Inspection on 09/05/05 for Dormy House

This inspection was carried out on 9th May 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 03/10/05

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 Berks SL5 9RL Lead Inspector Susan Cledwyn-Davies Unannounced 9 May 2005, 9.30am 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 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 H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dormy House Address Ridgemount Road, Sunningdale, SL5 9RL Telephone number Fax number Email 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 Dormy House (Sunningdale) Ltd Ms Rosemary Evelyn Lusty Care Home 63 Category(ies) of Old age, not falling within any other catgegory registration, with number (OP) of places DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom nursing accommodation is provided at any one time shall not exceed 63 beds, 45 nursing beds, plus 18 for personal care. 2. The category of persons to be accommodated shall be that of care home with nursing for persons aged 65 and over. 3. That the inner rooms numbered 4 and 22 are not used as sleeping accommodation. 4. That the three bedrooms out of use in Wentworth Wig are not registered until work on the fire escape is completed to the satisfaction of the Fire Service. 5. That thermostatic valves are fitted to all hot water outlets in service users areas as part of refurbishment. 6. That all policies and procedures are reviewed in line with the requirements of the Care Home Regulations and National Minimum Standards for older people by 31 December 2002. Date of last inspection 10 August 2004 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 accomodates up to 63 older people for both nursing care and residential care. the accomodation 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 H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place from 9.30am to 4.30pm. The visit included a tour of the home, discussion with residents, relatives and staff plus discussion with the manager. Records were seen. In discussion with the manager it was agreed that the name residents is commonly used instead of service users. Therefore this name will be used in the report. 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 H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 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 standard(s) 3, 4 and 5. Residents’ needs are assessed prior to moving into the home. Trial visits by prospective service users and/or relatives take place. Residents care needs are met. EVIDENCE: Care plans demonstrated that potential residents needs are assessed prior to admission to the home. Relatives confirmed visits prior to see the home. Care plans demonstrate that care needs are met. The registration of the home is for older people with physical frailty. The residents accommodated in Surrey Wing are admitted with a degree of memory loss that is causing some problem in managing the care needs e.g. wandering. Therefore this part of the home is accommodating people with dementia and the registration of the home needs to change. A requirement is therefore made. Further comments about the staffing of the wing are made in the section on staffing. DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10 The health, personal and social needs of each resident are included in the plan of care. Health needs are met. Residents are treated with respect and the right to privacy is upheld. EVIDENCE: Each resident has a plan of care. This plan includes assessments of needs and risk assessments. Plans are reviewed on a monthly basis. Plans demonstrate care given and changes that have taken place. Clear recording of unexplained injuries has been added to care records. Health care is initially provided by a local GP surgery. Care plans showed any medical input. Specialist nursing procedures by staff were noted. Staff were reminded that including the manufacturers number for any catheters used is important. In discussion with residents and staff the right to privacy and respect are upheld. This was confirmed by observation during the visit. DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and15 Residents’ lifestyle is varied and follows their own choice. Residents’ family and friends are able to visit as they wish. Residents diet is varied and appealing. EVIDENCE: During the visit a general knowledge quiz was taking place in the lounge and physical exercises in the Surrey Wing. There are 2 part time activities people who arrange varied activities including outings from the home. The month’s diary is displayed in each room and on the notice board. Relatives visiting and residents themselves confirmed that visitors are encouraged. Relatives were positive about the home and the care given. Residents spoke of having choice in the way they spent their day and having a choice of meals offered prior to the meal being served. Meals were served in three dining rooms; one having full silver service and the other two offered more active support to residents. The tables were attractively laid and music played. Residents enjoyed this service. People could also have meals in their own room. The food provided was freshly prepared and well presented. Residents were satisfied with the service. The House has received a Hospitality award from the Hotel service for good service. DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 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 standard(s) 16, 17 and 18 Complaints are taken seriously and acted upon. Residents are encouraged to vote and are protected from abuse. EVIDENCE: There is complaints procedure that is followed actively when concerns are received. Records show that all complaints are investigated and resolved as far as possible. Residents are encouraged to vote and a number used a postal vote in the recent elections. Adult protection issues are investigated fully. DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 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 standard(s) 19 and 26 Residents live in a safe and comfortable environment that is clean and pleasant. EVIDENCE: The house has had further redecoration and new furniture provided. The entrance hall and main stairway have been redecorated and recarpeted. The remainder of the corridors in the old house are scheduled for work this year plus some further bedrooms. It is understood that improvement of the whole house is continuing. There are also plans to extend some parts and rebuild on the site. An enclosed courtyard area has been floored and wooden furniture and plants provides. This area is now very attractive. New equipment including commodes and lifting hoists have been obtained. The call system has had faults in the past and is of older design. It is planned to replace this over the next year. The house was clean and tidy. DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Residents‘ care is met by sufficient staff. EVIDENCE: The staff team is adequate for the care of residents. This was confirmed in discussion with residents and staff. The exception is Surrey wing. A qualified nurse with training and experience in working with people with dementia runs this wing. Care staff are also taking a training course on care of people with dementia. The staffing level of this wing for 13 residents is a minimum of 3 in the morning, two in the afternoon and two at night. In discussion with staff and relatives there were times in the afternoon when a third member of staff was needed. All of the residents in this wing have poor memory and need a lot of staff attention. It has been required and agreed by the proprietor that this wing will be registered to accommodate people with poor memory. To provide for the care 3 staff will be provided in the afternoon also. The manager confirmed that this is partially happening already. A member of staff is going to help for part of the later shift from the main house. DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 13 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 38 The manager of the home is suitably qualified and experienced. Residents are asked for their views and their views are listened to and acted upon. Residents’ health and safety is promoted. EVIDENCE: The manager has worked hard to improve the home. She is moving away from the area and leaving the home in June. A new manager is being recruited. Quality assurance questionnaires have been completed on the food served and on the music played in the dining room. These views have been acted upon. An annual business plan is prepared and used to plan developments. Health and safety procedures are well regarded. The checks in the kitchen of temperatures and cleaning are well maintained. Hot water temperatures have been checked around the house and there is one floor where hot water can be limited. This is being monitored with a possibility of further action. DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 14 All domestic staff have received repeat training on COSHH practices and guidelines have been placed around the home. DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 3 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 3 15 4 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x x x x 3 DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 16 None Are there any outstanding requirements from the last inspection? 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 4 Regulation 6 Requirement That an application is made to register the Surrey WIng to accomodate people with dementia. That Surrey Wing will have increased staff in the afternoon. Timescale for action 1.6.05 2. 27 18 1.6.05 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. Refer to Standard Good Practice Recommendations DORMY HOUSE H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection 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 H52-H01-S10983-DormyHouse-V217761-090505Stage 4.doc Version 1.30 Page 18 - 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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