Inspection on 08/11/05 for Dormers Wells Lodge

This inspection was carried out on 8th November 2005.

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 24/10/06

Dormers Wells Lodge 04/05/06

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 Sarah Middleton Unannounced Inspection 8th November 2005 9.50 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.V260499.R01.S.doc Version 5.0 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.V260499.R01.S.doc Version 5.0 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 46 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.V260499.R01.S.doc Version 5.0 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. 19th April 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. Dormers Wells Lodge is situated on a residential road in Southall and is within easy reach of local amenities. Facilities at the home include single bedroom accommodation, two passenger lifts to the first floor, a private telephone room and four lounges. 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. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of five and half hours, 9.50am-3.20pm, was spent in the home. The Inspector carried out a tour of the home and inspected service users plans, staff files and maintenance records. Four staff, one visitor and three service users were spoken with as part of the inspection process. The home has ten service user vacancies and has recently decreased the number of places offered to service users from forty- six to forty. There were three staff vacancies at the time of the inspection. Several new members of staff have been employed over the past few months. What the service does well: What has improved since the last inspection? There has been a marked improvement in the number of anonymous complaints made to the CSCI. New members of staff have joined the team and the team aim to provide care and support to the service users under the direction and guidance of the Registered Manager and supervisors. The Registered Manager has settled into her role and is aware of the need to continuously monitor the home and explore ways to improve the quality of care offered. The home has made steps to provide daily structured activities for those service users wanting to engage with the various sessions that are now on offer. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 7 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.V260499.R01.S.doc Version 5.0 Page 8 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): 3 Service users are assessed prior to admission to ensure the home can meet their needs. The Registered Manager must continue to liaise closely with the local authority who has a block contract for respite beds, to ensure appropriate referrals are sent to the home. EVIDENCE: Two new service users files were viewed. These contained assessments that had been completed by both the Social Worker and the Registered Manager. These provided a clear picture of the service user needs, to include health, mobility and communication needs. The Registered Manager confirmed they assess service users prior to admission, but there had been difficulties regarding the respite beds. There are six beds used by a local authority for older people needing short term respite. Some of the referrals have not disclosed the full history of a service user and several service users using this respite service have had nursing needs. Where this has occurred the Registered Manager had made contact with the relevant person and the service user was moved to a more appropriate home. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 9 The ongoing difficulty is that many service users needing respite might be referred at short notice. In this situation the Registered Manager relies on the information sent by the professional involved with the service user. The Registered Manager stated they have discussed these issues with the appropriate professionals and is hoping this problem will be resolved. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 10 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 The health and personal needs of service users were not outlined on care plans. Detailed risk assessments were not in place. Staff must complete these documents as soon as a service user is admitted. Without these, staff are not aware of the current needs of a service user and how to meet those needs. Risk assessments must be completed in order to minimise identified risks and to safeguard service users. Health needs must be clearly recorded on care plans and appointments, treatment and any other issues regarding a service users health must be available for inspection to ensure the home is addressing these needs. Fridges that store medication must have their temperatures recorded daily to ensure the medication is stored within an appropriate range. There continues to be errors in recording accurately when medication has been administered. These shortfalls must be addressed in order to protect service users and maintain their optimum health. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 11 EVIDENCE: Two service user care plans were inspected regarding recent admissions into the home. The care plans and risk assessments for these two service users had not been completed. The Registered Manager acknowledged this information needs to be available to ensure all staff are aware of service users assessed needs. In addition these two files did not contain a photograph of the service user or clear details of their next of kin. This information, as listed in Schedule 3 of the regulations must be present on all service users files. A third care plan was viewed on a service user who has a formal diagnosis of dementia. Although their care plan had been completed, some of the contents were not dated. It was difficult to follow their needs and there was no evidence of consultation with the service user or their representative when reviewing the care plan. It is a requirement that care plans must be completed, with evidence of consulting with service users or their representative. Furthermore risk assessments must be completed and reviewed on a regular basis. This must include risk of falls, wondering off, pressure sores and any other relevant areas of a service users life. This is a requirement. Moving and handling assessments were in place and service users weight had been recorded. The care plans viewed did not contain obvious details of how service users health needs were met. Some health records were kept in a file in the clinic room. Lists of service users who had seen the Dentist, Chiropodist and Optician were seen. However there were no action plans or comments documented to inform the Inspector of the treatment individual service users had received. This is a requirement. Samples of medication administration records were tracked. As noted at the last inspection, there were several gaps on these record sheets. Staff had not signed for medication regarding one service user for almost two weeks. The senior member of staff stated they had administered this particular medication that morning. Staff must be vigilant when administering and signing for medication. This is a re-stated requirement. All medications were appropriately and securely stored. The home does not hold controlled drugs. Fridge temperatures were not available for inspection. Staff must be aware of where this record is kept and record daily the temperature. This is a requirement. It is recommended to replace the fridge thermometer, as it stated the fridge temperature was over ten degrees. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 12 Liquid medications had dates of opening on them. It is recommended the list of staff able to administer medication and their signatures be updated to reflect the current staff team who handle medication. The home recently had an audit by a local Pharmacist who also noted some of the above shortfalls Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 13 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 & 15 Social activities are in place and offer a variety of daily sessions to stimulate and occupy service users. Visiting is encouraged for service users to maintain contact with family and friends. Meal provision is varied and service user preferences are acknowledged and addressed. Menus change daily and provide a healthy balanced diet for the service users. EVIDENCE: The home has an activities co-ordinator and additional staff that assist with daily activities. An external person visits and offers keep fit twice a week. Various activities are planned for example, reminiscence therapy, watching films, having a manicure, or bingo. Service users spoken with said they could take part in any activity occurring in the home. The Registered Manager stated activities had improved over the past year for the benefit of service users. One visitor spoken with stated they could visit whenever they were able to. Other people were seen in the home visiting service users. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 14 Menus were available and reflected choices. The cook stated where possible fresh vegetables were used in meals. Dietary likes and dislikes were catered for. Service users spoken with said the meals were satisfactory and offered them a choice. The kitchen was clean and tidy at the time of the inspection. Fridge temperatures are taken and were recorded within an appropriate range. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 15 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 & 18 The home clearly records all complaints and seeks to address them. Service users and the visitor spoken with were confident any complaints they had would be listened to and acted on. Systems were in place for the protection of vulnerable adults. EVIDENCE: There has been a decrease in the number of anonymous complaints to the CSCI since the last inspection. Complaints records viewed noted the complaints and how these were to be addressed by the Registered Manager. There had been one complaint received by the home since the last inspection. The Registered Manager had investigated this appropriately. The CSCI had received one anonymous complaint soon after the last inspection. This complaint was investigated by the Registered Manager and was not upheld. Service users and the visitor spoken with said if they had any concerns they would discuss these with the Registered Manager. The home has a whistle blowing policy and procedure and a chart indicating the steps to take should an Adult Protection incident occur. During the inspection the Registered Manager could not locate a policy and procedure directly related to the Protection of Vulnerable Adults, (POVA), this was forwarded on to the Inspector after the inspection. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 16 The home has a copy of the local authority policy and guidelines and the Registered Manager is a POVA trainer. Staff had received training on this subject. There have been no POVA investigations in the home. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26 The home is well maintained and items are replaced and updated on an ongoing basis in order to offer a pleasant environment for service users. Service users are able to personalise their bedrooms to offer a homely place for them to relax in. Systems are in place in order to prevent the spread of infection and to safeguard service users health and welfare. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. These were being satisfactorily maintained. A maintenance list was viewed and this noted items that would need replacing over the forthcoming year. Bedrooms are decorated as and when they need attention. The home has recently provided shelter outside for the few service users who smoke, leaving all lounges smoke free environments. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 18 Service users bedrooms varied in size but those seen were adequately spacious to meet the needs of the service users. Many of the bedrooms were personalised with small items of service users furniture in them. Protective clothing is provided and was seen in the laundry room. Laundry systems are appropriate to minimise the risk of infection. The laundry person spoken with said they were due to attend a refresher course on infection control. The home was clean, tidy and free from odours at the time of the inspection. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 There has been an improvement in teamwork and the current staff team work well together. There are sufficient numbers of staff to offer continuity of care for the service users. NVQ training is encouraged in order to ensure staff have the up to date skills and knowledge to perform their role professionally. In house training is offered regularly in order for staff to be better equipped to care for the service users. The systems for recruitment of staff were robust and aimed to protect service users. EVIDENCE: There have been five new members of staff employed over the past six months. This has enabled the staff team to work together with new ideas and new skills. Staff, both new and long standing, who were spoken with, were positive about working together as a team and felt they could rely on each other for information, guidance and support. Those staff asked felt there were sufficient numbers of staff working on each shift. The rota reflected sufficient numbers of staff to meet the needs of service users. Due to the service user vacancies the Registered Manager had adjusted the levels of staff working on a shift. This review enabled some staff to provide structured activities for service users. There are adequate numbers of domestic staff employed. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 20 Over fifty percent of staff have either achieved an NVQ qualification or is in the process of starting the course. The home is aware of the need to continuously monitor the numbers of staff undertaking the NVQ qualification. One staff employment file viewed contained details of a newly appointed member of staff. Their completed application form, two references, medical declaration form, terms and conditions of service and Criminal Record Bureau check were seen. The Registered Manager confirmed that all necessary checks are carried out prior to the engagement of an employee. Staff receive training on an ongoing basis. New staff complete the Skills for Life induction programme and then attend mandatory courses run by both the Registered Manager and external providers. All staff spoken with felt the training offered to them was useful, regular and relevant. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36 & 38 The home is well managed and the Registered Manager aims to offer an approachable style of management. Meeting the needs of the service users continues to be a priority for both the Registered Manager and staff. The teamwork in the home has improved with staff working together to offer a high level of care to service users. Systems are in place for quality assurance and should enhance the quality of life for service users. Although there was evidence that some health and safety issues had been addressed. There were shortfalls in demonstrating that regular fire drills had taken place. These must occur for all working and living in the home to prevent any incidents occurring. The hot water temperatures recorded and noted on the inspection could pose a risk to service users who are vulnerable. Any concerns regarding health and safety issues must be acted on immediately. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 22 EVIDENCE: The Registered Manager has now been in post for over a year. They have various qualifications and the skills and knowledge to successfully manage the home, for example the NVQ level five. In addition they offer training to staff on moving and handling and on issues regarding Adult Protection. Staff spoken with stated the Registered Manager is approachable and offers advice and guidance to those who ask. The Registered Manager has continued to alter how the home operates and this had previously had an impact on long standing members of staff. Several staff have left, for various reasons and the current staff team find the Registered Manager open and transparent in their approach. There are expectations placed on all staff in order for them to successfully care for the service users. The home has regular regulation 26 visits carried out by various members of the committee and this information along with service users completed questionnaires and other audits carried out by the management team are available. It is strongly recommended the information collated is combined into a clear summary of findings that will highlight the quality of care offered in the home. The information is available but it could be difficult to ascertain where there is a need for improvement and where the home is operates well. The Financial Manager stated the home recently had an audit on the financial procedures in the home. No noted concerns were raised. The home is financially viable and is hoping to fill the service user vacancies in the near future. Staff spoken with confirmed they receive regular one to one supervision. Overall the feedback was positive with staff feeling able to talk to their supervisor about any queries or concerns they might have. Servicing records were viewed at random. Initially it was difficult to view all the records, as the Facilities Manager was not present during the inspection. They usually manage all the health and safety records. It was discussed with the Registered Manager that she should be aware of where all health and safety records are stored. Emergency lighting, hoists, fire equipment and the testing for Legionella were all up to date. There was no evidence that the Gas Safety certificate was up to date as it could not be located. This is a requirement. The majority of staff had attended fire training in June 2005 however there was no clear evidence of when fire drills had taken place since the last inspection. It had been a previous requirement that fire drills take place Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 23 regularly, with different members of staff and at different intervals/times. This is a re-stated requirement. Water temperatures had been recorded but the previous month it had been recorded in several service users bedrooms as over forty-four degrees. No action had been taken regarding these high temperature levels. The Inspector spoke with the maintenance person who had recently attended a course on Legionella. They had understood that the temperature was acceptable at sixty degrees to keep water free from bacteria. The Inspector explained to the Registered Manager and the maintenance person that the main water tank could be sixty degrees but that temperatures in the rooms where service users and staff access should not be above forty four degrees as this could scald a person. The Inspector went into several service users bedrooms with the Registered Manager to test the water. Although most hot water taps took a while to heat up, once they did most were very hot. The Inspector stated this situation must be remedied immediately and that risk assessments must be completed to prevent any incidents occurring. The Registered Manager contacted the company who had been due to replace all of the valves in service users rooms. They are not able to visit the home for two/three weeks. Following the inspection the Registered Manager informed the Inspector that the water tank temperature had been checked and this was found to be too hot. The temperature has been reduced which should then decrease the temperature in service users bedrooms. Additionally signs have been placed in all service users bedrooms warning people that there is hot water coming out of the taps and risk assessments had been completed. Finally the Registered Manager stated the maintenance person would be checking the temperatures daily to monitor the situation. The fault in the water temperatures should have been acted on and it is imperative that the Registered Manager is informed of any concerns regarding health and safety. Clearly there had been a breakdown in both communication and knowledge on acceptable water temperature levels. The above is a requirement and the Registered Manager is required to keep the Inspector informed on the progress of decreasing water temperatures and the fitting of new valves. All staff have been informed of the situation and have been asked to be even more vigilant when using the water to assist service users with personal care. Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 24 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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 x 3 x 1 Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 25 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 OP7 Regulation 15 Requirement Care plans must be completed on all service users. (Previous timescale 01/06/05 not met). There must be evidence of consultating with service users and/or their representatives when devising or reviewing their care plan. (Previous timescale 01/06/05 not met) Information on service users as noted in Schedule 3, such as next of kin details and a photograph of the service user, must be available for inspection. Risk assessments must be completed and reviewed on a regular basis. There must be clear evidence that service users health needs are addressed and the treatment they receive must be recorded. Medication Administration Sheets must accurately reflect medication that has been administered. If it is not administered the reason must DS0000027701.V260499.R01.S.doc Timescale for action 30/12/05 2. OP7 15 (1) & 15 (2) (c ) 30/12/05 3. OP7 17 (1) (a) 30/12/05 4. 5. OP7 OP8 13 (4) (c ) 12(1)(a)& 13(1)(b) 30/12/05 31/01/06 6. OP9 13 (2) 01/06/05 Dormers Wells Lodge Version 5.0 Page 26 7. 8. 9. OP9 OP38 OP38 10. OP38 also be recorded on these sheets. (Previous timescale 01/06/05 not met). 13 (2) Fridge temperatures where medication is stored must be recorded on a daily basis. 13 (4) (a) The Gas Safety Certificate must 23 (2) (c) be available for inspection. 13(4)(a)(c) Water temperatures must not &23(2)(c) exceed 44 degrees. Where it is noted as above this range appropriate action must be taken immediately to prevent incidents/accidents occurring. The Registered Manager must put in writing to the CSCI regarding how they have addressed this issue. 23 (4)(e) The Registered Person must ensure that regular fire drills take place at different intervals & are clearly recorded. (Previous timescale 01/06/05 not met) 08/11/05 31/01/06 08/11/05 30/12/05 Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 27 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. 3. Refer to Standard OP9 OP9 OP33 Good Practice Recommendations It is recommended that a new medication fridge thermometer be obtained to ensure an accurate reading. The list of signatures of staff that can administer medication should be updated. It is recommended that a more detailed report is available regarding the quality assurance the home carries out, in order to clearly identify where improvements have been made and where there are areas needing attention. It is recommended that policies and procedures are dated to ensure they are reviewed and updated on a regular basis. Radiator covers should be fitted as soon as possible to ensure the health & safety of service users is never compromised. 4. 5. OP37 OP38 Dormers Wells Lodge DS0000027701.V260499.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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.V260499.R01.S.doc Version 5.0 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!