Inspection on 23/03/09 for Dormers Wells Lodge

This inspection was carried out on 23rd March 2009.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dormers 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 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 09/07/2009.

CARE HOMES FOR OLDER PEOPLE Dormers Wells Lodge Telford Road Southall Middlesex UB1 3JQ Lead Inspector Clare Henderson-Roe Unannounced Inspection 10:00 23 & 31st March 2009 rd 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.V374620.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.V374620.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.V374620.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. 15th April 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 the 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. There is a conservatory attached to the dementia care wing. A shelter in the garden is provided for residents who smoke. The care team consists of the Registered Manager, five supervising staff and a team of care staff. There are domestic, laundry and catering staff, a finance Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 5 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.V374620.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 18 hours was spent on the inspection process, and was carried out by 2 Inspectors. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 10 residents, 10 staff and 2 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus surveys completed by residents and staff have also been used to inform this report. It must be noted that it is sometimes difficult to ascertain the views of residents with dementia care needs. Since the last key inspection 2 random inspections have been carried out and a Statutory Enforcement Notice was issued for medication management shortfalls. The second random inspection was to check compliance and the home was found to have complied with the Statutory Notice. What the service does well: Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. The home has an open visiting policy and visiting is encouraged. Information about advocacy services is available on display in the home. The food provision is good in the home, offering variety and choice, and work is ongoing to provide a picture menu for residents with dementia to more easily identify each meal choice available. The home has a complaints procedure and this is being followed. The home is also clear on the safeguarding adults procedures, and staff have received training in safeguarding. An audit of the home has been carried out for redecoration and refurbishment and there is a plan for this, with evidence of work already having taken place to improve the environment. Infection control procedures are in place and are followed. The systems in place for the vetting and recruitment of staff are robust, thus protecting residents. The home has 2 induction programmes and staff confirmed that they undergo a full induction when newly employed at the home. There is also evidence of training and updates in topics relevant to the diagnoses and needs of the residents, to include health & safety training. The Manager has the qualifications and experience to manage the home effectively, and staff and residents stated that the Manager is supportive and approachable. Systems for quality assurance are in place to provide an ongoing process of audit and review. Monies held on Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 7 behalf of residents are securely stored and clear records are kept. Health and safety is being well managed at the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dormers Wells Lodge DS0000027701.V374620.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.V374620.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides documentation to give prospective residents and their representatives clear information about the home and the services it offers. Prospective residents are assessed prior to admission to ensure the home is able to meet their needs. Staff have received training in dementia care to give them the knowledge to provide effective care. EVIDENCE: Since the last inspection the Service User Guide and Statement of Purpose have been updated to reflect the current staffing arrangements for the home, and any other relevant changes. We were informed that the home has introduced a new pre-admission assessment document, and were shown a copy, which is comprehensive and covers all areas of care. All 4 residents files contained a pre-admission Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 10 assessment and a copy of the assessment undertaken by Social Services. The information provided gave appropriate detail to ascertain that the home was suitable to meet the needs of each resident. The home receives referrals for respite care and this has identified that sometimes people exhibit differing behaviours when in a care home as opposed to their own home, and the Manager is aware of the importance of reporting any issues that come to light to Ealing Social Services. On the dementia unit staff had received training in dementia care. Whilst we observed that some activities were taking place this area needs to be further developed to incorporate the specific needs of the residents living with the experience of dementia. (see Standard 12) Dormers Wells Lodge DS0000027701.V374620.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 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plans are well completed and maintained up to date, thus giving a good picture of the residents needs and how these are to be met. Whilst there is evidence that there is involvement in the formulation and review of the care plan by some residents and their representatives, this needs to be implemented for all residents. Medications are well managed and residents medication needs are met. Staff care for the residents in a gentle, courteous and professional manner, thus respecting their privacy and dignity. Whilst systems are in place for identifying health deterioration and end of life care, records for this need to be maintained to ensure these are identified and can be fully met. EVIDENCE: We were informed that since the last inspection a new care planning system has been introduced throughout the home. Service user plans were viewed on each unit. On both units those viewed had been well completed and there was evidence of monthly review. The care plans viewed had been personalised to reflect the individual needs and preferences of the residents. Risk assessments Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 12 to include those for falls were in place. There was some evidence of involvement of residents and their representatives in the review of the service user plans, however more work is needed to ensure all residents, or where they are not able, their representatives have input into the formulation and review process. On the second day of inspection it was clear that more work had been done in this area, plus a checklist for all documentation to be included in each service user plan had been introduced. Continence assessments are completed by the District Nurse. Moving and handling assessments had been completed in all the residents files viewed and were comprehensive. Nutritional information was available in the care plan documentation and we suggested that a nutritional assessment is also introduced. This had been addressed by the second day of inspection. There was evidence of monthly weights being taken and we were informed that for residents who experience weight loss, a referral is made to the GP. We recommended that Social Services also be kept informed in such instances. Where residents require wound care management, blood glucose monitoring and insulin administration this is undertaken by the District Nursing team. Medication management was viewed. Lists of staff signatures and initials were available. Administration records were complete and where a medication had been omitted for some reason, the correct coding with an explanation for the omission had been used. Receipts, to include those for medications received mid-month had been recorded. We were informed that medication, which is no longer required for a resident, is returned to Boots pharmacy, and records of returns are kept. Room temperatures were being recorded and were within safe range. Minimum, maximum and actual temperatures for the medications fridges had been recorded and were overall within safe range. Entries in the controlled drugs register were viewed and the need to ensure both staff sign their names in full was discussed. This had been introduced by the second day of inspection. Liquid medications to include eye drops had been dated when opened. Dates of opening had been recorded on the boxed medication in use. For residents on medications with very specific administration instructions, these had not always been recorded in full on the medication administration record (MAR) or the instruction label on the box. We agreed that the Manager would address this with the dispensing pharmacist, and there was evidence of this in the audit carried out by the dispensing pharmacist on 24/03/09. Stock balances are checked weekly and recorded on the MAR. Stock balances had been clearly carried forward onto the new MAR. We were informed that Boots pharmacy had been carrying out regular audits, with a 4-6 monthly monitoring report being completed. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. Staff were seen knocking on residents doors and overall there was a attitude of respect for the residents. Staff were seen interacting well with residents and there was a good atmosphere throughout the home. Residents looked well cared for and were dressed to Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 13 reflect individual and cultural preferences. Residents wishes in relation to personal care and gender preference of the care staff are clearly identified in the care plans. Residents can have their own telephones - either landline or mobile, plus the homes telephone system has been replaced and residents can receive incoming calls on the cordless phone. Computer equipment had been made available in the home. We had a discussion with the Manager regarding the way in which residents are supported when their health deteriorates or they need to move on to nursing home accommodation. We suggested ways in which this information could be recorded in the care plan. Where residents have a specific wish not to be sent to hospital then this would be recorded. It is acknowledged that this is a sensitive area of care, and if people do not wish to discuss it as yet then this can be recorded. Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 14 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. The home provides a range of activities that are advertised, with more work to be done in the implementation of activities on the dementia unit, to fully meet all residents needs in this area. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the residents rights, choices and opinions are heard and respected. The food provision in the home is good, offering variety and choice, to meet the resident’s individual needs and preferences. EVIDENCE: The home employs a full-time activities co-ordinator. There is a programme of activities and this identifies activities led by staff and those led by others. The activities co-ordinator was not available on either day of inspection, however staff were seen implementing activities with the residents. The Manager told us that since the last inspection the activities co-ordinator had undertaken a course in activities specific to dementia care, and had been booked for further relevant training. Whilst progress has been made in improving staff knowledge and skills for dementia care, further work is needed to ensure activities specific to the needs of people with dementia care needs are available and taking place Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 15 each day. Residents religious needs are met through attendance at Church or church representatives visiting the home. Some information is available in the service user plan regarding residents hobbies and interests and religious needs. Outings are arranged each month from April to December and some staff have undertaken MIDAS training in order to drive the Community Bus. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and kept up to date with their relatives’ condition. Residents can receive visitors in one of the communal rooms or in their bedrooms, as they so wish. Information about advocacy services is displayed in the foyer, to include Age Concern contact details and various services offering financial advice in respect of care provision. We viewed the kitchen. The area was clean and tidy and records were up to date. The home has a 4 week menu and choices are available at all meals. Residents spoken with said that they enjoy the food and are offered a choice. Staff were seen assisting residents with their meals where needed, and also gently encouraging and supervising residents, promoting their independence. Asian diets are prepared for some of the Asian residents living at the home. Residents are encouraged to go to the dining room for their meals. A picture menu is available and we discussed the need to display this in the dining room and expand the choice of pictures to accurately reflect the menu. There was evidence of progress being made in this area by the second day of inspection. Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place for the management of complaints and for adult protection concerns, thus safeguarding residents. EVIDENCE: The home has a clear complaints procedure and copies are also available in the Statement of Purpose and Service User Guide. The home had received 1 complaint in the last 12 months and this had been investigated and responded to. One complaint had been received via CSCI and this had also been investigated and responded to. The Manager was clear on the Ealing Safeguarding procedures and said that she would ensure all incidents are reported appropriately. Following recent safeguarding investigations, CSCI is now being notified of any unexplained injuries and other relevant information. Staff spoken with were clear to report any concerns and understood Whistle Blowing procedures. Staff have received training in safeguarding adults, and updates had been scheduled. There was also evidence that where the need for staff training and updates had been identified due to the nature of the safeguarding incidents, this had been carried out, for example, further moving & handling training. Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: We carried out a tour of the home. There was evidence of new flooring in several areas, to include carpet in some bedrooms. At the time of inspection corridors were in the process of being redecorated and the new maintenance man confirmed that all areas of the home had been reviewed and all areas for redecoration have been identified. A copy of the redecoration and refurbishment plan has been forwarded to us. The lighting in the corridors has been partially renewed, with further work planned. There is a new conservatory on the dementia unit and plans are in place to provide a secure garden area as part of the dementia wing. The gardens are spacious and are well maintained, with twice monthly visits from the gardener. The home was Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 18 built in the 1960s and it is clear that the staff work hard to make it as homely as they can. The heating system has been reviewed and radiator guards are now in place throughout the home to protect residents from burns. The home has a laundry room with 2 washers and 2 dryers. They have installed the Otex validated ozone disinfection system, which works in conjunction with the washing machines. The wash programmes to be used were clearly identified and there is also infection control information on display. The home was very clean and fresh throughout. Protective clothing to include gloves and aprons are available. Infection control is being well managed. Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place and protect residents. Staff have received training to provide them with the skills and knowledge to care for residents effectively. EVIDENCE: At the time of inspection the home was being appropriately staffed to meet the needs of the residents and the home. Staffing levels are based on resident dependencies, and the Manager said that they ensure that additional staff are on duty for any outings to include hospital appointments. Duty rosters were available listing all staff on duty. The home provided information to confirm that over 50 of the care staff are qualified to NVQ level 2 or the equivalent, and there are 9 more staff working towards this qualification. We viewed 3 sets of staff employment records. These contained all the information required under Schedule 2 of the Care Homes Regulations 2001. POVA first checks are obtained for all new staff, and where there is a need to employ people without further delay, then these staff are chaperoned when in areas accommodating residents until a satisfactory Criminal Records Bureau check is received. Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 20 The home has 2 induction programmes – one is a general introduction to the home and the second is the Skills for Care common induction standards programme. Staff spoken with confirmed that they had undergone the relevant induction programmes for their role. There was also evidence of other training in topics relevant to the diagnosis and needs of the residents, to include dementia care training. Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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 Manager has the knowledge and experience to manage the home effectively. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are good, thus protecting residents, staff and visitors. EVIDENCE: The Manager is an experienced manager who has been in post for 6 years. She has attained NVQ level 5 in management and care. The Manager said that her recent training included safeguarding adults – managing people with dementia, leadership and motivation for care homes, managing end of life care for the elderly, and strategy of management in a care setting. Staff spoken with said Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 22 that the Manager is supportive, and it was clear from observation that there is good interaction between the Manager and residents. Regulation 26 unannounced visits on behalf of the Registered Person are carried out and reports from these are available. There is a year planner for meetings to include all areas of staff, residents and the Home Committee, and comprehensive minutes are written up. The last residents survey was carried out in January 2009, and some residents had completed these independently. Where people required staff assistance to complete the survey this was clearly recorded. Medication audits are carried out by the dispensing pharmacist and by the home. Work is taking place to ensure the service user plans are also audited and the auditing recorded. The home has attained Investors in People, and the last review was carried out in December 2008, with a very positive report resulting from the review. The home manages personal monies on behalf of residents. All income and expenditure is clearly recorded and receipts are issued for all incoming monies. There were also clear receipts available for all expenditure. We checked the records and balances for 4 residents and these were correct. Staff spoken with said that they do receive regular supervision, and a list of the most recent supervision and appraisal sessions was made available to us. The Manager is clear that care staff must receive supervision a minimum of 6 times per year. There is also evidence of other staff receiving supervision and/or appraisals. We sampled the servicing and maintenance records and those viewed were up to date. The home maintains a record of the most recent servicing of all equipment and areas. The records for the water temperature testing could be followed, however the home has now introduced a temperature record sheet that lists all rooms in the home, for ease of recording. Staff have received training in health & safety topics at the required intervals. There was evidence of regular fire drills taking place and records are maintained, however we recommended that the information be more comprehensive and this is being addressed by the home. The fire risk assessment was last completed in December 2008 and the action plan contained 2 actions, one of which was completed and the other in progress. Risk assessments were in place for equipment and safe working practices, and there was evidence of annual updates. Regulation 37 notifications are submitted to CSCI for all notifiable incidents. A recent issue regarding a lock on a door had been addressed and an appropriate locking device is now in place. Health & safety is being well managed at the home. Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 23 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 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 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP11 Regulation 12 Requirement There must be evidence that residents have been offered the opportunity to discuss their wishes in respect of health deterioration and end of life care, and the outcome of such discussion must be recorded so that their wishes can be met. Activities suited to the needs of residents with dementia care needs must be provided as part of daily life in the home, so that their specific needs can be catered for. Timescale for action 01/06/09 2. OP12 16(n) 01/05/09 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 the practice of involving residents and/or their representatives in the formulation and review of the service user plan documentation be increased to ensure such involvement is evidenced for all residents. Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Dormers Wells Lodge DS0000027701.V374620.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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