Inspection on 06/05/08 for Dormie House

This inspection was carried out on 6th May 2008.

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

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Dormie House 16 Cliff Road Sheringham Norfolk NR26 8JB Lead Inspector Jenny Rose Unannounced Inspection 6th May 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dormie House DS0000070717.V364059.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. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dormie House Address 16 Cliff Road Sheringham Norfolk NR26 8JB 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) 01263 823353 armoogum2001@yahoo.co.uk Mr Roger Laval Patrick Armoogum Mr Roger Laval Patrick Armoogum Care Home 7 Category(ies) of Old age, not falling within any other category registration, with number (7) of places Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 7 Old age, not falling within any other category Date of last inspection Change of Proprietor Brief Description of the Service: Dormie House is a care home providing personal care and accommodation for 7 older people. The home is owned by Mr Roger Armoogum who is also the manager of the home. The home is situated close to the centre of the coastal town of Sheringham and is close to all local amenities as well as being within walking distance from the sea and beach. The home was first opened in 1982 and has continued to provide residential care to a small group of service users. The proprietor lives on the premises and is involved in the day-to-day running of the home with a small group of care and domestic staff. The accommodation is provided on two floors with five single bedrooms on the first floor and one double room on the ground floor. There is a stair lift to the first floor. The home has a small patio/garden area where service users can sit. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The rating for this service is 1 star. This means that people using the service experience adequate outcomes. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This was a key, unannounced inspection and took place on 6th May 2008, the first since the change of proprietor/manager who had taken over the Home in November 2007. The proprietor/manager was present throughout the inspection and there were 7 residents living in the Home. A tour of the building was undertaken. Policies, procedures, care plans and other records were examined. The Commission had received no Annual Quality Assurance Assessment, although a partially completed one was available on the day of the Inspection and a completed one before the end of the report process. On the day, all the residents were spoken with, two in private. A visiting healthcare professional was spoken with, as well as two members of staff in private. The information provided in discussion is reflected in this Report. What the service does well: • The Home is domestic in character with a relaxed atmosphere and there have been a number of improvements to the environment as well as further plans. “This is a very nice Home” was a comment from one resident. The Home does not accept a resident into the Home until assessments are made and that a potential resident’s needs can be met within the Home and within the existing resident group. There are good care plans which set out clear instructions for staff in supporting residents as individuals, providing information with regard to hobbies, interests and past occupations in order to better involve • • Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 6 residents in activities which most interest them and to maintain contacts in the local community • The residents confirmed, together with a healthcare professional, that the change of ownership did not appear to have had any negative impact on the management of the Home. Residents and staff spoken to confirmed that relatives and friends are welcomed into the Home and offered refreshments. Residents have choice in whether to administer their own medication, although most wish for this to be done by the staff, (who have received training in medication). • • What has improved since the last inspection? This was a first inspection after 6 months under a new Proprietor. • • Care plans now contain risk assessments and action to be taken to mitigate those risks. There are regular reviews. The AQAA states that three members of staff have undertaken an NVQ2 qualification . The proprietor has completed the NVQ 4 certification and hopes shortly to have the Registered Managers’ Award. Staff files also contain training certificates in medication, safeguarding adults and dementia. However attention needs to be paid to other areas of training. Staff files are well organised and a new application form showing gaps in employment is being used. However, there is room for improvement and certain documents were missing. Appraisals have taken place for some members of staff and supervision is taking place on a day-to-day basis. However there is room for improvement in this area. There has been redecoration in the communal areas, recarpetting and renewing flooring in the kitchen. Radiators have been covered for residents’ safety. There are new chairs, curtains and flat screen TV in the sitting room. There is improved lighting. Obstacles have been removed for increasing residents’ mobility, particularly in the hallway area. Meal times are now more flexible and residents have a choice if they wish to eat at a different time and of where they eat. • • • • Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 7 What they could do better: • • All residents should be in possession of a Statement of Purpose and Service Users’ Guide giving information on the service. Training in moving and handling, safeguarding adults, infection control for all members of staff needs to be implemented as part of the staff development programme. The complaints procedure should be clearly displayed in the Home, together with the complaints book and in a format as appropriate for individuals. In addition consideration should be given to the provision of a suggestion box where concerns or comments could be made anonymously if necessary. Local procedures for reporting potential safeguarding incidents should be readily accessible to staff. Formal, recorded supervision sessions for staff should take place on a regular basis. Staff photographs should be included in their files, together with all the relevant recruitment documents. For the further health, safety and welfare of residents, Legionella testing should be carried out and the frequency of the fire alarm testing should be checked with the fire authority and various risks in the house should be assessed to provide staff with clear guidance about how they should be managed. Certain matters, such as training in moving and handling, the formal supervision of staff for all staff have not yet been addressed. These had formerly been highlighted in previous reports in respect of the previous provider. Although a healthcare professional, visiting at the time of the Inspection, expressed a positive view of the care provided in the Home and the implementation of advice by staff, a quality assurance system should be put in place to gather views of residents, relatives, staff and healthcare professionals’ opinions, in order to properly monitor the quality of care delivered. The Commission will be asking the Proprietor to produce an Improvement Plan which will need to set out how and when these and other matters, particularly in relation to safeguarding issues, are going to be addressed. DS0000070717.V364059.R01.S.doc Version 5.2 Page 8 • • • • • • • • Dormie House Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 9 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 Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People looking to live in the Home have their individual needs assessed in order to ensure that the Home can meet those needs, but everyone living in the Home should be in possession of the Statement of Purpose, including a service user guide and basic information so they know about the service the Home is offering. The Home does not offer intermediate care. EVIDENCE: Two pre-admission assessments for recently admitted residents showed that the Home received information from health and social services workers before residents are admitted and these assessments form the basis of the care plans. The Proprietor said that he had visited both these residents in order to assess their medical and social care needs and whether the Home was able to meet those needs within the existing resident group. Neither resident was Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 11 able to visit the Home prior to admission, although it is the Home’s policy to encourage preliminary visits where possible, but their relatives had done so. There is a Welcome Letter for residents giving details of staff etc. Reviews were undertaken four weeks after admission and all residents had received new contracts on change of Proprietor. There is a draft Statement of Purpose which was seen and the Proprietor explained it was intended that every resident should receive a copy when the Statement had been finalised. Although there is a welcome letter for new residents, at present Service User Guides setting out information on various aspects of the Home are not available for every resident. As the fully completed AQAA had not been returned to the Commission there was no information from surveys on whether residents and relatives had received sufficient information before being admitted to the Home. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are detailed care plans in place in place to ensure that staff have the information to deliver the necessary care and helping to respect the privacy and dignity of those people living in the Home. EVIDENCE: Four care plans seen included detailed information, which were well organised and easy to read for staff to follow. They, and the front sheets of the Daily Notes, contained photographs of respective residents with relevant contact details. Personal and health care needs were identified including physical and mental status, moving and handling needs and medical information with skin and weight charts. There were also details of social histories and interests where residents or relatives were content for this to be included in their care plan. The plans were seen to be reviewed monthly and it is the intention for these to be fully reviewed annually, or sooner if necessary. Risk assessments for falls and for maintaining privacy and dignity were seen to be in place. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 13 One care plan seen was signed by the resident’s relative, although other care plans were unsigned. The Manager said that the residents and their relatives or representatives participated in their care planning, where appropriate, but not all care plans were signed. There are questionnaires for new residents giving details of likes and dislikes on admission and it was evident from observation on the day of the Inspection that residents’ personal preferences were well known to the staff and the Proprietor. The healthcare professional who was visiting on the day of the Inspection said she found the residents appeared quite happy and “well looked after”. She said that it was a friendly Home and that the Manager always made himself known and introduced her to the residents. The team are asked to visit when appropriate and advice is followed through. There were no residents needing attention for pressure areas. It was her opinion that the change in management had not adversely affected the residents. A Chiropodist and an Optician visit the Home on a regular basis. The administration of medication has been reorganised and there is now a purpose made lockable cabinet for the storage of the Monitored Dosage System, which is now used. The medication records appeared to be well recorded and contained a photograph of each resident. All staff administering medication have been appropriately trained. There was evidence that residents are offered the choice of administering their own medication, together with a risk assessment for this. However, all residents had chosen for staff to administer their medication. There was no one requiring Controlled Drugs at present, but the facilities were in place should this become necessary. Staff were observed treating residents respectfully, speaking in a kind, good humoured way. The residents spoken with confirmed that they were treated with respect and dignity. The Proprietor explained that residents were able to receive telephone calls in the privacy of their rooms with the aid of a mobile handset Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home have choice in their lifestyle within the limits of a small establishment. EVIDENCE: On the day of the Inspection residents were observed spending their day according to their choice. Four residents were watching television in the afternoon; three others preferred to be in their rooms. One resident in particular prefers to spend all her time in her room, as she explained she was used to her own company before coming to the Home. It was observed that residents enjoy listening to music in the dining room at lunchtime and some enjoy a glass of sherry with their meal. A sing-a-long entertainer had been booked to visit in two weeks time. There had been recent celebrations with about 25 visitors to the Home for a 104th birthday This is a small Home and is part of the local community. Many of the residents have lived in the town or nearby all their lives, their family roots being well known. The Home is situated near the centre of the seaside town, which enables residents to visit the town in the warmer weather, as one resident had done the day before with her relative. Three residents spoken to said that their relatives visit on a regular basis. One resident continues to attend the Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 15 Day Centre twice a week in order to “maintain contact with my friends”. A member of staff spoken with said that some residents like to take breakfast in their room while watching morning television, whilst others prefer to take their breakfast in the dining room. On the day of the inspection it was observed that another resident preferred to go back to bed after breakfast until lunch time. The AQAA states that ministers of various denominations visit on a regular basis. A member of staff spoken with said that residents had a bath once a week, hair washing more frequently and when residents requested, as well as being supported with personal hygiene every day. A hairdresser visits once a fortnight. Residents spoken with did not have any comments to make about the frequency of bathing. However, the Proprietor said that one resident in particular did not like the chair seat into the bath and he was intending to convert a private bathroom into a wet room in order to provide residents with more choice in this respect. The meal at lunch time was seen to be appetising, well presented and prepared using healthy ingredients. Residents’ food preferences are well known to the staff and shopping takes place with these in mind. A member of staff spoken to said that ingredients are sourced locally and freshly cooked. In response to residents’ comments, meal times had been made more flexible and, within reason, could be taken at different times and meals taken in residents’ rooms if they so chose to do. One resident was observed needing encouragement to eat in the lounge, which was done discreetly. Two residents spoken with said that they enjoyed the meals. The evening menu is often sandwiches, as many residents find these easy to eat as finger food while watching news on TV, but it was observed that other choices were offered. Homemade marmalade cake was being served on the day of the Inspection. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home has a complaints procedure, but a clearer procedure for concerns would further ensure that people living in the Home could feel that all concerns were listened to and acted upon. The Home’s procedures and training for all staff, specific to the Home, need improvement to adequately ensure that residents are safeguarded from abuse. EVIDENCE: There is a complaints policy and procedure. The complaints book seen contained one complaint, which was a complaint between two residents. This was appropriately recorded, together with the action taken to resolve the issue. However, the complaints procedure was not displayed in the Home, although there is a notice board. Two residents spoken with privately said they would know how to make a complaint, but it was not clear whether others would know how to do so. Neither was it clear that all staff realised the importance of listening to and then acting on residents’ concerns. The healthcare professional spoken with said that her team had received no complaints about the Home. The Proprietor said that he was intending to place a suggestion box in the hall for those who wished to have the opportunity to raise concerns or suggest improvements, anonymously if desired. However, the complaints procedure Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 17 should also be clearly displayed and available in other formats, e.g. large print, if required. It was evident from staff files that some of the staff have received training in Safeguarding Adults, but with other employers. Others had a limited understanding in this important area, also in when and how to use the policies and procedures in respect of ‘whistle blowing’ and restraint. (see under Staffing) The Proprietor said that there had been a notice displayed regarding the Safeguarding of Adults Procedures, but this had been moved during the redecoration. This should be reinstated and the local procedures for reporting any safeguarding incidents should be readily available for the staff. The Proprietor reported that there was no one living in the Home at present without relatives/representatives, but he was mindful of the importance of advocacy in certain cases and this is referred to in the draft Statement of Purpose. Dormie House DS0000070717.V364059.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. 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 provides a comfortable and clean environment for the people living there, though some risk assessments are needed to ensure residents are protected. EVIDENCE: There have been a number of improvements in the Home in the six months since the change of ownership. The sitting room and hallway have been redecorated and new lighting installed. Residents had been consulted as to the colour scheme. There are new chairs in the sitting room, together with a new TV and new carpets in various areas. A drinks cabinet has been provided in the dining room and hi fi for music. Three bedrooms have been redecorated and all radiators, previously unprotected, have been covered in an attractive way. Also a new medication cabinet has been installed. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 19 Residents’ rooms seen were personalised with their own possessions and the Home is domestic in character with a relaxed atmosphere. Additional to the existing bathroom, there are plans to provide a wet room, in addition to the existing bathroom, and a possible extension to the dining room to provide a choice of environment for residents to sit. The choice is limited at present to the sitting room, or residents’ bedrooms. At the change of ownership there was a removal of several items of furniture, together with some pictures and ornaments in order to facilitate better ease of residents’ mobility. However, as a consequence, this area is now devoid of some of the local memorabilia and items of interest for the people living in the Home. At the last inspection under the previous proprietor, it is not clear that a risk assessment on the premises including the top of the stairs where the chairlift is left open to form a barrier had taken place, particularly in relation to the safety of those residents whose rooms are on the first floor. In the kitchen there has been refurbishment including, new fridges and flooring as a result of visits by the Environmental Health Officer in January and March 2008...(see under Management and Administration.) However, there does not appear to be a risk assessment regarding the use of the utility area at night for laundry which has to be carried through the kitchen, when food preparation is taking place All areas of the Home seen on the day were clean and tidy. Some staff employed are experienced and have received infection control training, but this training should include all staff. (see Staffing) Dormie House DS0000070717.V364059.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. 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 people living in the Home appear to be satisfied that the care they receive meets their needs, but additional staff training and more rigorous recruitment procedures would ensure that a good quality of care would be sustained. EVIDENCE: One resident who prefers to spend most of the time in her room commented, “The staff are nice, when they pass by they stop for a chat and ask what I need”. There is a small staff group, some of whom have had many years’ experience. At the beginning of taking over the Home, the Proprietor said he had the help of one particular experienced member of staff, as well as others, who stayed on specifically to help the change of ownership to get established. She has now left for personal reasons, but returns to visit the residents. There are seven members of staff and the Proprietor works alongside staff members and the healthcare professional spoken with said that there was always a senior member of staff on duty with whom the team could confer and give advice, which was carried through. On the day of the inspection the senior carer was on holiday, but a carer with many years’ experience said that there are handovers at the end of shifts and she displayed a knowledge of safeguarding issues and was very familiar with the likes and dislikes of the residents. Another member of staff spoken with said that he felt able to ask any member of the staff team for advice and Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 21 particularly the Proprietor and senior carer. Four staff files were seen. They were well organised and indexed and all contained the necessary CRB checks and an application form containing an employment history covering any gaps in employment. However, although three files contained two written references, there was one file with only one reference, although there was an explanation of the reason for this. In addition, none of the files contained photographs. It was evident from the files that the staff responsible for administering medication had received training, another had certificates in safeguarding issues, moving and handling, dementia, First Aid, Food Hygiene and has completed her NVQ2. The Proprietor hopes to support this member of staff to complete the NVQ3. He is aware of the gaps in staff training, including in infection control, and has plans to improve this. From his previous experience and qualifications he recognises the importance of training and works alongside the staff, especially in new tasks. However, although there was evidence from one file that that person had signed to say she had read all the policies and procedures, it was not clear that all staff understood the Home’s implementation of the Whistle Blowing Policy, and the procedure for reporting safeguarding incidents, in particular. The Proprietor said that he was intending to implement a programme of staff development and training to ensure that all staff receive the statutory training, particularly in moving and handling, as well as the protection of vulnerable adults, food hygiene and infection control, The Proprietor explained that there were emergency arrangements for staff cover, outside the normal rota, but this does not at present appear on the staff rotas. Dormie House DS0000070717.V364059.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Proprietor who has several years’ experience is working hard with the staff team to ensure that the Home is run in the best interests of the people living there, but there are still improvements to be made. EVIDENCE: The Proprietor has been a trained general nurse for fourteen years and has worked in hospital and residential care settings with people of all ages, but predominantly older people. He has experience of managing staff as a senior staff nurse and has worked as an assistant manager in a residential care home for older people for two years and also covered for the manager in times of absence. He has completed basic and updated training in social care and holds a qualification in teaching and assessing care of the elderly and a Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 23 certificate in management. He has recently completed his NVQ4 and shortly hopes to achieve his Registered Managers’ Award. He holds a Food Hygiene certificate. It is to the credit of the new Proprietor and the staff that there were no comments from residents, staff or the healthcare professional on any negative impact of the change of ownership and the Proprietor displayed an understanding of the ties of the Home with the local community. It was observed that his management style is one of openness and approachability and there were comments to this effect from residents and staff members. He lives on the premises and is very involved in the day-to-day care of residents as well as the management of the Home. In this he is assisted by a Senior Carer, who has just achieved her NVQ 2 qualification. She was on holiday at the time of the Inspection. The Proprietor held a residents’ meeting on 1 January 2008. All residents were present and a relative and all residents received a questionnaire of their likes and dislikes. It was also observed on the day that the needs and preferences of the residents were sought. The AQAA had not been returned in time for surveys to be sent to residents. However, the Proprietor said he intended to implement a monthly topic audit seeking the views of residents, relatives, staff and healthcare professionals. This was confirmed in the later received, completed AQAA. The Home only takes responsibility for small amounts of personal allowances for residents. Records are kept in individual books to which relatives have access, and monies are kept in individual purses in a locked box to which there are only two keys. Two amounts were checked at random and found to be correct. A staff appraisal for one member of staff was seen and it was observed that on the job supervision was taking place and forms in preparation for recorded staff supervision were seen to be in place, although none had been recorded as yet. The Proprietor aims to provide a safe environment for staff and residents. There are individual fire risk assessments in each care plan but staff have not yet had all the appropriate formal training in moving and handling and although some have had training in First Aid and Food Hygiene and the Proprietor is keen to encourage training, the requirement for this is made elsewhere in this Report. (see Staffing) The Inspector is not competent to inspect against standard 38.4, which is in the remit of the Environmental health Department, but the Proprietor is confident that he (the Proprietor) is in compliance with the relevant legislation and has received visits from the Environmental Health Officer and is confident that he is in compliance. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 24 Various records such as Gas Safety Record and the Fire Protection Log Book were seen, it was seen that systems were being tested monthly on a regular basis, although the sheet stated that it was a weekly record. Legionella testing had not taken place since the change of ownership, however, water temperatures were tested on a regular basis and Accident and Incidents were recorded. Dormie House DS0000070717.V364059.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 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 3 2 X 2 Dormie House DS0000070717.V364059.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 OP1 Regulation 4(2) 5(2) Requirement All people living in the Home should have an up-to-date Statement of Purpose and Service User’s Guide in a relevant format to ensure that they have information regarding the aims and objectives of the Home and the care the Home offers. All people living in the Home should have access to a clear complaints procedure to ensure that their concerns are listened to and acted upon. Robust local procedures for reporting safeguarding issues should be clearly accessible for staff to ensure that all people living in the Home are protected from abuse. Staff files must contain photographs and two written references in line with Schedule 2 of the Care Homes Regulations 2001 in order to ensure that all people living in the Home are protected by the recruitment procedures A programme of staff training DS0000070717.V364059.R01.S.doc Timescale for action 31/07/08 2. OP16 22(1)-(6) 30/06/08 3. OP18 12(1)(5) 06/05/08 4 OP29 19(4)( c) 31/07/08 5. OP30 12(1)(a)b 31/10/08 Page 27 Dormie House Version 5.2 6. OP36 18(2) 7. OP38 23(c)(v) 8. OP38 13(4)(a) 9. OP38 23(5) and development should be implemented to ensure that staff fulfil the aims of the Home and meet the changing needs of the residents, particularly in moving and handling, safeguarding and infection control. Formal staff supervision should take place on a regular basis (the NMS recommend that this should be at least 6 times a year). This will ensure monitoring of care practice within the Home for the benefit of the people living there. Consultation with the fire authority should take place particularly with regard to testing fire equipment at suitable intervals to ensure the safety of the people living in the Home. A risk assessment for the access to the top of the stairs should be carried out in consultation with a Health and Safety Officer to ensure the safety of the people with bedrooms on the first floor. A risk assessment for Legionella should be carried out in consultation with the Environmental Health Officer to ensure that unnecessary risk to the health of the people living in the Home are identified and so far as possible eliminated. 31/10/08 06/05/08 06/05/08 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It would be good practice to state the reason for a DS0000070717.V364059.R01.S.doc Version 5.2 Page 28 Dormie House 2. 3. OP16 OP19 4. OP27 signature being absent on the relevant signature sheet of the care plan. It would be good practice to provide a suggestion box in the hall for those who wished to raise any concerns anonymously if so desired. It would be good practice to carry out a risk assessment on the restriction to the night use of the utility area for laundry when food preparation is not being carried out in the kitchen, in consultation with the Environmental Health Officer. It would be good practice to show emergency arrangements for staffing on the rota. Dormie House DS0000070717.V364059.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dormie House DS0000070717.V364059.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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