Inspection on 03/07/07 for Dormy House

This inspection was carried out on 3rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Dormy House 29/06/09

Dormy House 02/07/08

Dormy House 31/07/06

Dormy House 03/10/05

Dormy House 09/05/05

Dormy House 10/08/04

Dormy House 11/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dormy House Ridgemount Road Sunningdale Berkshire SL5 9RL Lead Inspector Yvonne Souden Unannounced Inspection 12:30 3rd July 2007 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 DS0000010983.V339292.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. DS0000010983.V339292.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dormy House Address Ridgemount Road Sunningdale Berkshire SL5 9RL 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) 01344 872211 01344 875111 dormy@caringhomes.org www.caringhomes.org Dormy House (Sunningdale) Limited Sian Belinda Davis Care Home 63 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (63) of places DS0000010983.V339292.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the inner rooms numbered 4 and 22 are not used as service users bedrooms until advised by Fire Service 31st July 2006 Date of last inspection Brief Description of the Service: Dormy House provides residential/nursing care and accommodation for 63 older people. The home is a large mansion that has been extended on three sides, providing single and double rooms with en-suite facilities. The main house provides care and accommodation to people who require residential/nursing care, and the Surrey Wing provides care and accommodation for 13 people who have dementia. The gardens overlook a golf course and have seating provided. Dormy House has a Statement of Purpose and Service Users Guide available on application to the home. Email dormy@caringhomes.org Information CSCI received 06/07/2007 confirm that fees range from £500 to £1000 dependant on assessment, and dependant on whether the room is residential shared/single en-suite, or nursing shared/single en-suite. Additional charges for Hairdressing, Daily Newspapers, Chiropodist, Physiotherapist, Escort duties, Dry cleaning, Private dentistry and Toiletries. DS0000010983.V339292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information gathered to support this report include inspection records, documentation received from the home, Health and social care returned CSCI surveys, ‘Have Your Say About Dormy House’, and a 6-hour site visit to the home. The site visit enabled the inspector to observe care practice within the home and hear the views of the service from residents, visitors, staff and management. The site visit also gave the inspector an opportunity to view further documentation, and view the care plans of six residents’. From the evidence seen by the Inspector and comments received, the Inspector considers that the service would be able to provide a service to meet the needs of individuals of various religion, race, or culture. The home follows the departmental policy and guidelines to manage issues relating to equality and diversity. What the service does well: What has improved since the last inspection? The home reports that they have improved their call bell system, and have bought some kitchen equipment. The home now has planning permission to build a new dementia care unit with sensory garden and 2 new residential/nursing care wings and hope to start building in September 2007. DS0000010983.V339292.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000010983.V339292.R01.S.doc Version 5.2 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 DS0000010983.V339292.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are informed and their needs are assessed prior to a placement offer. EVIDENCE: The Inspector observed that service users have a copy of the homes Statement of Purpose and Service Users Guide within their rooms. Pre-admission/dependency assessments, admission assessments and admission checklists, viewed at the site visit identified the diverse needs of the service users. Service users needs assessments viewed had been completed by the home and external health and social care professionals prior to a residency agreement. The home does not provide intermediate care. DS0000010983.V339292.R01.S.doc Version 5.2 Page 9 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health and social care needs are met with dignity and respect as detailed within their plan of care and risk assessments. EVIDENCE: Individual care plans viewed at the site visit were clearly written, detailing the diverse needs of the service users, how to meet those needs and how to minimise associated risks. Records of appointments and outcomes identify that service users have access to health and social care professionals to ensure their health and social care needs are met. Records do not evidence service user/representative involvement in the review of care plans, but from discussions with service users and their relatives it was clear that the service users needs are met as they would have chosen, and that their relatives are fully informed. As quoted by a relative “Mum has got a care plan, went through the care plan when she first came in, there has not been a review of care that we have been invited to, staff keep us informed. DS0000010983.V339292.R01.S.doc Version 5.2 Page 10 The Inspector tested the call bell system and it was met with a quick response, and observed staff assisting service users with a hoist in a dignified and respectful manner. The home has a contract with a specialist disposal service for the disposal of drugs and sharps. The home has a policy and procedure for the control, storage, disposal, recording and administration of medication. The Inspector observed only trained staff administer service users medication from a monitored dosage system. Records identify that registered nurses had completed medication training and a medication competency assessment prior to administering medication to the service users. DS0000010983.V339292.R01.S.doc Version 5.2 Page 11 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activity plans support the diverse needs of the service users. Service users enjoy choice and are involved in menu planning. Service Users are enabled to maintain links with family and friends. EVIDENCE: Service users within the home are predominantly of a Christian faith and a minister delivers a service within the home. A service user on the dementia unit said she likes to attend church and staff confirmed that the service user is enabled to visit a local church on alternative Sundays. The inspector observed various activities taken place within the lounge/dining room of the dementia care unit, where service users could choose to participate or not. Most of the service users on the dementia unit are able to verbally make choices in their lives, for those who cannot, staff said as quoted, “we know from their body language what the SU wants”. Some service users had gone on an organised outing on the day of the site visit, as quoted by a service user, “today they have went out in the bus to town, I could not go as the physiotherapist was visiting, next week I will go”. The inspector observed that each service user has a monthly list of the DS0000010983.V339292.R01.S.doc Version 5.2 Page 12 activities/entertainment/outings available, and that posters of the next scheduled entertainment was accessible to all. Service users are encouraged to maintain contact with their family and friends and are able to have visitors at any time. The inspector observed visitors within the home and had opportunity to speak to a few. The home provides a varied and nutritious menu designed to meet the needs of the service users. Staff have attended food and hygiene training and the home has regular ‘meet the chief meetings’ to promote service users choice. Fresh fruit and vegetables, and homemade cake were observed on the day of the site visit. DS0000010983.V339292.R01.S.doc Version 5.2 Page 13 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaint procedure is readily available to service users and their representative, and service users are safeguarded from abuse. EVIDENCE: No complainant has contacted the commission with information concerning a complaint made to the service since the last inspection. Service users and their representatives have a copy of the homes complaint procedure. The home has received 7 complaints within the past twelve months, 86 were resolved within 28 days, 1 complaint was upheld and 1 waiting for an outcome. Discussions with staff identify that they are aware and have knowledge of multi-agency policy and procedures to safeguard service users, and are aware of the homes whistle blowing policy. Staff spoke of training received, and staff training records confirm staff have attended safeguarding adults training. DS0000010983.V339292.R01.S.doc Version 5.2 Page 14 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 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users live in a safe environment that needs updating to improve the overall appearance and comfort of the home. Service users live in a home that does not maintain a standard of cleanliness throughout. EVIDENCE: The entrance hall, dining area are pleasantly decorated and furnished to a good standard, but deficiencies in the external decoration, carpeting, heating, bathing facilities and the overall appearance of the home is of an unacceptable standard. Following many months of planning the home now has planning permission to build a new dementia care unit with sensory garden, and 2 new wings to improve the environment and give SU more living space. Refurbishment of other areas is planned. Management confirmed that work should commence September 2007. DS0000010983.V339292.R01.S.doc Version 5.2 Page 15 Records identify that maintenance equipment is serviced for example, lift, fire equipment, the emergency call system and gas. The home has a contract for the disposal of clinical and soiled waste. Staff have attended health and safety training. The home said within a CSCI questionnaire that they have improved by introducing a housekeeper, and domestic staff said that they clean the bathrooms and rooms every day. This was not evident from observations made and from discussions with service users and visitors. Within the main house the inspector observed a service users room in need of painting, the bed linen was not of a high standard, but was clean. As quoted by a visitor “the room mum is in really needs decorated – they have been saying for a few years now that improvements are to be made, the room is not of a standard that mum would have been use to”. The stairs leading to the first floor were un-swept and dirty. As quoted by a visiting relative “I think they need to step up cleanliness, especially the stairway as it smells sometimes, bins are not always emptied and dead wasps have been lying on the stairway for days”. The wallpaper and paintwork was observed to be dirty and ripped within the corridor of the first floor and a radiator front panel was loose. The kitchen was observed to be clean with systems in place to ensure cleanliness is maintained. The chef informed the inspector of new equipment purchased. An environmental health officer visited the homes kitchen 26/06/07 and made requirements that have been met. The main lounge on the dementia unit (Surrey Unit) had an unpleasant odour, staff said, “they keep cleaning it but the smell is still there”. There is a ramp from the main lounge that enables the service user to access the garden, but relatives report that access from the main house is difficult, as quoted, “access to the garden is difficult due to steps, and to access the garden from the front entrance you need a key as the gate is always locked”. The sluice room on the dementia unit had an unpleasant odour and was storing 4 mattresses, making it difficult to access the facilities. The inspector observed that a room occupied by a service user was cold. The windows were open and no heating was on (it was mid summer, but was a cooler rainy day), a staff member immediately closed the windows and checked the heating. Furniture stored within the service users en-suite blocked the shower facilities and partially blocked the sink – staff said they use a bowl to assist the service user with personal care, and that the main bathroom is used to assist service users’ with bathing. The cleaning schedule within the room stated the room had been cleaned the day before the site visit. There are two bathrooms on the dementia care unit and management informed the inspector that only one bathroom is used. The two bathroom viewed were DS0000010983.V339292.R01.S.doc Version 5.2 Page 16 in a poor stare of repair, chipped paintwork, and were unclean. The last regulation 26 visit undertaken by the regional manager prior to this site visit was 12/06/07, and comments in the report stated ‘monitor housekeeping please daily’ and ‘clean bathroom please’. The inspector requested that the area manager and deputy manger view the bathrooms, the cleanliness was discussed and the managers agreed that is was not of an acceptable standard. Gloves and aprons were available to promote infection control and colour coded bags were used to ensure infection control within the homes laundry. Staff discussion and records viewed confirm that staff have attended infection control training. DS0000010983.V339292.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Dormy House has a diverse staff team that are competent, trained and sufficient in numbers to meet the health and social care needs of the service users. EVIDENCE: A group of seven care staff spoke of their induction and of training received since commencement of their employment, and training records confirmed that staff have attended mandatory and specialist training. The home employs qualified nurses, and over 50 of care staff have an NVQ in care, with 19 working towards the qualification. Observation of staff identified patience and understanding of the individual service users needs, and discussions with staff identified a caring staff team who were knowledgeable of the diverse needs of the service users. Recruitment of staff has taken place since the last inspection. Discussions with staff and records viewed confirm that the process of recruitment protects the service users by ensuring references and security checks are in place prior to employment. Staff appeared sufficient in numbers on the day of the site visit to meet the needs of the service users. The home has an equal opportunity policy to promote equality and diversity. DS0000010983.V339292.R01.S.doc Version 5.2 Page 18 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager follows clear corporate policies and procedures within the management of the home, and seeks the view of service users and their representatives to develop the service. The home does not ensure an action plan is enforced following recommendations made. EVIDENCE: The registered manager was not present at the site visit, but had completed a CSCI questionnaire that has provided information to support this report. The Homes Manager is an experienced nurse and has attained the Registered Managers Award. There was a positive and relaxed atmosphere within the home on the day of the site visit, and records identified that staff, service user and relative DS0000010983.V339292.R01.S.doc Version 5.2 Page 19 meetings take place. As quoted by a visitor, “ they have relative meetings – useful especially now with the planned new building”. Records and discussions with management show that monthly auditing of the standards takes place, which includes a regulation 26 inspection of the home, however monthly auditing of the home did not ensure an improvement plan was implemented/monitored to ensure the cleanliness of the home as discussed within the environmental standard of this report. Customer satisfaction surveys are used to gain the view of the service users and their representatives and the results of the annual survey are used by the Organisation to measure the homes success in meeting its published aims and objectives. The Organisation also regularly audits training, the environment, meals, health & safety and accident trends and the home is scored against its own Organisational standards. Discussions with staff and records of meeting minutes viewed, confirm that management are supportive of the staff team, and that staff receive appraisals. DS0000010983.V339292.R01.S.doc Version 5.2 Page 20 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 3 X 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 2 X X X 2 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 3 DS0000010983.V339292.R01.S.doc Version 5.2 Page 21 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 OP19 Regulation 13, 23 Requirement The provider must provide CSCI with an up-to-date plan that details the proposed commencement and completion date of the proposed new build, and must include information on how they will ensure service users live in a comfortable, clean and safe environment whilst the building works takes place. The registered manager must promote infection control for the service users’ by not storing service users’ mattresses in the sluice room. The registered Manager must not store furniture in the service user’s en-suite facilities to ensure they are accessible to the service user. 3. OP25 23 The registered manager must ensure the temperature within the individual service user’s room remain within a safe and comfortable level for the service user. DS0000010983.V339292.R01.S.doc Timescale for action 31/08/07 2. OP19 23 20/07/07 03/07/07 Version 5.2 Page 22 4. OP26 23 The registered manager must ensure the service users’ live in a clean and fresh environment that has no unpleasant odours. 31/08/07 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 OP23 Good Practice Recommendations Within the planned refurbishment of the home the manager should review the service users’ access to the garden from the main house, with a view to promote the service users’ independence and safety in accessing the garden. The registered manager and responsible individual should review their monthly quality assurance audit of housekeeping to ensure action is taken to maintain an acceptable level of cleanliness within the home. 2. OP33 DS0000010983.V339292.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000010983.V339292.R01.S.doc Version 5.2 Page 24 - 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!