Inspection on 31/07/06 for Dormy House

This inspection was carried out on 31st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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 Julie Willis Unannounced Inspection 31st July 2006 09:35 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.V294725.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 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 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 Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 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 3rd October 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. A private company owns the home. 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. The cost of a bed within Dormy House residential wing is £650 per week. The nursing beds range from £750 - £850 per week and the EMI unit is £875 per week, but varies depending on need. The weekly rates do not include chiropody, hairdressing or daily newspapers for which extra charges are levied. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 09:35 am – 4:30 pm on a weekday morning and afternoon. The accumulated evidence used to inform this report includes a pre-inspection questionnaire completed by the manager of the home; examination of the records on file; receipt of 4 service user surveys; discussion with 8 service users 4 relatives and 5 staff. The inspector was assisted throughout the course of inspection by the Homes Registered Manager to whom brief feedback was provided. All requirements from the previous inspection had been met. The CSCI have not received any complaints about the home in the past year. What the service does well: The home provides good quality care to its users. Staff are respectful and kind and provide personal care to users discreetly and with sensitivity. There are enough care & nursing staff on duty to meet the personal & healthcare needs of residents effectively. Staff are well trained and professional. Staff files are well documented and staff recruitment practices are well carried out to protect the safety and welfare of residents. Written records are well written and up-to-date and provide staff with the information they need to provide quality care. The home offers users a wide range of leisure activities including trips out, games, crafts and quizzes as well as the opportunity to see outside entertainers. Service users are treated with dignity and respect at all times by the staff. The manner of address used by staff to speak to users is friendly, respectful and courteous. Food provided by the home offers users variety and choice and is well presented in pleasant comfortable surroundings. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 6 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.V294725.R01.S.doc Version 5.1 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 Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. Service users are fully assessed prior to admission to ensure their needs can be effectively by the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Examination of the pre-admission assessment documentation for 5 users evidenced that all necessary information about the users health and personal care needs are sought prior to admission, along with information about the users dietary needs, communication needs, mobility needs, history of falls, continence and mental state. The majority of the current service users have been referred through the Care Management system. In each case the home obtains a summary of the Care Management assessment and referral prior to admission. The home then carries out its own needs assessment of the individual either at home or in hospital. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 9 In cases of privately funded admissions a full needs assessment is carried out by the Registered Manager, which conforms to the requirements of the National Minimum Standards and includes all aspects of the individuals health and welfare including a social history. Service users and their relatives confirmed that they had been provided with information about the home prior to admission and been offered the opportunity to visit the home informally to meet staff and other users. Service users and relatives said that they had been “shown around the home and that management had answered their questions in an open manner” One relative said that the staff seemed “warm and welcoming” and “put them at ease.” One relative said, “that they had looked at a number of homes, but had decided on Dormy House because the home was clean, nicely furnished and felt safe”. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. Clear information is in place to enable staff to effectively meet the health & personal care needs of users effectively. Service users are encouraged to participate in the care planning and review process from the outset. Service users are provided with care in the way the wish to be cared for and in a manner, which maintains their right to dignity, privacy, independence and choice. The systems for the administration of medication are good with clear and comprehensive arrangements in place to ensure the safety of users. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The inspector spoke at length to 9 of the service users and 4 relatives that were visiting at the time of inspection. Users were generally complimentary about the qualities of the staff. One service user said they had chosen to live at Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 11 the home because the care staff, nurses and management were “cheerful and welcoming” and “appeared helpful and kind”. Two users said that “they were sometimes kept waiting for attention, especially at night” and “that occasionally night staff kept them waiting for a long time before assisting them to the toilet”. The Manager undertook to investigate the users concerns following the inspection and to inform night staff that they must respond more quickly to call bells at night. In general however, the feedback from users was very positive about the quality of services on offer and they said that they were happy living at the home. The files of five service users were examined in detail and case tracked from pre-admission assessment to date. The written records were well-documented and provided staff with sufficient information to enable them to offer the appropriate level of care to users of the service. Clinical tools were being used routinely to assess the risks associated with manual handling, nutrition, skin integrity, bathing, falls and use of restraint devices such as cot sides. Where a risk was identified there were effective risk reduction measures in place. The care plans and treatment plans gave clear guidelines on how staff should reduce the risks identified. Service users confirmed that they were provided with access to health and social care professionals when required and were seen in the privacy of their own bedrooms. This was well documented in service user plans. Doctors round book is kept in the office, which identifies which service users, need to be seen each week. Service users confirmed that screening and preventative treatments are offered routinely. Two service users confirmed that they had been offered a flu vaccination by their GP prior to winter and were in receipt of regular chiropody treatments and eye tests. Two users told the inspector that they “could see their doctor when necessary as there was a weekly clinic held at the home” and that “the doctor was called out at other times if the need arose”. Observation of care practice concluded that users, particularly those with mental frailty, were encouraged to remain as independent as possible by providing appropriate levels of support to maintain the users privacy, dignity and independence. Staff were observed to provide personal care in a discreet and sensitive manner and were heard to be polite and courteous to users. Examination of the daily records clearly validated the content of the plans and evidenced that care was being delivered in accordance with the individual’s wishes. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 12 From examination of the medication administration system and discussion with senior nurses it is clear that the home follows best practice guidance in relation to the storage, administration and disposal of drugs. From examination of staff files it was evidenced that nurses are in receipt of regular refresher training in the safe administration of drugs. The storage systems for medication are effective and disposal systems are safe. The ‘Doom box’ system has been adopted by the home for the disposal of waste medication and the home has an appropriate contract with a registered disposal company. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area was good. A range of activities is offered that provide opportunity for mental and physical stimulation. Service users are encouraged to maintain contact with their family and friends and are able to have visitors at any time. The home provides a varied and nutritious menu designed to meet the needs of users. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The inspector had the opportunity to meet 4 visitors to the home during the course of the inspection. They were able to confirm that the home has unlimited visiting hours and that relatives and friends are made welcome at any time. One relative told the inspector that they could meet their mother in the privacy of her own room if they wished but chose to spend their visiting time in the communal areas where they could meet other residents and could join in activities. One relative said that she “felt most welcome at every visit” Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 14 and that “ there was a family atmosphere at times, especially during functions, parties and special events”. Relatives confirmed that staff are always warm and welcoming and offer them appropriate hospitality during their visits. Relatives confirmed that they are kept well informed about the health and welfare of the users. They said that staff phone them if the resident becomes unwell and invite them to review meetings to discuss care. They said that they felt that they were kept involved and included in the way that care is delivered. The inspector observed the daily routines. The home is run flexibly around the needs of its users, within a semi-structured framework. Meals tend to be at set times but can be adjusted to meet the needs of individuals. Service users confirmed that they rise and retire at a time of their choosing and are offered appropriate choices in relation to everyday life. At the time of inspection music was playing in various parts of the home and service users were engaged in a range of activities. Bingo was being played in the main lounge after lunch. Two users told the inspector that they were not fond of this activity “but joined in anyway, to while away the time”. One user said that they particularly enjoyed quizzes and pub lunches and would like to have the opportunity to go out of the home more often in the minibus. The inspector was told about musical entertainments that regularly take place and of the weekly film shows that were particularly enjoyed by users. Details of forthcoming activities were displayed prominently on notice boards in various parts of the home so that service users could be kept informed of forthcoming entertainments. Most users take their meals in the large pleasantly presented dining room. Lunch on the day of inspection was smoked mackerel or asparagus soup followed by Cornish pasties or turkey cutlets with creamed potatoes, parsley potatoes, fresh cauliflower and French beans. Dessert was ginger sponge and custard or strawberry ‘Pavlova’ & cream. The meal was served in a relaxed and unhurried manner. Users that required assistance at mealtimes were being supported appropriately. On each table of four residents, there were jugs of squash, serviettes, condiments and glasses. A number of users had beer or wine with their meal. Service users said that the food was always “tasty”, “nicely cooked” and “well presented”. They confirmed that there were always alternatives available to the main meal and that the chef would prepare “anything if they asked for it”. The inspector had the opportunity to talk with kitchen staff and the chef who confirmed that if users required an omelette, jacket potato or sandwich he would happily prepare it. Special diets could be catered for. Regular meetings are held between the residents and chef and minutes of these meetings were Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 15 well documented. It is clear that the home is meeting the nutritional needs of users well. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. The home has a satisfactory complaints system. Service users feel their views are listened to and acted upon. Service users are protected from abuse and exploitation by well-trained and competent staff that can demonstrate knowledge of the homes abuse of vulnerable adults and whistle-blowing policies. This judgement has been made using available evidence including a visit to the service EVIDENCE: Service users said that that they felt confident that any concerns or complaints would be taken seriously by the home and efforts would be made to remedy any problems in a timely fashion. Two relatives confirmed that they had never had to make a complaint because they felt that management were approachable and would deal with any concerns quickly before the problem escalated into a formal complaint. The complaint policy in the home meets the requirement of Standard and Regulation. Service users are provided with information on how to make a complaint to the CSCI at any stage in procedures. Examination of the complaint records indicated that there have been 3 complaints made to the home since 1st April 2006. The details of the complaints were well documented and indicated the investigation that had taken place and the outcomes provided to the complainant. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 17 There have been no complaints reported to the CSCI about the home since the last inspection. There was evidence in staff files and from discussion with staff, that they receive training in the protection of vulnerable adults as part of their formal induction to the home. There learning is later consolidated when undertaking NVQ training in which it forms a core module. Observation of care practice by the inspector evidenced that staff were patient and understanding when dealing with residents and appeared mindful of the need to respect the privacy and dignity of users at all times. Staff interviewed were aware of the homes whistle-blowing policy and understood the importance of protecting users from abuse and exploitation at all times. Service users confirmed that they felt safe and well cared for by kind, professional staff. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 26 Quality in this outcome is poor. Although parts of the home including, the entrance hall, premier bedrooms and dining area are pleasantly decorated and furnished to a very high standard, deficiencies in the external decoration, kitchen equipment, carpeting, heating, bathing facilities and the overall appearance of the dementia wing detracts from the overall judgement. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There have been a number of improvement works undertaken on various parts of the home since the last inspection, which have improved the environment for users. The entrance hall is very welcoming and the dining room is spacious, light and airy. There is a pleasant seating area in the internal atrium, which is Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 19 well used by residents in the hot summer weather. This area has been provided with shading and has seating and tables for users. A number of the bedrooms on the ground floor (rooms 1, 2 & 4) have been completely refurbished and are decorated and furnished to a high standard. These rooms are ‘Premier’ en-suite rooms and attract a higher fee per week than other bedrooms. There are plans to continue refurbishing other bedrooms to this high standard throughout the home over time. The call bell, fire and telephone systems are all brand new following a recent lightening strike and rooms 34 & 35 have been redecorated following an electrical fire. The 1st & 2nd floor corridors have also been redecorated. Window restrictors have been fitted throughout the home to prevent accidents and aid security. The toilets next to the lounge on the ground floor have recently been refurbished and are clean and attractive. Two users told the inspector that they did not find the toilets as easy to use as previously. They said, “they felt unsafe”. Consideration should be given to asking an Occupational Therapist for their advice on how to improve facilities further, so that users do not feel unsafe when mounting the step in front of the toilet. The users also said that they thought there should be more than two toilets as there was often a queue and would have to wait their turn. There are a number of serious environmental deficiencies in ‘Surrey’ dementia wing, which require the Providers urgent attention. There is an urgent need to replace the Parker bath in this area as it has been condemned and is currently out of use. Service users should be provided with access to bathing facilities, which can adequately meet their need. The kitchenette is in disrepair, worktops are holed, and drawer fronts are dilapidated and could pose a hazard to users. The toilet has a badly stained floor. Wallpaper is torn and missing in some bedrooms and carpeting needs replacing throughout. The inspector was told that the Proprietors wish to completely re-build the Surrey wing and replace it with a modern purpose built unit and are awaiting planning permission to carry out these major works. It will be a requirement of this report that the CSCI is kept informed of progress in respect of the building works as this part of the building has serious deficits and does not provide a comfortable environment for its users. Externally the building requires repainting. Rotten window frames should be repaired or replaced. The gardens are bland and uninteresting particularly adjoining the dementia unit. These could be improved to provide a more stimulating environment for users. The heating system needs to be overhauled as only one boiler is functioning at present and this could impact on the home in the forthcoming winter months. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 20 A number of the radiator thermostats are broken and radiators need bleeding by the maintenance man every day when they are on. An audit of all bathrooms and toilets should be carried out to ensure the home is effectively meeting users needs. Several baths and bath hoists were broken and needed replacing and there were areas of the home that were being used as storage areas for extraneous items which could pose a hazard to users Although food produced in the homes kitchens is of good quality there is a need to consider repairing or replacing some of the kitchen equipment. This should be carried out in consultation with the Environmental Health Officers. The inspector was informed by management and the chef that the plate warmer is not functioning on both sides, the hot trolley is rusted, the ‘Bain Marie’ is not in working order, the combi oven is broken and requires repair, replacement or removal and the deep fat fryer is not currently functional. From discussion with service users and relatives it is evident that users think that the improvements to the environment have been beneficial. Service users and relatives said the home was always clean & hygienic. Service users were highly complimentary about the dining room which one user said was “like eating in a quality restaurant” and the atrium which one user said was “really lovely during the hot weather”. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. Staff individually and collectively were able to demonstrate that they have the necessary skills and experience to effectively meet the needs of service users in their care. Staff recruitment procedures are robust and transparent and protect service users from harm. Staffing levels are sufficient to meet the needs of users of the service. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Examination of 6 staff files evidenced that the selection and recruitment procedures at this home are robust. All necessary checks are carried out on staff to ensure that they possess the necessary attributes to care effectively for users. There was evidence that care staff have been properly inducted and have received training in core skills such as customer care, fire safety, first aid, manual handling, food hygiene, health & safety, COSHH and infection control. All staff have received training in POVA (protection of vulnerable adults) as part of their induction and as a core module in NVQ training. All staff at the home are well motivated and have either achieved or are working towards a National Vocational Qualification at level 2 or 3. There has been a review of staffing since the last inspection. The dementia unit is staffed with a nurse and two carers during the day and a nurse and carer at night and the nursing/residential wing is staffed by two nurses and ten care Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 22 staff during the day and a nurse and four carers at night. This is sufficient staff to effectively meet the needs of users. The Proprietor Organisation has recently purchased a training company in order to provide more efficient, cost effective training, to staff. There are plans to provide courses in dementia care, dealing with challenging behaviour and diversity in forthcoming months. The qualifications of nurses have been checked effectively to ensure they are fit to practice. The nurses Pin numbers and Statement of Entry on the Register were well recorded and up-to-date. All nurses are provided with regular refresher training in core skills and the safe administration of medication and these sessions are recorded. All nurses have also been provided with pressure area prevention training and care assessment and care plan training. The home regularly provides placements to student nurses. The inspector had the opportunity to meet and speak with a student during the inspection period. The student confirmed that they were enjoying their placement at the home and felt well supported by the permanent staff and management. The inspector spoke to 5 staff that confirmed that they feel well supported by management and have the opportunity to express their views in regular monthly team meetings, staff handovers and in formal supervision sessions. It was clear that those interviewed had a good understanding of how their individual role benefits the work of the team and a thorough knowledge of the key values that underpin their work with service users. Service users and their relatives were complimentary about the staff. They made positive comments about the qualities and caring attitude of the staff. They told the inspector that staff were “friendly and warm”, “helpful, understanding”, kind” and “responsive.” Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 23 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, 38 Quality outcomes in this area are good. Service users benefit from living in a well managed home, where there is evidence that their health welfare and safety is of primary importance. The registered manager is qualified, competent and experienced to run the home for the benefit of residents. The policies and procedures regarding service user finances safeguard the interests of residents and keep their personal monies safe. This judgement has been made using available evidence including a visit to the service EVIDENCE: The Homes Manager is an experienced nurse and has attained the Registered Managers Award to further enhance her knowledge and skills. The manager is supported by a team of committed and caring staff, some of whom have worked at the home for several years. Staff appear well motivated and cheerful and confirm that they have the opportunity to express their opinions openly in Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 24 staff meetings, supervision sessions and staff handovers. They say that they are provided with plenty of opportunity to express concerns, share information and to feel included and involved in the way the service is delivered. Service users and their relatives confirm that the “office is always open and accessible to them” and “that the manager always makes time to speak to users and their relatives” and to address concerns. The home is pro-active in monitoring its own performance against quality standards. An examination of the homes quality audits evidenced that it seeks the views of users, relatives and staff on an annual basis. The results of the annual survey is 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. From discussion with users it was evident that they are regularly consulted on issues that affect them and feel that their views are taken into account. From examination of the minutes of residents meetings there was evidence that when requests are made or concerns expressed in the meetings the issues raised are followed up by management. Examination of a sample of service user cash accounts indicates that a safe procedure is followed for deposit or withdrawal of resident’s monies. Receipts are kept of all cash spent and balances in accounts were accurate and up-todate. Service users confirm that financial matters are dealt with efficiently by the home. Examination of health & safety records indicated that they were up to date and in good order. Routine servicing and maintenance of equipment is undertaken at appropriate intervals to maintain the home as a safe and risk free environment for users. All risks to users are effectively risk assessed and managed. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 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 x 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 2 1 1 3 3 2 2 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 3 x 3 x x 3 Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 26 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 OP19 Regulation 23 Requirement That the Proprietor provides the CSCI with an up-to-date plan of re-building works for Surrey wing The Provider should ensure that the external woodwork around windows is repaired and repainted where rotten. The Provider should ensure that the boiler and heating system are in serviceable condition and that radiators are fitted with thermostats to avoid scalding. The Provider should ensure that all baths and bath hoists are repaired or replaced where broken as identified during inspection. The Provider should consult with Environmental Health Officers about repair or replacement of defective kitchen equipment in the main kitchen. That the Provider in consultation with Environmental Health improves and makes safe the kitchenette on Surrey wing. Timescale for action 30/09/06 2. OP19 23 30/01/07 3. OP25 23 (2) p 30/11/06 4. OP21 23 (1) j 30/11/06 5. OP38 23 (1) j 30/09/06 6. OP26 13 (4) 30/09/06 Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP22 Good Practice Recommendations The Provider should ask an Occupational Therapist to provide advice on how to improve the toilet facilities on the ground floor in order that service users can feel safe when using them. Dormy House DS0000010983.V294725.R01.S.doc Version 5.1 Page 28 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.V294725.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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