Inspection on 04/05/06 for Dormers Wells Lodge

This inspection was carried out on 4th May 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 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 23/03/09

Dormers Wells Lodge 14/08/07

Dormers Wells Lodge 24/10/06

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 Unannounced Inspection 4th May 2006 11:40 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.V288628.R01.S.doc Version 5.1 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.V288628.R01.S.doc Version 5.1 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 Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 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. 8th November 2005 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 non-profit 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 single bedroom accommodation, two passenger lifts to the first floor, a private telephone room, three lounges and a large dining room. One lounge on the ground floor is equipped with a loop facility. This assists service users who might have a hearing impairment and are dependant on hearing aids. The homes rear garden is attractive and well maintained with a pond, summerhouse, seating areas and raised flowerbeds. There are paved areas to and around the garden allowing easy access for service users who are dependant on mobility aids. 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 and administrative assistant, handyman and facilities manager. The weekly fees, from the 1st April 2006, are £440. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 4th May 2006 from 11.40am to 7pm. The Finance Manager was present, together with two senior supervisors, who were able to assist with the inspection. There were thirty six service users in the home, and four vacancies. Two of the service users were in the home for respite care. Almost all of the service users were met at the lunchtime meal or when sitting in the lounges. As the Registered Manager was not present, additional visits were made on 11th and 31st May to meet with her and discuss with her the progress of the requirements from the previous inspection and examine further records. The inspection process took a total of sixteen hours. In addition to looking at documentation and records, two tours of the home took place, one with the Registered Manager. At the first visit, the lunchtime meal was sampled. A magician entertained the service users during the afternoon and most of the service users attended. Activities, including craft work for the forthcoming sale, were taking place with the Activities Organiser at the second visit. At the third visit, a clothing party was being held. The majority of service users were positive about the care and support that they received in the home. The conditions of registration, which allow for one service user who is under sixty five years of age and one service user with dementia to be accommodated, remain. The possibility of providing a dementia unit was discussed with Registered Manager as several other service users have the early signs of dementia, although are not yet diagnosed. The health needs of the service users will be required to be kept under regular review, with appropriate professional referrals, to ensure their future needs can be met. During March 2006, the central heating in the home ceased to work and portable heaters have had to be used. The Registered Manager confirmed that the heating will be replaced during the summer and quotations were being sought. At the inspection in November 2005, there were ten requirements. Of these, seven have been met and three are repeated as not fully completed. A further fifteen requirements have been made at this inspection. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Improvements to the admission and assessment procedures are required to ensure that service users’ needs are taken fully into account before they are admitted. Service users need to have it confirmed, prior to admission and in writing, that the home can met their needs. The terms and conditions, in respect of accommodation and services provided to service users, needs to be included in the fees and a copy of the local authority agreement where applicable. The improvement of care plans is ongoing but it needs to be demonstrated that all of those required are in place and kept under regular review. Where any equipment to aid mobility or restrictive equipment, such as bedsides, is used, the assessments to reduce the risks must be fully documented. Systems must be in place to ensure that medication can be stock controlled and stock monitoring must be seen to be undertaken. The information on complaints is required to be maintained in good order and be available for inspection. Following an issue raised by a service user, which was not reported under adult protection procedures, the Registered Providers need to ensure that service users and their representatives are aware that any allegations of abuse have to be reported appropriately. Service users need to be made aware of the home’s responsibilities in helping to safeguard adults. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 7 Where service users have concerns with incontinence, its management must be undertaken with the involvement of the appropriate health care professionals and care plans. With the plan to install new central heating and, in view of the frailty of the service users, the provision of radiators which reduce any risk of burning to the service users must be considered when the new system is installed. Not all of the bathrooms are in use, and it must be shown that adequate bathroom facilities, which are suitable for the needs of the service users, are available. The staff records seen did not contain all of the information required under the National Minimum Standards and Care Home Regulations 2001. It must be demonstrated that those required before employment are in place and the records are maintained in good order, with all of the information in place for inspection. Information on the training undertaken by each staff member, with evidence that it is up-to-date, is also required. As part of the quality assurance and quality monitoring procedures, regular checks need to be undertaken by the Registered Manager, and those visiting on behalf of the Registered Persons, to ensure that records are being maintained satisfactorily. The confidentiality of service users and staff records should be maintained by more secure storage. A number of health and safety issues need to be addressed. It must be shown that the servicing of the gas appliances is in accordance with the Landlord’s gas safety check. The fire precautions need some improvement. In particular, the Registered Persons must ensure that regular fire drills take place at different intervals and are clearly recorded. This is restated from the previous inspection as it was not fully completed. It must also be demonstrated that all of the staff have participated in regular fire drills, the times of which are recorded and in accordance with the London Fire and Emergency Planning Authority’s guidance for day and night 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.V288628.R01.S.doc Version 5.1 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.V288628.R01.S.doc Version 5.1 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): 1, 2, 3, 4, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users are provided with information to assist them with making a decision about the home. The referral and assessment procedures need to be improved so that it can be demonstrated that service users’ needs are being fully considered before admission is agreed and it can be shown that these are within the home’s category of registration. EVIDENCE: The home has a Statement of Purpose and Service Users Guide. There were minor amendments to be made which the Finance Manager carried out during the final visit. Copies of the Service Users Guide are kept in the service users’ rooms. Service users are given details of the facilities available in the home through the Service Users Guide and a copy of the contract/terms and conditions. These were seen in two of the files examined, although the individual information on fees was not included for those service users who are not Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 10 privately funded and this need to be provided. A copy of the Local Authority agreement was not seen in any of the files examined and this should be made available to service users, where applicable, under Regulation 5 (3) of the Care Home Regulations 2001. A number of local authorities contract with the home, including Ealing, Hounslow and Hillingdon. There is no longer a block contract for six respite beds from Hillingdon, although respite care is still available. Needs-led assessments have been carried out by the Local Authorities where they are contracting with the home. However, in the files examined, the documentation did not show that there had been an assessment by the home’s staff of the service users, prior to admittance, to show how their needs would be met. In one file, the referral indicated that the service user probably had early-onset dementia. The home is not registered to admit service users with dementia, although there are other service users who may also have this condition and they need to be referred for appropriate professional assessments. It was discussed with the Registered Manager that the home must not continue to admit people outside of its category of registration. The possibility of an application for a separate dementia unit within the home, to accommodate and support current and future service users, was also discussed with the Registered Manager. No evidence was seen in the files that service users had been informed, in writing, by the registered person that the care home is suitable for the purpose of meeting the their health and welfare needs. This is a requirement under Regulation 14 (1) (d) of the Care Home Regulations 2001 and service users should be informed of this. The Registered Manager confirmed that service users have every opportunity to visit prior to admission. There is no Intermediate Care unit in this home, so this National Minimum Standard was not assessed. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 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, 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although all of the files examined showed that service users’ care planning information in place, these were not seen to have been produced in consultation with, or provided to, the service users. Progress has been made in getting care plans up-to-date, but the risk assessments need to be strengthened to include risk reduction plans and guidelines for the service users who require assistance with manual handling, are supported with special equipment or have health needs which require individual guidance. Monitoring is required to ensure that all of the care plans are reviewed on a regular basis. EVIDENCE: It was a requirement at the previous inspection that the care plans must be in place for all service users. The files of two recently admitted service users both contained a variety of information on their care needs. However, in a sample of five files, not all of the care plans were fully completed. These were not seen to have been agreed with the service users or their representatives and are not in a format which could be shared with the service users. The care plans did not have any guidance to show how service users prefer their personal care to be Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 12 provided and some contradictory information was seen regarding the service users’ wishes. These need to be clarified. Inadequate risk assessments were seen to be in place for service users where risks, such as manual handling, are identified. This was particularly so for those who had been shown to be at a high risk and who require assistance with hoists, wheelchairs and other equipment. Where restrictive equipment is used, such as bedsides, permission for their use should be agreed and documented, and the necessary risk assessments be put in place. Following a requirement at the last inspection, the recording of visits from General Practitioners, opticians, chiropodists and other health professionals are now in place on an individual basis. However, the health needs of service users were not always seen to be clarified in the care plans seen and information on the treatment, following health care professionals’ visits, is sometimes recorded in the service users’ notes, rather than on the record of visits. This can make the tracking of appointments and outcomes more difficult to follow, particularly if notes have been archived. In the sample of care plans examined, not all of the care plans were seen to have been reviewed monthly, in accordance with the National Minimum Standards. The reviews are carried out by the service users’ key workers and monitoring is required to ensure that these are all completed. The Registered Manager said that the requirement to have service users or their representatives involved in the care planning had been fulfilled and consent forms, to the care plans, are completed. However, none were seen in sample of files examined and these should be included to demonstrate that service users are enabled to have input into their support. Copies of the care plans are not provided to the service users at present but, under the Care Home Regulations 2001, should be made available to the service users. There have been requirements made at the last two inspections regarding the medication administration. No errors were found in respect of administration at this inspection, but it was found that the stock held on one medication was not accurately reflected on the Medication Administration Sheet and was therefore not possible to stock check. A recent visit from the pharmacy supplying the home’s medication required the home to have a separate medication cupboard for its controlled drugs, which is now in place. The General Practitioner was visiting the home during one of the inspection visits. A room is set aside for these visits, which is used unless service users are too unwell to go to the room. The option of having medical examinations and treatment carried out in their own bedrooms, in accordance with the National Minimum Standards, should be offered to service users. The district nurses carry out the medical tasks, and were treating one service user for pressure sores and providing daily insulin injections for two service users. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 13 Those service users spoken to during the course of the inspection confirmed that they were treated with respect and information was seen in their files regarding personal preferences. There is no policy on same gender care within the home, and this is not always provided. The Registered Manager said that service users are asked, upon admission, about their preference regarding personal care. It is recommended that this is seen to be kept under review to ensure that service users, once they have settled into the home, can make decisions based on their experiences. All of the service users have single bedrooms where they can see visitors. Although the three separate lounges may not be available for private use, there is a dining room and garden which can be used to see visitors if required. The care plans examined had information regarding the funeral arrangements for each of the service users and included, in some cases, details of their personal wishes with regard to special arrangements. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 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. An activities organiser is employed and a full programme of activities is in place, with the opportunity for the service users to enjoy a variety of entertainers and outings, as well as bingo and crafts. The meals are generally satisfactory but more variety of vegetables, and making fruit more readily available, could help to aid nutrition. The introduction of menus for the service users, with the full range of meals and snacks on offer, would enable service users to be more involved in choosing their meals. EVIDENCE: On the first day of the inspection, a magician was in the home during the afternoon. Outside entertainers attend the home on a regular basis and the large dining room allows for all the service users to attend if they wish to do so. The rights of those service users who did not wish to attend are respected, although most did so and those spoken to afterwards said that it had been most enjoyable. Bingo is also played regularly. The activities organiser was arranging for some of the service users to assist with craft items for the fair that was to be held in the home. This took place between the second and third visits and was very successful, the proceeds being used to pay for entertainers Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 15 and outings. The activities are planned for each weekday afternoon between 1 and 4pm. It was confirmed that visitors are welcome to the home, although none were seen on the visits to the home. Staff said that visitors are not encouraged at mealtimes or late at night. The preferences of the service users with regard to getting up and going to bed are noted in the service users’ assessments. A number of service users confirmed that they were able to choose how they spend their days. There are a variety of lounges in which to sit as well as the dining room and pleasant garden. Some service users prefer to sit near to the entrance where the home is busiest. Smoking is allowed only in the garden. Service users eat in the large, ground floor dining room. The meal of the first day of the inspection was lamb casserole, mashed potatoes, cauliflower and broccoli. The alternative was spaghetti bolognaise. Both meals are served with the same vegetables. The dessert was strawberry gateau. The menu has been reduced in variety and a two week rolling menu is in operation, although the same main courses were available at the following week’s visit. The kitchen staff reported that there were three diabetic service users and one vegetarian. Fruit is offered to diabetic service users as a dessert. It is recommended that, where other alternatives are available, such as desserts made with sweetener, that these are advertised on the menu. Although the menu is on displayed near to the serving hatch, it is recommended that service users would have better information if the menus could be displayed, in a suitable format, on the tables. None of the service users asked were aware of the dessert being served, or alternatives, and knowledge of this could be useful in supporting them to make choices. Whilst most service users said that the food was satisfactory, some did not like the alternative of spaghetti and did not have any vegetables with this choice. The Registered Manager said that service users are asked for their views on the menu and this needs to be kept under review. Meals taken are recorded on individual service users’ daily notes. Staff said that they serve a certain number of service users each, enabling them to check if service users are not eating well. Fruit is generally only available at mealtimes but it is recommended that service users are encouraged to eat fruit between meals to aid nutrition. The addition of a third vegetable is recommended to ensure that service users have a better choice and are encouraged to eat the five portions of fruit and vegetables a day recommended by nutritionalists. Meal times are set, with breakfast at 8.30am, lunch at 12.30pm and tea at 5.30pm. The menu does not advertise an evening snack as being available. Some staff spoken to said that they offered drinks and biscuits but did not Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 16 usually provide snacks, except to diabetic service users. Service users were not aware of what was on offer. To meet the National Minimum Standards, a snack meal should be offered in the evenings to ensure that there is no more than a twelve hour gap between meals. It was confirmed that some culturally appropriate meals are made available to meet the needs of one service user. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 17 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. Not all of the information regarding complaints made was available and this is required to be in place to evidence that service users have their concerns and complaints dealt with appropriately. An issue, which may have been a potential abuse situation, was not reported to the relevant organisations, including the Commission for Social Care Inspection, and the management of the home must ensure that this is carried out in future. EVIDENCE: A log of complaints with some associated documentation was seen. Not all of the documentation corresponded to the log and this needed to be put into order. The complaints information was not available at the last visit to the home, due to being locked away by an absent member of staff. It must be accessible in the event of an unannounced inspection. Most service users spoken to said that they felt they would be able to make a complaint should this be necessary, although one felt that this would not be particularly productive. One complaint was seen to have been made since the last inspection which was seen to have been dealt with appropriately within the timescales. The first visit of the inspection took place during polling day for the local council elections and the service users who wished to do so where able to go to the polling station to vote. Postal votes had not been applied for and it was Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 18 recommended to the Registered Manager that this is carried out when names are required for the next electoral register. The Registered Manager is a Protection of Vulnerable Adults trainer and has provided training for the staff team. The records evidenced that approximately half of the staff had attended training this year. It was not shown if the remaining staff have attended this training and, if not, this should be provided. A situation regarding an allegation of money missing from a service user was not reported to the Commission for Social Care Inspection, or the Safeguarding Adults coordinator, as the service user did not want it reported. The Registered Providers must have in place a policy and procedure for dealing with allegations of all types of abuse and ensure that the service users are aware of the actions that will need to be taken should allegations be made. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a variety of areas in which the service users can spend their time, with a pleasant garden and comfortable lounges. EVIDENCE: The home provides spacious accommodation for forty service users, with three separate lounges and a large dining room, which is used for activities. The rooms were seen to be well maintained and the lounges are pleasantly furnished. The lounges are carpeted, but the other communal areas and the majority of bedrooms have floor covering. One bedroom with a carpet was found to be quite odorous of urine, although had been shampooed the previous day. The Registered Manager said that floor covering would be considered for this room. The option of a bedroom carpet should be one that can be offered to service users and the management of incontinence needs to be provided by the involvement of the appropriate health care professionals and care plans. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 20 There have been problems with the central heating system and, in March, it ceased to work. Problems have been noted in the past with the system. Oil filled electric heaters are having to be used throughout the home. The Registered Manager ensured that, during the colder weather, the temperatures of the bedrooms and communal areas were satisfactory, providing evidence of this information to the Commission for Social Care Inspection. She confirmed that the heating is due to be replaced in the summer of 2006 and quotes were being sought. The previous heating system did not provide radiators which were either covered or had low temperature surfaces. In view of the frailty of the service users, the provision of radiators which reduce any risk of burning to the service users must be considered when the new system is installed and a risk assessment is required to be undertaken. The garden was seen to be well maintained on all visits to the home and makes a pleasant area for the service user to enjoy. It has a pond, with fish, garden furniture, a greenhouse and a shelter for those who smoke. No smoking is allowed in the home. The Registered Manager said that service users who might be at risk are supervised in the garden. As supervision cannot be always guaranteed, and service users should have choice about being in garden if they wish to do so, the risk assessment must be kept under regular review to minimise any risk to service users, particularly in relation to the pond. At the first visit to the home, it was noted that the water supply to one of the baths was not functioning. The Registered Manager said that the water had been turned off when the hot water regulators were installed and made arrangements have it turned on again. However, staff said that the bathroom was not used as it was unsuitable. Another of the six bathrooms is also not in use. It must be shown that there are adequate bathroom facilities, which are suitable for the needs of the service users. The National Minimum Standard of one bathroom for eight service users must be maintained. There are no en suite bedrooms, but each has a wash hand basin and a commode. The home has a variety of equipment, including hoists and wheelchairs, which were seen to have been serviced recently. However, the risk assessments seen in the service users’ files did not specify which equipment should be used to meet individual needs and this needs to be done. The home is accessible, with two lifts to the first floor. There are three steps, with a stair lift, between the dining room and the ground floor bedrooms. A small number of bedrooms were seen on this inspection as the majority of the service users were in the lounges. Those that were seen were satisfactory and pleasantly furnished. It is not noted in the Service Users Guide that service users’ own items of furniture can be brought to the home, space permitting, and this should be included if it is the policy of the home. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 21 The home was found to be clean and hygienic on this inspection with no malodour, apart from the bedroom mentioned previously in this report. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 22 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. The training records for the home were insufficient to demonstrate that individual staff had the required and up-to-date training, although a Training and Development plan for the staff team, with outcomes, was in place. The recruitment practices are in need of improvement to meet the Care Home Regulations 2001. EVIDENCE: The rota allows for four staff and a supervisor to be on each early and late shift. There are currently five supervisors working on the day and night shifts. An additional member of staff is employed from 6am to 10am to assist with the busy time in the morning when service users are getting up. Three staff are employed on the night shifts, including one supervisor. Staff work from 7am to 2.15pm and from 2pm to 9pm. There is a 15-minute handover period, one of which was attended by the Inspector, where staff pass on information to the next shift to provide continuity of care. Four of the staff have been on long-term sick leave, but the recruitment of several bank staff has assisted with providing regular care workers. In the five staff files examined, not all in the information required by the Care Home Regulations 2001 was in place. Photographs of the staff have not been included. A full employment history, together with a satisfactory written explanation of any gaps in employment, was not always documented and not Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 23 all of the files showed that two references has been obtained. Statements regarding the mental and physical health of staff were not in the files. Some staff have been employed before their Criminal Records Bureau disclosure checks had been received but no POVA First checks were included in the files. The Registered Manager must ensure that all of the information required to be in place, under the Care Home Regulations 2001, Schedules 2 and 4, is obtained before staff are employed. The records must be maintained in good order and be available for inspection. The information on staff training was seen in the staff files examined and this included induction records for some of the staff. The Registered Manager undertakes the induction of new staff, which includes an introduction to manual handling, first aid, food hygiene and fire training. Although information was available on which staff had attended courses, there is no training and development record for each individual staff member which shows that they all have the core training and any specialist courses required to carry out their work. The Registered Manager is a manual handling trainer and carries out the manual handling training for the staff team. The home has a good record of National Vocational Qualifications training and six of the staff have National Vocational Qualifications Level 2 or 3. A further five are in the process of taking the qualification or are awaiting their certificates. Twenty three care staff and supervisors were in post at the time of the inspection. When the National Vocational Qualifications are completed, it will bring the total of staff with National Vocational Qualifications to just under 50 , which needs to be maintained. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 24 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, 32, 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 was found to be satisfactorily managed, although further monitoring is required to ensure that all of the records are maintained in good order, are up-to-date and available for inspection. This is due, in part, to the absence of staff in two key management posts and should improve with the recent recruitment of a Deputy Manager. EVIDENCE: The Registered Manager has the National Vocational Qualification Level 5 in management. The home has been without a Deputy Manager and the Facilities Manager has been on long-term sick leave. The absence of staff in these posts has not assisted the management staff to keep all of the records up-to-date but, with the appointment of a Deputy Manager, this situation should improve. The staff who were spoken to were positive about the management of the Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 25 home and service users were generally appreciative of the care and support they receive. After a period of staff leaving the home, and with four staff on long-term sick leave, recruitment has taken place and ten new staff have been recruited so far this year, many of them as bank staff. This has enabled the home to have more continuity of care. Disciplinary action has being undertaken with two of the staff, with both cases ongoing. Regular monthly visits are made by members of the Trustees under Regulation 26 of the Care Home Regulations 2001 on behalf of the Registered Providers. These are submitted to the Commission for Social Care Inspection as required. However, the reports do not record any evidence that records are being examined on a regular basis and this should be carried out as part of the quality monitoring processes to ascertain that they are maintained in good order. Quarterly meetings are held with the service users and their family members to discuss a variety of issues and the last one was held on 30th April. There is a system in place to administer the personal allowances and other finances of the service users, which are managed by the home’s Finance Manager. The majority of the money is brought to the home by relatives and small number of service users manages their own finances. The Dormers Wells Lodge Trust is the appointee for three of the service users and some are managed through the London Borough of Hounslow’s Customer Affairs department. The accounts of the three service users for whom the home is appointee are kept in one account initially, but are transferred to individual accounts when large sums accrue. The Finance Manager went through the system, which was found to be kept in very good order. Although each service user has an individual record and money is kept separately, the receipts are kept collectively. The Manager was advised that these should be retained separately so that confidentiality is maintained and individual records can be easily checked. She was advised that every transaction shown on the individual records should be signed. Accounts are audited twice yearly by the accountant for the Trustees. Information regarding each service user’s individual financial arrangements should be recorded to ensure that the information would be available if the Finance Manager is not available. The Registered Manager and members of the Trustees, who undertake Regulation 26 visits, do not carry out checks on the finances. The Registered Providers must ensure that regular monitoring of all systems within the home takes place to assist with the smooth running and to support the safeguarding of staff and service users. Senior staff are responsible for providing supervision to the care workers and samples of the comprehensive records, which are in the form of pre-printed booklets, were seen. The Registered Manager said that one booklet is Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 26 completed every two months, meeting the National Minimum Standards target of six supervision sessions a year. The keeping of confidential records was discussed with the Registered Manager as staff supervision and service users’ records were seen to be kept in the clinic room used by general practitioners to see service users. While there is limited access to the room, the records are not kept within cabinets and could be accessed easily. The Registered Manager said that the room is kept locked when not being used by senior staff. In order to maintain confidentiality, service users and staff record should be stored in cupboards or cabinets which should be locked when not in use, so that access can be seen to be limited. Service users’ files were also seen to be unattended in one of the lounges on the first visit to the home and a system of ensuring the confidentiality of the information needs to be put in place. The person responsible for carrying out the health and safety responsibilities in the home has been on sick leave for six months and other staff have been delegated to carry out the tasks. Whilst much of the information was accessible with the assistance of the Registered Manager and Finance Manager, the information needs to be held so that it is accessible on an unannounced inspection by the Commission for Social Care Inspection. Where it was indicated that work needs to been carried out, on the lift and water tanks for instance, it was not immediately clear if the work had been completed. Monitoring of the records needs to be made to ensure that they are up-todate, maintained in good order and any required works can be seen to be carried out. Since the last inspection, thermostatic valves have been fitted to the hot water outlets to minimise the risk to service users. A sample of maintenance records was examined. Servicing on the lifts took place in January 2006, small electrical appliances were tested in November 2005, wheelchairs were checked in February 2006 and the hoists are maintained twice yearly, the last service being in December 2005. Fire extinguishers were examined in May 2006 and the four of the fire points are now checked on a weekly basis. Water temperatures are taken weekly in the bedrooms. The fire records indicated that, although fire drills are held on a regular basis, and names of those taking part recorded, there is no schedule to ascertain that all of the staff have participated. It is London Fire and Emergency Planning Authority guidance that all staff attended two drills a years and night staff attend four. It needs to be demonstrated that this has taken place and the times of drills need to be recorded. The fire risk assessment seen was dated February 2005 and should be reviewed on a more regular basis. At the first visit to the home, it was seen that nine of the staff had attended fire training. On the last visit, the Registered Manager said that twenty staff have now been trained. This training needs to be extended to the remaining staff as soon as possible. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 27 A gas servicing certificate had been obtained, following a requirement for the Landlord’s Gas Certificate to be available at the last inspection. The wording on the certificate states that it is “not the Landlord’s Gas Certificate”. The Registered Providers need to ensure the work carried out and the documentation are sufficient to fulfil the requirement and provide documentary evidence of this. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 28 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 2 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 3 2 2 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 3 2 2 YES Version 5.1 Page 29 Are there any outstanding requirements from the last Dormers Wells Lodge DS0000027701.V288628.R01.S.doc inspection? 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 OP2 Regulation 5 (1) (a) Requirement The terms and conditions, in respect of accommodation provided to service users, must include the amount of fees to be paid. Where the local authority has contracted with the home to place service users, a copy of the agreement for the provision of personal care must be supplied to the service users. Following the assessment of the service users, the Registered Person must confirm in writing that the home can meet their needs, which must be within the category of registration. Care plans must be completed for all service users and kept under review. (Previous timescale of 30/12/05 not fully met). Where restrictive equipment is used, such as bedsides, permission for their use must be agreed and documented, and all necessary risk assessments be put in place. Risk assessments for each service user must in place to ensure that every precaution is taken to reduce the risk and DS0000027701.V288628.R01.S.doc Timescale for action 31/07/06 2 OP2 5 (3) 31/07/06 3 OP3OP4 14 (1) (d) 30/06/06 4 OP7 15 (1) (2) 31/07/06 5 OP7 13 (4) b & c, 13 (8) 30/06/06 6 OP7OP22 13 (4) b & c 31/07/06 Dormers Wells Lodge Version 5.1 Page 30 7 8 9 OP9 OP16 OP18 13 (2) 22 (8) 13 (6) 10 OP19 12 (1) (a) 11 OP19 13 (4) a & c 12 OP21 23 (2) (j) 13 OP29 17 (2) 19 (1)(b) 14 OP30 18(1)c(i) 17(2)6(g) 17 (1),(2) & 15 OP33OP35 any equipment being used for this purpose must be documented. (Previous timescale of 30/12/05 not fully met). Systems must be in place to ensure that medication can be stock controlled. Information on complaints must be maintained in good order and be available for inspection. In order to safeguard service users and staff, the Registered Providers must ensure that service users and their representatives are aware that allegation of abuse must be reported appropriately. The management of incontinence must be undertaken with the involvement of the appropriate health care professionals and suitable care plans. In view of the frailty of the service users, the provision of radiators which reduce any risk of burning to the service users must be considered when the new system is installed and a risk assessment must be carried out. It must be shown that there are adequate bathroom facilities, which are suitable for the needs of the service users. The Registered Manager must ensure that all of the requirements of the Care Home Regulations 2001, Schedules 2 and 4, are obtained before staff are employed and then available for inspection. Information on the training undertaken by each staff member, with evidence that it is up-to-date, is required. As part of the quality assurance DS0000027701.V288628.R01.S.doc 30/06/06 30/06/06 30/06/06 31/07/06 31/07/06 30/06/06 30/06/06 31/07/06 31/07/06 Page 31 Dormers Wells Lodge Version 5.1 (3), 26 16 17 OP37 OP38 17 (1)(b) 13 (4)(a) 23 (2)(c) 23 (4)(e) 18 OP38 and quality monitoring procedures, regular checks must be undertaken by the Registered Manager, and those visiting on behalf of the Registered Persons, to ensure that records are being maintained satisfactorily. The confidentiality of service 30/06/06 users and staff records must be maintained. It must be evidenced that the 31/07/06 servicing of the gas appliances is in accordance with the Landlord’s gas safety check. It must be demonstrated that 31/08/06 all of the staff have participated in regular fire drills, the times of which are recorded and in accordance with the London Fire and Emergency Planning Authority’s guidance for day and night staff. (Previous timescale 30/12/05 not fully met) 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 OP10 Good Practice Recommendations It is recommended 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. It is recommended that, where alternatives are available for diabetic service users or other special diets, such as desserts made with sweetener, that these are advertised on the menu. It is recommended that, to enable to have more information and choice, menus are displayed, in a suitable format, on the dining tables. DS0000027701.V288628.R01.S.doc Version 5.1 Page 32 2 OP15 3 OP15 Dormers Wells Lodge 4 OP15 5 OP17 The addition of a third vegetable is recommended to ensure that service users have a better choice and are encouraged to eat the five portions of fruit and vegetables a day recommended by nutritionalists. That service users are offered the opportunity to vote by post. Dormers Wells Lodge DS0000027701.V288628.R01.S.doc Version 5.1 Page 33 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith 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. 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