Inspection on 24/10/06 for Dormers Wells Lodge

This inspection was carried out on 24th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 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 9:50 24th October 2006 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.V312515.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.V312515.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 40 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (0), of places Physical disability over 65 years of age (0) Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named service user who is not yet 65 years old. Approved by the Commission For Social Care Inspection on the 10th May 2004. The service user may remain resident until such time when the home is unable to meet the service users assessed needs and care plan. This condition will be removed once the named service user has reached their 65th birthday or is no longer accommodated by this service. One named service user with Dementia can be accommodated, as agreed by the Commission For Social Care Inspection, on the 12th October 2005.The home must advise CSCI when the service user no longer resides at the home. As agreed on 27th June 2006, one specified service user over the age of 65, with Dementia, can be accommodated. The home must advise CSCI when the service user no longer resides at the home. 4th May 2006 2. 3. 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. Facilities at the home include all single bedroom accommodation, bathrooms and toilets throughout the home, a small stair lift, and a lift to the first floor, three lounges and a large dining room which accommodates all of the service users. 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 service users 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 2006, are £440. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 24th October from 9.50am to 5pm. The Registered Manager was present. At a second visit on the 2nd November, two Inspectors met with the Registered Manager to look at further records. The inspection process took a total of fourteen hours. The home was in the process of having extensive pipe work renewed as the first stage in the replacement of the central heating system. Although the work was behind schedule, it was due to be completed shortly. Temporary heating was being provided in the bedrooms and communal areas. On the first visit, the majority of the service users were seen sitting in the lounges, foyer, or the dining room, and at lunch. A “keep fit” session was held in the afternoon, which service users said they enjoyed. A variety of records were examined, including those for service users, staff, maintenance and training. A number of staff, including the domestic and catering staff, senior staff, care workers, and the Finance Manager, were met and spoken with during the inspection. Two relatives were met in the course of the first visit and they, and the service users spoken to, were positive about the support they receive from staff. For an assessment of all of the key standards, this report should be read in conjunction with the report of the 4th May 2006. At that inspection there were eighteen requirements. The majority of these had been met but three have been repeated. An additional eleven requirements have been made at this inspection. The home accommodates a small number of service users from ethnic minorities and the cook provides some Asian dishes to suit the service users who wish to have them. Religious services are held in the home twice a month, involving two different churches. Service users are able to receive communion on a monthly basis in the home and one service user attends a temple with family members. What the service does well: Service users are offered the opportunity to enjoy a programme of activities, including entertainers and outings. The home is spacious and provides service users with a variety of areas in which to spend their time. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: When prospective service users are referred to the home, the assessment must take fully into account the information received regarding their medical diagnoses, in relation to the home’s registration categories. Although care plans are regularly reviewed, the information on changes has not always been included in the new care plans and this needs to be done to ensure the service users’ health and social needs can be monitored and met. Consultation with the service users, and their representatives, could be evidenced by individual care plans being signed. Improvements are required to the risk assessments, particularly where any restrictive equipment is in place, and for moving and handling. Individual risk assessments should be in place so that each service user’s needs can be reviewed regularly. While staff have been monitoring the medication systems, no evidence was in place to show when this had been carried out and this needs to be recorded. Complaints were seen to have been investigated and the outcomes recorded. However, where there are any allegations of missing money or valuables, the appropriate organisations need to be informed, including the Commission for Social Care Inspection under Regulation 37. Work being carried out on the central heating system will not be completed for some years. As the current radiators will remain for the foreseeable future, and where service users may be a risk from the hot surfaces, covers must be provided. The training records provided showed that some staff still require some of the basic training courses. These included moving and handling, first aid, food hygiene, infection control, medication and other basic courses necessary for fulfilling their roles in the home. Few staff have National Vocational Qualifications and an Action Plan is required to show how 50 of the staff will be trained to National Vocational Qualifications Level 2 within a reasonable timescale. There were some improvements required in the recruitment practices, including the verification of references. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 7 While service users’ views have been sought, and the monthly visits by Trustees are now more detailed, a full review of the quality of care in the home, including an improvement plan, is still outstanding taking into account all of the quality assurance and quality monitoring procedures in the home. The health and safety in the home generally satisfactory, but a full fire risk assessment for the premises is outstanding and needs to be completed to minimise any risks to service users and staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dormers Wells Lodge DS0000027701.V312515.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.V312515.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 (There is no Intermediate Care in this home, so NMS 6 was not assessed) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More attention needs to be paid to the admission processes for new service users to ensure that their requirements fall within the home’s category of registration. Improvements are being made to the admission documentation to provide service users with the full information about fees and financial procedures. EVIDENCE: The Finance Manager provides the service users with either a contract, or the terms and conditions, including fees, when she has the relevant information from the local authority. She is now confirming to service users that their needs can be met by the home, prior to admission, and is also recording details of any financial arrangements made with service users and their representatives so that there are comprehensive records regarding the management of service users’ finances. Samples of these were seen. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 10 Three service users’ files were examined, which included two of the most recently admitted service users. Although assessments had been carried out, the needs-led assessments from the commissioning authorities implied that they were outside of the home’s category of registration. It must be demonstrated that all of the needs that service users have been considered, particularly with regard to any health or mental health issues. The Registered Manager needs to ensure that service users are only admitted whose needs can be met within the home’s category of registration. Where the referrals from the commissioning authorities are unclear, with regards to a diagnosis, information needs to be sought from health professionals to ensure that the information is current and has been assessed accurately. This has been a previous concern in the home and the assessments carried out need to show that service users’ needs have been considered fully. A variation to the home’s registration has been agreed, since the last inspection, for one service user with dementia to remain in the home. Discussions took place with the Registered Manager about the possible provision of a dementia unit within the home which would provide more specialised support and accommodation for those with dementia. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the care plans and risk assessments are still required to be made to ensure that service users’ current needs are identified and met. Although reviews have taken place regularly, the information, where needs have changed, is not being incorporated into new care plans. The risk assessments, for individual service users, are not all in place or in sufficient detail. EVIDENCE: On both visits to the home, a sample of service users’ files was examined and it was noted that a number of the care plans were out-of-date. Although monthly reviews had taken place, not all of the care plans reflected all of the support that the service users required and had not been amended to take account of any changes. Some of the care plans did not cover all of the categories of care and support that the individual service users appeared to need from the information seen on assessment. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 12 While there were some notes to show that service users had been involved in their care planning, the opportunity for service users or their representatives to sign each individual care plan should be provided. This would demonstrate their agreement, particularly when changes have taken place and need to be confirmed as being acceptable. On the second visit to the home, the Registered Manager was advised that the risk assessments for service users using bed rails need to be more specific. These must identifying the need for the equipment, whether it is appropriate, and show how any risks will be minimised. These should be reviewed monthly in case circumstances change. In the files seen, only manual handling risk assessments had been carried out. A new form had been introduced for the manual handling assessments but did not have all of the information, such as skin integrity, equipment to be used, or the method by which transfers will be carried out. Information on other risk assessments were kept in an office file, although these were generally generic and not in respect of individual service users. Risk assessments need to be provided for each individual service user, in the areas where potential risks have been identified, and show clearly how the risks can be minimised. The Registered Manager was recommended to keep all of the relevant risk assessments within the service user’s file so that they can be kept under review. The records did not evidence that risk assessment training had been undertaken and all staff compiling risk assessments, particularly for manual handling, need to be trained to do so. Service users’ health appointments were seen to be recorded in their care planning files. Although information is recorded on the visits made by health professionals, this was not always in accordance with the care plan. In one example seen, the care plan recorded that the chiropodist visited every two months, but the recorded visits did not evidence this. The Registered Manager said that the service users sometimes refuse the treatment offered. It was recommended that this information is included so that there is evidence that the professional staff and the home have tried to meet the health need. The medication system used in the home is administered from a four-weekly blister pack system. It is stored in a medication trolley and dispensed at mealtimes in the dining room by senior staff. A random sample of the nonblister packed medication was carried out and all of the stock checks were in order. The senior member of staff on duty said that monitoring is carried out by senior staff but no record is kept when this are undertaken. This should be rectified so that there is evidence of the checks. A medication book is maintained for controlled medication which was seen to be recorded satisfactorily. From the records provided, only three of the staff have undertaken medication training. It needs to be demonstrated that all of the Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 13 staff who are undertaking this administration are trained and have been shown to be competent. The Registered Manager said service users are asked, upon admission, if they mind the gender of the care staff carrying out their personal care. One member of staff said that not all of the female service users liked to have male carers and one male service user did not wish to have female carers. It is recommended that same gender care is provided until service users have had the opportunity to settle into the home and may feel happier to discuss their preferences. Dormers Wells Lodge DS0000027701.V312515.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 at least once during a 12 month period. 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 service users were complimentary about the activities and enjoyed the keep fit session on the day of the first visit. The employment of an activities organiser and visits from entertainers ensure that there is a regular programme in which service users may participate if they wish. EVIDENCE: Service users who were spoken to during this inspection confirmed that they had the opportunity to join in activities such as bingo and keep fit. An exercise session was taking place on the first visit and service users said that they had enjoyed this. The Activities Organiser works during the afternoons and provides a variety of activities. Regular entertainers visit the home. The large dining room is used for communal activities, as there is sufficient space for all of the service users to attend. A sample of the monthly newsletter was seen and provides service users and their families with information about forthcoming events. A bazaar was due to be held on the 11th November as part of the fundraising for future outings and entertainers. The newsletter showed service users photographed on a visit to the coast and there had also been visits to Kew Gardens. Two visitors were Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 15 met during the first visit to the home and were positive about the support for their relative. The meal being provided on the first visit was turkey in gravy with mixed vegetables, diced swede, carrots and potatoes. An alternative of chicken and noodles was available. There are further options of a vegetarian meal, soup, sandwiches, an omelette or dhal. There are alternatives offered for the small number of service users from the Asian community, although the cook said that they often choose to have what is on the menu. The family of one service user bring in culturally appropriate dishes from time to time. The dessert was jelly and ice cream, which one service user said was her favourite. The cook said that she is able to make some of the desserts, such as apple crumble and custard, with sugar substitute for the diabetic service users. There was no information in the kitchen about the diabetic service users, or others with special dietary needs, but the cook said that she was aware of who they were. It is recommended that this information is kept readily accessible in the kitchen so that it is available for all of the staff who prepare food. The comments on the meals were generally favourable and most service users said that alternative would be made available if the meals were not liked. However, one service user commented “if you say you don’t like a meal, you are told that other people do”. From the home’s recent survey, the majority of service users, rated the food from “good” to “excellent”. The Registered Manager said that she holds regular meetings with service users and their families to discuss meals. Although the cook said that she had not attended any of the meetings, she does meet with the service users at meal times. A cooked breakfast and cooked teatime meal are available. Snacks are available in the evening. The cook said that the kitchen is “deep cleaned” weekly by the handyperson. Fruit is served only after the evening meal and some service users choose to buy their own. It was suggested that this could be available throughout the day, particularly between meals, so as to encourage a healthy diet. Religious and cultural needs are being met by regular access to church services, twice monthly, from two different churches. Communion is available on a monthly basis and one service user visits a temple with family members. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the service users’ financial records and procedures help to safeguard them. Complaints regarding missing money or valuables had not been reported to the Commission for Social Care Inspection, or other appropriate authorities. EVIDENCE: The majority of service users who were spoken to during this inspection said that they would feel able to complain, if it became necessary, and a total of six complaints had been made since the inspection in May 2006. Information on these was recorded appropriately. There have been no adult protection issues reported by the home. However, all of the complaints were in regard to missing items, including money. Whilst the outcomes were satisfactorily concluded, the Registered Manager was advised that the appropriate authorities, including the Commission for Social Care Inspection, should be informed, under Regulation 37, of any allegations made by service users regarding missing money or valuables. It was recommended at the previous inspection, which took place during an election, that service users are given the opportunity to have postal votes. The Registered Manager said that this had now been arranged. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 17 The records showed that all but eight of the staff have been trained in the safeguarding adults procedures during the last year. This should be extended to the remainder of the staff to ensure their awareness of the processes. The Finance Manager had, since the last inspection, formalised the procedures for recording the individual financial arrangements for each service user. This ensures that the information has been agreed with the service users and their representatives. An audit of the financial procedures had taken place, and the Finance Manager was awaiting the report, although had been verbally informed of a satisfactory outcome. The representative of the Trustees, during their monthly visits under Regulation 26, now undertakes the checking of a sample of financial records. The Finance Manager has also introduced a system to retain the receipts for each service user individually, to support confidentiality. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is spacious, with sufficient communal areas for the service users to have a choice of where they spend their time. To help prevent any potential risks to service users, the covering of the radiators, or the provision of low surface temperature radiators, is required. EVIDENCE: The home has three lounges, but most service users were seen to use the two larger ones. A small number of service users enjoy sitting in the home’s foyer and dining room where staff and visitors pass by regularly. Following problems with the heating system, including leaking pipes under the kitchen floor, work on replacing the system had commenced. This had been due to start in the summer but was delayed. The current phase, of replacing pipe work and pumps, due to finish by the time of the second visit to the home, was still in progress and the radiators were not on. While the work has Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 19 been carried out, small electric radiators are provided in every room. The service users said that they had been warm enough, although one said that was cold in the bedrooms in the evenings before getting into bed. The Registered Manager confirmed that the electric radiators in bedrooms were turned off during the day. A suitable level of heating is required to be maintained, particularly should service users wish to use their rooms during the day. There are three phases planned to replace the heating, to take place over the next two to three years, and the replacement of the radiators is not due until the end of the process. The provision of low temperature radiators which reduce the risk of harm to service user was required at the last inspection as it was not known that this would not be included in the current work. Because of the frailty of the service users, any risk of burning from the radiators and pipe work needs to be minimised by the provision of covers, rather than the strategic placement of furniture. The Finance Manager said that the project manager involved in the heating replacement system was in the process of sourcing suitable covers. No changes had been made to other areas of the home. The garden is well maintained and a pleasant area for the service users to enjoy. A small outdoor shelter provides the only smoking area in the home. There was no malodour detected in the home on this inspection. The Registered Manager said that where there had been continence problems, this has been solved by the provision of incontinence pads. The home had eight domestic staff at the time of this inspection, excluding the kitchen staff, and the home was found to in a good state of cleanliness. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While staff have received training in supporting people with dementia and diabetes, the records demonstrated that not all of the staff had undertaken all of the basic training courses, such as food hygiene and first aid. A small number of care staff also required manual handling training. Staff recruitment was not found to be fully in accordance with the Care Home Regulations 2001 and it needs to be evidenced that staff are only employed after all of the checks have been completed. EVIDENCE: At the time of this inspection there were thirty eight service users in the home. Seven staff, including a senior, were on duty on the early shifts and six on the later shifts. The Registered Manager said that there were two full-time care vacancies at the present time. The post of Deputy Manager had been filled at the last inspection but the recruited person did not commence work and the post is being readvertised. It is not intended to fill the post of Facilities Manager, who was responsible for health and safety. The home’s handyman and other staff are undertaking the health and safety checks. The Registered Manager is a manual handling trainer and undertakes the training of the staff team. The training records showed that four of the care Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 21 staff required training and two staff required a refresher course. The records did not show that domestic staff had undertaken moving and handling training and, to support their health and safety, this should be part of their basic training. The training list provided at the second visit to the home demonstrated that the majority of staff had training in adult protection, fire safety and health and safety. However, not all of the staff have been on first aid courses, although a course was planned for the end of November 2006 for nine of the staff. The records showed that another eleven care staff required this training. Not all of the staff have attended food hygiene or infection control and both should be part of the staff’s core training. Almost all of the staff team have training in working with people with dementia and recent training on effective communication and diabetes has been held. Where staff are involved in risk assessing and medication administration, it need to be demonstrated that they the required training. The Registered Manager has a National Vocational Qualification Level 5 in management, and the Finance Manager has Level 4. Of the twenty two care staff currently employed, two staff have NVQs at Level 3 and two have Level 2. A further four staff are undertaking the qualification. The National Minimum Standard, to have 50 of the staff trained to National Vocational Qualification Level 2 or above, has not been reached and an Action Plan is required to show how this will be achieved within a reasonable timescale. A sample of four recruitment records were examined. Whilst most of the requirements of the Care Home Regulations 2001 were in place, there were gaps in the employment history of one staff member and another staff member appeared to have started before the Criminal Records Bureau disclosure or POVA First had been obtained as the starting date was recorded as being before the documentation was received. Some staff had supplied references from their previous employment and it was not documented that the originals had been seen. References should be sought by the home directly from the previous employer or referee whenever possible. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. To support a review of the quality of care, service users have been surveyed for their views and the reports of the monthly visits by the Trustees are providing a more detailed record of the home and its activities. These, together with other quality monitoring systems, should be combined to provide the development and improvement plan for the home. A more comprehensive schedule has been prepared to evidence that all of the maintenance and servicing for the home is carried out, and at the required time. There has been an improvement in the keeping of confidential records. The fire risk assessment had not been produced and this is required to be completed as soon as possible to help to minimise the risks to service users and staff. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 23 EVIDENCE: Under Regulation 24 of the Care Home Regulations 2001, a review of the quality of care is required to take place, on a regular basis, which takes into account all aspects of the home’s quality assurance procedures. As part of the quality monitoring in the home, the Registered Manager seeks the views of service users by questionnaires each year and the report of the 2006 survey was made available. This gives an analysis of the results of the questionnaires in relation to food, care, staff, comfort, entertainment and complaints. Thirty three of the service users, some with the assistance of family, staff or visitors, had participated. The results were positive, with almost all services being scored good, very good or excellent. Regular meetings are also held with service users and their families. The Board of Trustees, under Regulation 26 of the Care Home Regulations 2001, undertakes regular monthly visits and these are now more comprehensive. However, to fulfil the review of the quality of care, the full range of quality monitoring procedures, which may also involve family, friends, and professionals involved in visiting the home, should be included in an annual development and improvement plan. Improvements have been made in the storage of records held in the clinic room, which is used by medical staff visiting the home. The records for service users, and other confidential information, is now stored in a filing cabinet, which can be locked. Other confidential records are held in the Registered Manager’s office. A rolling schedule has now been prepared which shows the required frequency of the maintenance checks and servicing visits and when they are carried out. This includes the hoists, bath equipment, wheelchairs lift and fire servicing and provides easy to access evidence that the home is being maintained in good order. A copy of a fire risk assessment was not available at the first inspection of the home. At the second visit, a checklist to help prepare the fire risk assessment was available, which had been prepared by the visiting fire company. The Registered Manager had also acquired the new Fire Regulations for residential care which came into force in October 2006. The Registered Manager is aware that, from this information, she will need to complete a full fire risk assessment. Service users who smoke have a shelter in the garden for this purpose and any risks associated with individual service users, or staff, who smoke will need to be included in the assessment. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 24 The information available showed that regular fire drills take place. It is recommended that a schedule, such as a matrix, is maintained to demonstrate more easily that each staff member has attended these throughout the year. Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 3 2 Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 (1) Requirement The assessment of prospective service users must take fully into account their medical diagnoses in relation to the home’s registration categories, and evidence that these have been considered. The service users’ care plans must be updated, in consultation with the service users or their representatives, when any changes to their care and support are identified during reviews or at other times. Where restrictive equipment is used, such as bedsides, the risk assessment must consider the need for the equipment, whether it is appropriate, and show how the risks will be minimised. Risk assessments for individual service users must in place to ensure precautions are taken to minimise the risks. (Previous timescales of 30/12/05 and 31/7/06 not fully met). The health needs of the service users, as detailed in their care plans, must be monitored to DS0000027701.V312515.R01.S.doc Timescale for action 31/12/06 2 OP7 15 (2) 31/01/07 3 OP7 13 (4) b & c, 13 (8) 31/12/06 4 OP7 13 (4) b & c 31/12/06 5 OP8 12(1) a,b (13)(1)b 31/12/06 Dormers Wells Lodge Version 5.2 Page 27 6 OP9 13 (2) 7 OP18 13 (6), 37 (1) 8 OP19 13 (4) a & c 9 OP28 18 (1) 13 (4),(5) 10 OP28 18 (1)(c) (i) 11 OP29 17 (2)19 (1)(b) 12 OP33 24 ensure that they are being met. Where service users refuse any services, this should be recorded. Systems must be in place to provide evidence that regular monitoring of the medication administration is carried out. (The previous timescale of 30/06/06 not met) In order to safeguard service users and staff, any allegation of missing money or valuables must be reported under Regulation 37 of the Care Home Regulations 2001, and to other appropriate services. The previous timescale of 30/06/06 not met) In view of the frailty of the service users, the provision of covers for the radiators or low surface temperature radiators must be fitted where service users are at risk. Moving and handling training must be provided to all staff who have not undertake this course, including those who carry out domestic duties. An Action Plan is required to show how 50 of the staff will be trained to National Vocational Qualifications Level 2 within a reasonable timescale. The Registered Manager must ensure that all of the requirements, in respect of good employment practices, are met before staff commence work in the home. To complete the review of the quality of care, an improvement plan for the home must be produced on a regular basis and supplied to the service users and the Commission for Social Care Inspection. DS0000027701.V312515.R01.S.doc 31/12/06 30/11/06 31/01/07 31/01/07 31/01/07 31/12/06 28/02/07 Dormers Wells Lodge Version 5.2 Page 28 13 OP30 18 (1)(c) (i) 14 OP38 23 (4a) The provision of core training 28/02/07 courses in first aid, food hygiene, infection control, adult protection, and other basic courses necessary to perform their work, must be provided for all of the staff who have not undertaken these or whose training is no longer current. A full fire risk assessment for the 31/12/06 home must be completed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP8 Good Practice Recommendations That all of the relevant risk assessments, for individual service users, are kept with service user’s care plan so that they can be kept under review. That, where there is a refusal by service users to have any treatment from health professionals, such as the chiropodist, this is recorded to evidence that the home and the professional have tried to meet the service user’s needs. That the wishes of the service users with regard to personal care and same gender care is kept under review, so that service users can express their preference once they have settled into the home. That written details of the service users requiring special diets, such as diabetic, are available to all of the staff who prepare food. That a record is maintained, on a spreadsheet, or matrix, of all of the staff who have attended fire drills to evidence that they have all attended. 3 OP10 4 5 OP15 OP38 Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dormers Wells Lodge DS0000027701.V312515.R01.S.doc Version 5.2 Page 30 - 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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