly newsletter is produced to advertise the outings and entertainments. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 16 We found, however, that there was little activity in the dementia unit. We had been disappointed at the inspection in February 2008 to find an apparent lack of activities in the unit. There is a small activity room which has seating for only two or three people. We were pleased to see that the room was open for use. However, there is limited interest in the room and, particularly for those people able to walk about, the room could be adapted to provide items of interest or as a sensory or music room. In one of the dementia lounges, a musical video was being played but not everyone was seated where the television could be seen. A person in the residential lounge said that they found the television was on all of the time and found it too loud. However, the person did not wish to sit in her room all the time. We discussed with the Manager that there were ways in which the environment could be improved, such as a rearrangement of the chairs. These could be changed to provide for more interaction between those people able to converse. There would also be the opportunity to look into the pleasant garden as people currently are sitting looking into the room. The addition of a table in the rooms could support the residents to participate in small group work, which might stimulate discussion and interest in games or other activities. Family and friends are able to visit the home and some were in the home on the day of the inspection. They are invited to attend residents’ meetings on a quarterly basis and a good attendance was noted at the last one. One visitor was met on this occasion and was appreciative of the home’s care. We found some information in the care plans relating to the people’s individual choices. Those people in the residential unit are generally able to choose where to spend their time and confirmed this. The dementia unit has key pads for security which does restrict movement around the home. A secure garden, accessed from the dementia, would enable those people who can use the garden independently to do so and this should be given consideration. All of the meals are served in the main dining room, which is sufficiently large to accommodate everyone. There is a choice of main meal each day, with a suitable diet provided for the Asian people living in the home. In addition to a basic menu, various additional dishes are available each day. An Asian cook is employed and one of the Asian residents was very complimentary about the food. We spoke to three people who had other comments about the food. These included the comments that it was not always hot. Two of the people said that they would have liked to have more but had been told it was not available. We discussed the general comments with the Manager but she did not feel that this was a fair reflection of what the home offers. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 17 We recommend that the views of the people who are able to express them are sought to ensure that, where there is any room for improvement, action can be taken. As some people wished for anonymity, it is suggested that ways of carrying out the surveys discreetly are explored. The cook was on holiday during in the inspection and a care worker, who assists in the kitchen, was preparing meals. Some fresh vegetables were seen. Food that had been opened or prepared was covered and dated in the fridge. A meal of pork chops or spaghetti bolognaise, in addition to an Asian diet, were on offer. There was jelly and ice cream for dessert. We observed a support worker assisting a person with their meal in an appropriate manner. However, she was also involved in assisting two other people in different areas of the dining room. Staff said that not all of those people require help at all times, but this is an area which needs to be kept under review to ensure that there are sufficient staff for this task. Dormers Wells Lodge DS0000027701.V362079.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, 17, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all of the people in the home are confident about making their concerns known or do not feel action will be taken. Safeguarding training takes place but procedures are not always correctly followed. Staff may not feel confident to “whistle blow”. People are supported to exercise their right to vote. EVIDENCE: One complaint was notified to the Commission for Social Care Inspection in December 2008 and was dealt with by the Dormers Wells Committee, being completed in March 2008. At the inspection in February 2008, we viewed the complaints records and saw that there had been three complaints since the previous inspection. From information in the file, it appeared that we should have been informed under Regulation 37 of the Care Home Regulations 2001, regarding alleged verbal abuse to a person living in the home. This had resulted in disciplinary action against a member of staff, who no longer works in the home. The information was passed to the London Borough of Ealing’s safeguarding adults coordinator. A further issue arose in the home which resulted in a meeting with the London Borough of Ealing’s safeguarding adults department, the Commission for Social Care Inspection, a representative of the Dormers Wells Committee and the Manager. This looked at the implications for the people living in the home and was not taken further. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 19 However, this had not been reported by the Manager at the time the issue arose. It had been a previous requirement in the home that issues must be raised as they occur. Any concern, which may affect the wellbeing of the residents, must be reported so that appropriate action can be taken at the time. No further complaints had been made since February 2008. However, during our discussions with people living in the home, some expressed a reluctance to make complaints directly to the management of the home. Ways in which people can be enabled to raise their concerns need to be explored. Committee members make regular visit to the home under Regulation 26 and it is recommended that they are involved in improving this area of concern. One member of staff confirmed that safeguarding adults training had been undertaken recently and the training records indicated all but one of the staff has had this training. The events leading to the meeting with the safeguarding adults coordinator in Ealing suggest that further training in whistle blowing would be constructive. To support people with their legal rights, the Manager said that postal votes had been received for the forthcoming elections. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 20 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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The layout of the home would allow for smaller group living to take place, in a homely atmosphere, but this is not translated into practice. There could be evidence of more widespread choice, autonomy and equality being offered to the people living in the home. EVIDENCE: We toured the home during the morning of the visit. The repairs that were noted during the inspection in February 2008 had been completed. We understand that the home has had difficulties in recruiting and retaining a handyperson but has employed external companies to complete the work required. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 21 There are three lounges and a large dining room available for the forty five people living in the home. The garden is a well maintained and pleasant area for people to enjoy. However, although it was noted that people are now able to access the garden from the ground floor lounge in the dementia unit, no changes have been made to provide a safe area in the garden for people to walk. Although there are plans to build a conservatory in the future, which would divide the garden, every effort should be made to make a suitable areas for those with dementia to walk. The door to the garden has a frame along the ground which could be a possible trip hazard and needs to be adapted to be safer. We felt that areas of the home would benefit from upgrading and the Business Plan records that a Capital Grant has been obtained to refurbish the dementia unit. Although bedrooms are personalised with photographs and pictures, the bathrooms and bedrooms are quite plainly furnished and would benefit from making more homely. Many of the bedrooms have floor covering, rather than carpet, and it should be an option to have carpet if people would prefer. The Manager reported in the Business Plan that the dining room is in need of new furniture and flooring. The bedroom of a newly admitted resident had not been decorated although it was noted to be in need of upgrading at the previous inspection. The residential unit lounge does not offer sufficient seating for the twenty two people who can be accommodated in the unit. A small number of people prefer to stay in their bedrooms and there are other areas where people may sit, such as the dining room and foyer of the home. On the tour of the home, we found that there were two bathrooms where the water was not sufficiently hot and one where the water was too hot for safety. The Manager said that these had been reported and they were expecting them to be repaired on the day of the inspection. Problems with the temperatures of the water were found at the last inspection and it may indicate that the water supply needs further investigation. We found that the requirements made in August 2007 to have covers on the radiators in the bathrooms had not yet been completed. This was repeated at the February inspection. There are areas where the exposed pipe work to the radiators is hot and one of these was at handrail level. A risk assessment needs to be carried out on these areas to ensure that, where people may be at risk, that the pipes are covered. The portable heaters in the bedrooms, which were found in the bedrooms in February and were potentially dangerous as very hot and not protected, have been removed. Should people require additional heating in their bedrooms, then heaters which are safely placed and reach only a safe temperature, need to be available. The replacement of the heating system is an ongoing project for the home and the Business Plan records that this should be completed in 2008. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 22 We found that the home was clean and tidy on our tour. The staff member working in the laundry confirmed that the equipment was in good working order. The Manager has reported, in the Business Plan, that the laundry facilities require updating and expanding. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 23 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. Staffing levels may not be always sufficient to fully meet the needs of the people using the service. Staff receive basic training on a regular basis, but more specialist training is not always evident. The access to National Vocational Qualifications needs to be improved if the home is to meet its 50 target. The service has a recruitment procedure that meets statutory requirements and the National Minimum Standards. EVIDENCE: The information provided to us showed that six staff were on duty for the home, two of whom work until 10.00am to cover for the busy period in the morning. The Statement of Purpose states that three staff and a supervisor are on each of the residential and dementia units. The Statement of Purpose needs to reflect the level of staffing that is available and the periods covered. We observed a person who lives in the dementia unit being verbally aggressive to another person whilst no staff were in the lounge. Staff need to be aware of the movements of a person who may be aggressive to ensure that others are protected. The staffing levels need to be shown to be sufficient, as it was reported that other incidents have taken place. The records provided showed that all of the staff, except one, had moving and handling training since July 2006, the majority in 2007. We met one staff Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 24 member who said that training had taken place some months after being employed. The recruitment record was checked and this was confirmed. No certificate was in place from the person’s previous employment to show that training has been completed. The Manager is a trained moving and handling trainer, but does not undertake all of the training. As staff are using equipment to provide manual handling, it must be demonstrated that they have the training before they commence this work and are deemed to be competent. Another record seen did not have the manual handling recorded, but the Manager said that this was a recording error. We examined a sample of four files for newer members of staff and those viewed had all the required documentation present. We checked on the progress of the staff having or undertaking National Vocational Qualifications. In the team of twenty four care staff, seven staff have Level 2 or 3. Five have commenced NVQ training, and one person who has Level 2 has commenced Level 3 training. The Business Plan says that the Manager is to investigate further NVQ training to enable the home to meet the target of having 50 of the staff team trained. An Action Plan to show how the home will achieve this is required. Details of the in-house induction were viewed and the home uses the Skills for Care induction standards. Not all parts of the documentation had been signed off to evidence that the new member of staff had worked through the areas. New staff are also given information about the home as part of their induction and the home is in the process of providing the staff with Staff Handbooks. Details of staff training were provided, giving dates of the training undertaken by all of the staff team. All of the staff team, except a newly recruited person, have had dementia training. Staff who had not undertaken their induction this year were shown to have had refresher training in the basic courses. We noted that some staff have been undertaking English classes to improve their skills. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 25 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, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s management needs to demonstrate that, in a variety of areas, that the services it provides are regularly monitored, reviewed and that action is taken when concerns are found. People’s finances are safeguarded by the good record keeping. Health and safety recording is generally good but staff awareness of potential hazards is not always satisfactory. EVIDENCE: The Manager has worked in the home since 2004 and had achieved the National Vocational Qualifications Level 5. The number of requirements which have not been met, particularly with regard to medication and the quality of life for people with dementia, need to be seen to be addressed. In our discussions with the Manager, we did not always find that she was willing to discuss the findings of the inspection, or to investigate where Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 26 concerns had been raised, such as the medication errors which had been found. When passing on concerns, made by people in the course of the inspection, the Manager was not receptive to the general comments, such as those regarding the food. We felt that the people making the comments need to be confident that the management will take them into consideration and acknowledge that there could be areas where improvements can be made. A report was made in 2007 of the results of the surveys undertaken with the people living in the home and the Manager reported that surveys had recently been undertaken again. The new health and safety procedures should also ensure that there is quality monitoring in this area. The Finance Manager explained procedures to us in regard to the finances held by the home. Two people have Dormers Wells Lodge as their appointee. The remainder have relatives or solicitors to support them with their finances which are generally held for hairdressing, newspapers and other small expenditure. The Finance Manager showed us the system she has for asking relatives for additional money when funds are running low. They are provided at this point with a copy of the expenditure to date. The finances of two people were checked at random and found to be correct at the time of the inspection. Audits are carried out at regular intervals. All of the systems were found to be clear and efficiently maintained. We were shown information regarding the supervision and appraisal systems in place. The home has had the Investors in People award, which is due to be renewed, and systems have been revised to accommodate this. Although a number of supervision records were seen, there was no overall record of the number of supervision sessions for each staff member. This would help to demonstrate that the National Minimum Standard of six sessions a year has been met. It was not possible to ascertain if all of the staff had met this standard and it is recommended that a system is introduced, such as a spreadsheet, to show that all of the staff have this. Minutes of the monthly team meetings were made available. We found that the maintenance records are satisfactorily recorded. A list of dates when the health and safety services, reviews and Licence renewals were provided to us. These included Legionella testing in January 2008 and the gas safety check in October 2007. Servicing of the lifts took place in March 2008, the hoists in April 2008 and the fire extinguishers in May 2007. The fire alarms was checked in March 2008, the emergency lighting in April 2008 and small electrical appliances in November 2007. At the last inspection it was required that the fire risk assessment was completed. The current one had not been fully updated in line with the most recent legislation and this needs to be carried out. Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 2 X 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 3 18 2 3 2 3 X X X 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 3 3 2 Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 4 (1), 6 (a) 14 (1) Requirement Timescale for action 30/06/08 2 OP3 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 reflect the staffing levels. The Registered Manager must 30/06/08 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. (Previous timescale of 1/10/07 not met) The Registered Manager must 30/06/08 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. (Previous timescale of 05/03/08 not met) The Registered Manager must 30/06/08 ensure that care plans, particularly those for people with dementia, demonstrate how the quality of life for the person can DS0000027701.V362079.R01.S.doc Version 5.2 Dormers Wells Lodge Page 29 5 OP7 13 (4) b & c 6 OP9 13 (2) 7 OP9 13 (2) 8 OP9 13 (2) 18(1)(a) 9 OP12 18 (1)(c) (i), 4 (1) (a) be enhanced. (Previous timescale of 1/11/07 not met) 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 timescales of 31/12/06, 1/11/07 and 31/03/08 not fully met). The Registered Manager must ensure that sufficient monitoring of medication records take place with evidence that this is carried out. These must include checks on Medication Administration Record sheets, medication in stock and medication being administered. The Registered Manager must ensure that all medication received into the home is recorded and that there is a clear audit trail of administration and disposal. The Registered Manager must ensure that monitoring is undertaken to ensure that staff who administer medication are competent to do so and are complying with the policies and procedures of the home. (Previous timescale of 31/03/08 not met) The Registered Manager must ensure that there are suitable activities and stimulating pastimes available, particularly for people with dementia, and that staff have the training and experience, and are available in sufficient numbers, to support the residents with these. (Previous timescale 01/11/07and 31/03/08 not DS0000027701.V362079.R01.S.doc 31/05/08 31/05/08 31/05/08 31/05/08 30/06/08 Dormers Wells Lodge Version 5.2 Page 30 10 OP20 13 (4) 11 OP18 37 12 OP25 13 (4) a & c 13 OP27 18 (1)(a) 14 OP30 18 (1)(c)(i) 15 OP38 23 (4)(a) met). The Registered Manager must ensure that the exit from the ground floor dementia unit lounge, to the garden, does not constitute a trip hazard. The Registered Manager must ensure that the Commission for Social Care Inspection is notified of any incidents which may affect the well-being of the people living in the home. 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. (Previous timescale of 01/11/07 not fully met). 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 provide an Action Plan to show that the opportunities for completion of the National Vocational Qualifications are available to enable to the home to meet the target of having at least 50 of the staff trained to Level 2 or above. 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. (Previous timescale 01/11/07 and 31/03/08 not met). DS0000027701.V362079.R01.S.doc 15/06/08 31/05/08 31/05/08 30/06/08 30/06/08 31/05/08 Dormers Wells Lodge Version 5.2 Page 31 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 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 medication for each person is stored separately, preferably in separate containers. 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 a spreadsheet, or other system, is used to evidence that the National Minimum Standard of minimum of six supervision sessions a year, for all staff, is being met. 2 OP7 3 4 OP9 OP12 5 6 OP20 OP36 Dormers Wells Lodge DS0000027701.V362079.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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