Inspection on 03/10/05 for Dormy House

This inspection was carried out on 3rd October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dormy House 29/06/09

Dormy House 02/07/08

Dormy House 03/07/07

Dormy House 31/07/06

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 Susan Cledwyn-Davies Unannounced Inspection 3rd October 2005 10:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dormy House DS0000010983.V252297.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. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 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 House (Sunningdale) Limited Ms Rosemary Evelyn Lusty 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 Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 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 10th May 2005 Date of last inspection Brief Description of the Service: Dormy House is situated on the edge of a small town. There are local shops and services. The house is a large mansion house that has been extended on three sides. The home is owned by a private company. The home accommodates up to 63 older people for both nursing care and residential care. The accommodation varies from large single suites with ensuite facilities to bedrooms with ensuite facilities to some single bedrooms. There are a few large double rooms. The house is gradually being upgraded. The gardens are extensive, overlooking a golf course. The house is arranged into distinct areas used for residents with different needs. The Surrey wing is used for people with limited memory, the main house for people with nursing care needs and the wings for abler people needing residential care. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 10.40am and 5.45pm. Included in the inspection was a tour of the main home, discussion with the manager and area manager and with 6 care staff. There were conversations with nine residents. Records were inspected including staff recruitment, rotas and training, residents’ finances and care plans and health and safety records. The term resident is used for people living in this home so is used in the report instead of service user. What the service does well: What has improved since the last inspection? 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. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 6 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 Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The statement of purpose has been reviewed and all residents are assessed prior to moving into the home. EVIDENCE: The statement of purpose has been reviewed to show the new manager. In discussion a more detailed review is planned. Care plans showed that all residents have a preadmission assessment completed prior to entering the home. This assessment aims to show that the home can meet the needs of the prospective resident. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 8 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 and 9 Each resident has an individual plan of care. Health care needs are met. Medication is administered responsibly to residents. EVIDENCE: Two care plans were seen in detail on this visit. Preadmission assessment took place. Care plans are reviewed monthly. An audit has taken place by an external professional from the company. This audit concluded that care plans were well maintained. Health care is provided via a local GP surgery. The Doctor provides a caring and responsive service. All residents have an annual health check. Medication administration and storage was satisfactory. Records kept of medication administration were checked for completeness. A few spaces were seen and the manager was advised of this. The care manager monitors the records. Disposed of medication can now not be returned to the pharmacy. The provider is negotiating a new contract for disposal. The new manager is starting to complete a review of each qualified staff administering medication to ensure that medication is administered according to the home’s procedure. This review will then take place 6 monthly. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 9 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 and 15 Residents’ preferences and interests are known and respected. Residents maintain contact with family and friends. Residents receive a balanced diet in pleasing surroundings. EVIDENCE: There is a planned monthly diary of events that is displayed in each resident’s room. There have been changes made to the activities to ensure that activities take place in the Surrey wing and in the main lounge. There are a variety of activities in and outside the home. Group activities were seen during the visit. Relatives and friends are able to visit the home as they wish. Meals are served in an attractive dining room with a second dining room used by people needing assistance with eating. Residents are also able to eat in their own rooms. There is a three-course meal served and two choices of hot main meal. Residents are asked for their choice prior to the meal. Alternative meals are also prepared. Some residents were disappointed with the meals. The meal seen during the inspection was tasty and enjoyed by residents. The meal service is to be reviewed to ensure consistency of standard. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 10 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 and 18 Residents are confident that their complaints will be listened to. Residents are protected from abuse. EVIDENCE: There is a full complaints procedure. The manager has a proactive approach to complaints and encourages residents to talk about their concerns. All complaints are investigated fairly. A complaint has been received by CSCI and is being investigated by the manager. The manager is arranging new POVA (protection of vulnerable adults) Training shortly. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 11 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 and 26 The environment was improving. The home was clean and tidy. EVIDENCE: The house has some areas that are well decorated and furnished. The entrance and communal areas are welcoming and attractive. There are parts of the house needing redecorating and new carpets. In some parts the structure of the house is deteriorating e.g. windows, fittings. Two bedrooms and first floor corridors are being decorated currently. The proprietor has applied for planning permission to rebuild the Surrey wing as a purpose built unit and possibly provide some flats on the site. The development plans are not yet decided. A requirement is made that CSCI be advised of the changes to be made and ensuring that work continues to update the current house. The home was generally clean, tidy and comfortable. One residents room was noted to the manager as needing carpet cleaning. One domestic store cupboard was seen without a lock. A bolt was put on and a lock will be applied. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 12 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 and 30 Residents’ needs are met by sufficient skilled staff. Staff are trained and competent to do their jobs. The home’s recruitment practice is thoughtful but references were not always obtained. EVIDENCE: The staff rota showed sufficient cover in each area. There has been some increase in the staffing in the afternoon in Surrey wing. The manager is observing in this unit to ensure that there is sufficient staffing. Qualified staff plus senior carers provide senior cover in the home. Staff training is responsibly managed. Clear records are maintained and training is updated as necessary. There is good evidence that staff receive the minimum training each year. There was a recent clinical audit by an external auditor. From this audit the inspector was advised that 50 of care staff have achieved or nearly achieved the NVQ 2 training. Staff recruitment records were seen of the last 4 staff recruited into the home. Of these three did not have the minimum number of references. Two came via an agency and the references were obtaining later during the visit. The third file seen was a recently appointed carer that references had not been sent for. These were sent for during the inspection. These staff had been recruited when there was no manager in post. The administrator has responsibility for ensuring that the recruitment is complete. It was acknowledged that there Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 13 was a fault, and the inspector was advised that recruitment is taken very seriously. A recommendation is made to review all recruitment files to ensure that these are complete. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 There is an experienced manager newly appointed who is not yet registered. Quality assurance audits are completed to maintain good practice. Residents ’ financial interests are safeguarded. Staff are appropriately supervised. Health and welfare issues are promoted. EVIDENCE: The newly appointed manager is experienced and has previously been a registered manager. The application to register has not yet been received and therefore a requirement is made that an application be made. Both staff and residents spoke well of the new manager. The proprietor has arranged for a full audit to take place in the home. This was very thorough, covering care practice and the building. The result provided a grading of 81 with the comment of maintaining a good standard. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 15 Residents finance held by the home was seen. Money is held securely in individual containers. Individual records are kept including credits and debits; receipts are kept. A copy of the appropriate record is sent to relatives monthly and/or when requesting further monies. No member of staff acts as signatory for the DSS. There are only the manager and admin staff that are able to access the money. Individual staff supervision takes place; care staff confirmed this. Records show that the number of supervisions achieved is lower than expected to achieve 6 times a year. The manager has noted this and advised senior staff to arrange for supervision meetings. Health and safety was partially covered. The medication fridge was seen and the temperature was checked daily. This record showed that for over 2 weeks the temperature had been between 10 and 12 degrees. The drugs within the fridge should be stored at up to 8degrees. The thermostat on the fridge was turned down and staff will be observing that the temperature is within the required boundaries. A requirement is made to ensure that this fridge is working at proper levels or is repaired/replaced. During the visit a latch was put on a COSSH cupboard door. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 16 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 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? No 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 19 Regulation 23 Requirement That the proprietor advises of the planned development of the home and of improvement work of the house to be carried in the next year. That the manager applies to register with CSCI. That the medication fridge is maintained at a safe temperature. Timescale for action 01/12/05 2 3 31 38 8 23 01/11/05 01/11/05 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 1 Refer to Standard 15 29 Good Practice Recommendations That the catering service is reviewed to ensure consistency. That all recruitment files are reviewed to ensure that full information is retained. Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Dormy House DS0000010983.V252297.R01.S.doc Version 5.0 Page 19 - 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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