Inspection on 15/01/07 for Dorothy House

This inspection was carried out on 15th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dorothy House 17/11/08

Dorothy House 16/01/08

Dorothy House 11/07/07

Dorothy House 21/08/06

Dorothy House 19/10/05

Dorothy House 23/06/05

Dorothy House 22/02/05

Dorothy House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dorothy House 186 Dodworth Road Barnsley South Yorkshire S70 6PD Lead Inspector Christine Rolt Key Unannounced Inspection 15th January 2007 09:20 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 Dorothy House DS0000018245.V321094.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. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dorothy House Address 186 Dodworth Road Barnsley South Yorkshire S70 6PD 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) 01226 249535 F/P 01226 249535 none None Mr Azar Younis Vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2006 Brief Description of the Service: Dorothy House is situated on the main road from the M1 motorway to Barnsley town centre. The home is an extended bungalow that stands well back from the main road at the top of a driveway. The home shares the grounds with its sister home, The Firs. The gardens are landscaped and there is adequate car parking space. There are no stairs or steps either approaching or within the home therefore it is accessible to persons using walking frames or wheelchairs. Notices around the home inform all concerned that the home will be no smoking with effect from February 2007. The weekly fee was £327.50. Hairdressing, newspapers, toiletries, chiropody, dry cleaning and taxis were not included in the weekly fee and were charged separately. The acting manager supplied this information during the site visit on 15th January 2007. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. A Pre-Inspection Questionnaire was sent to the home in November but was not returned to the Commission for Social Care Inspection. A second copy was sent at the beginning of January but this was not completed and returned either. The site visit was from 9.20 am to 5.50 pm on 15th January 2007. The majority of residents were seen throughout the day, some were chatted to and two were asked detailed questions about the home. Two residents were tracked throughout the inspection. Questionnaires were sent to the home; 15 for residents, of which seven were completed and returned, 10 for relatives, of which eight were completed and returned and six for staff, of which two were completed and returned. Two relatives were also contacted by telephone for their comments. Care practices were observed, a sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the acting manager, members of staff, residents and relatives for their assistance and co-operation. What the service does well: What has improved since the last inspection? The home had a Service User Guide and all residents had been issued with copies of this document Residents had contracts/statements of terms and conditions, and care plans now contained residents’ assessments of needs. The majority of risk assessments had been incorporated into care plans and were reviewed in line with the care plan reviews. Redecoration had commenced but not necessarily in the order of priority. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 6 There was evidence that staff had, or were undertaking, National Vocational Qualifications in Care and a recognised standard of induction training. 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. Dorothy House DS0000018245.V321094.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 Dorothy House DS0000018245.V321094.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, 2, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents had some information to enable them to make a choice but this needed expanding. Residents had written contracts/statements of terms and conditions. Residents’ needs had been assessed but there was no written verification that the home could meet residents’ needs. The home does not provide intermediate care. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home did not have a Statement of Purpose. The Service User Guide was displayed and copies were also seen in residents’ bedrooms. The Service User Guide was checked. The complaints procedure needed to be included and some information needed expanding, which was discussed with the acting manager. The Acting Manager said that prospective residents and their relatives were given a copy of the home’s Service User Guide, taken round the home, the home’s routines were explained, and questions were answered. Two residents’ files were checked. Both contained copies of the home’s contracts/statement of terms and conditions and copies of assessments. The acting manager said that she carried out the assessments and then verbally informed the prospective residents whether the home could meet their needs. However, there was no written information on files to confirm this as required by regulation. Reasons for choosing this home was that it was near to where residents or their families lived, they were familiar with this home and the home was small. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents’ individual plans of care did not provide sufficient detail of all their needs. Health needs were not met fully. Medication procedures needed improvement to ensure residents were protected. Residents were treated with respect and their rights to privacy were upheld. EVIDENCE: Two care plans were checked in detail. The care plans did not include information of residents’ social needs or information on their life history, which would provide insight into their individuality. Some of the identified physical care needs did not provide sufficient detail of how the needs were to be met. Daily recording stated that residents’ needs were met but did not provide sufficient detail to determine which physical needs had been met and there was no consistency in the recording of meeting residents’ other needs. Risk assessments had been incorporated into the care plans but the moving and Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 11 handling risk assessments did not include information of the environment i.e. where beds were against the walls, to determine whether there was a risk to resident or staff. The manager said that risk assessments were reviewed with the care plans at least once a month in consultation with the resident or their representative. Accidents forms were completed but were not filed. Residents who had had falls or accidents were monitored and records were kept but the system needed improving to ensure that medical attention was sought earlier. This was discussed with the manager. The home did not have a policy or procedure for dealing with accidents. The CSCI had not been notified of issues relating to residents’ wellbeing as required by Regulation 37 of the Care Homes Regulations. These issues were discussed with the prospective manager. Staff dealing with medication had undertaken accredited training. The home used a monitored dosage system for the majority of medication but some medication was supplied in packets. The medication for three residents was checked. The supply of one medication in the monitored dosage system for one resident had no corresponding information on the MAR sheet. This had not been highlighted or dealt with when the medication had been booked in and had not been queried when the medication had been given to the resident. The acting manager confirmed that this was a regular medicine for the resident and contacted the pharmacy immediately to rectify the discrepancy. All other medication tallied with the MAR sheet. Medication requiring refrigeration was not suitably stored. It was not kept at the correct temperature and there was no monitoring of the temperature. None of the residents administered their own medication and there were no risk assessments in place to determine residents’ capabilities and the reasons. This was discussed with the manager. There was information on residents’ care plans that residents were offered keys to their bedrooms. However, information on whether residents had been offered keys for their lockable facilities was not always completed. This was particularly relevant where residents chose to deal with their own finances and was discussed with the acting manager. Residents were observed to be treated with respect and dignity and residents confirmed this. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ experience of the home did not fully satisfy all their needs including recreational interests and needs. They maintained contact with family and friends but contact with the local community was limited and depended on family involvement. Residents’ right to choose was not met fully. Meals provided an appealing and balanced diet with choices available. EVIDENCE: There were no organised group activities or individual activities taking place in the home during the site visit, and the home did not employ an activities coordinator. Residents sat in lounge or their bedrooms. Residents who were capable made their own entertainment by reading newspapers or books. Others just sat without any stimulation. The television was on but no one watching it. There was no information on care plans of residents’ individual interests or life histories, which would have helped staff assess residents’ interests and social needs. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 13 Families and friends could visit at any time and residents confirmed this. Residents had some choices e.g. getting up and going to bed, use of bedroom, keys to bedrooms but could not choose whether to have a bath or shower. Residents had previously had a choice of a bath or shower but the bathroom had been out of commission prior to the last inspection because of a broken bath hoist. Therefore the requirement made at the last inspection was still outstanding. The acting manager said that the bathroom was to be refurbished and an adapted bath had been ordered. Two residents mentioned that they would like the choice of having a bath instead of a shower. (See also Standard 19). Residents said that the meals were good. The menu board showed a choice of meals for the lunchtime meal and staff were observed offering choice for the teatime meal. Comments about the food were “Can’t fault it”, “Plenty of choice” and “Brilliant!” Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives were confident that their complaints would be listened to and residents were protected from abuse but improvements could be made. EVIDENCE: Copies of the complaints procedure were displayed throughout the home. There were no complaints or allegations of abuse. The home’s adult protection procedure was out of date and needed amending to include local information to ensure that staff left in charge of the home knew what to do and who to contact. The home had the local authority multiagency adult protection procedure. The acting manager said that with exception of new employees, all staff had undertaken adult protection training. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 15 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. The home was clean and pleasant but needed redecoration, replacement and repairs EVIDENCE: The home environment raised the highest number of comments from surveys and discussions. The home was welcoming and there were no offensive odours. All bedrooms and communal areas were checked. All were clean and tidy. Comments were “Cleanliness is maintained by the staff” and “Wonderful”. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 16 One of the corridors was in the process of being redecorated but bedrooms that had been noted at the previous inspection had not been redecorated. The majority of bedrooms were looking dated and drab and some had damaged wallpaper. Comments about the environment were “I feel that certain areas of the building could be improved and redecorating to brighten the home up a little”, “In need of refurbishment”, “Is in need of some refurbishment in various places”, “…I do feel some areas in the home would benefit from refurbishment and decoration such as the toilet and bathroom areas”, “Looking a bit dated but doing the redecoration” and “Room could feel more comfortable if it was redecorated. It has not been done in the time I have been here.” Some bedroom furniture had damaged paintwork and missing veneer strips. The fretwork on some radiator guards was damaged. Some beds had no bed heads. In the past, the dining room had presented well but the furniture had been replaced with mismatched tables and chairs. The manager was advised to audit dining chairs to determine whether they were sufficiently stable for resident use. Mobility aids and equipment, i.e. wall bars, raised toilet seats, support rails, were provided to enable residents to maintain their independence but the bath hoist was broken therefore residents could not use the bathroom and were having to use the shower (see also Standard 14 re lack of choice). At the last inspection (August 2006), the acting manager said that the problem with the hoist was being addressed and quotes were being obtained. At this inspection she said that the bathroom was being refurbished and an adapted bath was on order. Comments about the bathroom were “Since I entered Dorothy House I have been unable to have a bath as this facility is unavailable. Given the fact that I (information on fees paid), I consider this a matter of some urgency”, “Would feel better if bath was repaired or renewed as a shower once a week is not enough” and “My (parent) has been unable to have a bath since entering Dorothy House. as this facility is broken”. Dorothy House DS0000018245.V321094.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 adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff who were trained to do their jobs met residents’ needs. Residents were not supported and protected fully by the home’s recruitment procedures. EVIDENCE: At the time of this inspection there were nine residents. There were two staff on duty at all times. The acting manager said that staff received induction training to a recognised standard and produced a letter from the training organisation as evidence of this. The acting manager supplied the names of all care staff and confirmed that 64 had attained NVQ Level 2 or above. She also said that the remaining staff were either in the process of completing NVQ Level 2 or were waiting for start dates for this training. Three staff files were checked. Criminal Records Bureau disclosures and POVA checks for recent employees were available but not for long-term staff. There Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 18 was no evidence of interviews having taken place and no consistency in the provision of identity documentation and references. The need to audit staff files to ensure all relevant documentation was included was discussed with the acting manager. Comments about the staff were “Very nice”, “Lovely” and “They look after me” and “…I know she is taken care of and is safe all the time” Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 19 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 poor. This judgement has been made using available evidence including a visit to this service. This home does not have a registered manager. There was no quality assurance system to ensure that the home was run in the best interests of residents. Accounting procedures to safeguard residents’ finances need to improve. Policies and procedures need reviewing and updating. The health, safety and welfare of residents were not fully promoted. EVIDENCE: The home has not had a registered manager for several years and has been overseen by the registered manager of the sister home The Firs, which is in the same grounds. An acting manager was appointed at the end of summer Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 20 2006 and was undertaking the Registered Managers Award but had not applied for registration with the CSCI. This was discussed during this site visit. The home did not have a Quality Assurance monitoring system. The need to implement this was discussed with the acting manager. The registered provider did not carry out visits and produce written reports as required by regulation. The CSCI had not been notified of incidents that affected residents’ wellbeing as required by Regulation 37 of the Care Homes Regulations. (See Standard 7) The CSCI sends out Pre-Inspection Questionnaires (PIQ) to assist with inspections. The person in charge is asked to complete and return these documents within a given timescale. This home did not complete and return the PIQ for this inspection or the previous inspection. Policies and procedures had not been reviewed, some were out of date and at least one was missing. Further details of these are under each relevant standard. The home’s facsimile machine was not working. The need for this to be repaired or replaced as soon as possible was discussed with the acting manager. Money held on behalf of residents was stored safely. The money held for two residents was checked against the records and in both cases there were accounting errors. The acting manager was advised of accounting and auditing methods to reduce the risk of discrepancies. The acting manager could not produce any records or documentation to verify that staff had undertaken mandatory health and safety training. At the last inspection it was recommended that a matrix of staff training would provide easy reference to staff training needs but this had not been implemented. There was very little documentation to verify that the servicing and maintenance of systems and equipment within the home had been carried out Two of the three certificates that were available were out of date. Therefore the only proof of up to date maintenance was for fire extinguishers. There was no system in place to ensure that maintenance and servicing of systems and equipment within the home was carried out within the timescales as required by the relevant regulations. Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X 2 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 1 X 2 X X 1 Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement A Statement of Purpose must be provided and must include the information listed at Schedule 1 of the Care Home Regulations. Timescale of 13/11/06 not met The Service User Guide must be updated to include the Complaints Procedure and provide more details Prospective residents must be informed in writing that the home can meet all their needs Care plans must provide details of how residents’ physical, health, emotional and social needs are to be met and records must verify that all the needs have been met. The Commission for Social Care Inspection must be notified without delay of all deaths, illnesses and other events that adversely affect the well-being or safety of residents. Timescale of 30.10.06 not met Where residents’ beds are against the wall, risk assessments must verify that there are no risks to residents or DS0000018245.V321094.R01.S.doc Timescale for action 09/04/07 2 OP1 5 09/04/07 3 4 OP3 OP7 14 12, 13 12/03/07 12/03/07 5 OP7 37 29/01/07 6 OP8 13 29/01/07 Dorothy House Version 5.2 Page 23 7 OP8 13 8 9 OP8 OP9 17 13 10 OP9 12,13 11 12 OP9 OP10 13 12 13 OP12 16 14 OP12 12 15 16 OP14 OP18 12 13 17 OP18 13 staff. The system for monitoring residents who have had accidents/falls must improve to ensure that medical attention is sought without delay. A policy and a procedure for dealing with accidents must be implemented. The correct procedures for the receipt, administration, recording and disposal of medication must be adhered to. Requirement outstanding from or before 20/11/05 Service users must be given the opportunity, within a risk management framework, to administer their own medication. Requirement outstanding from or before 30/11/05 Medication requiring refrigeration must be suitably stored and temperatures monitored Residents must be offered keys to lockable facilities, particularly where they choose to deal with their own finances. A programme of group activities, in line with residents’ abilities and needs must be implemented in consultation with residents. Timescale of 13.11.06 not met. Residents must be consulted about and supported in their individual interests both inside and outside the home. Timescale of 13.11.06 not met Residents choice must be promoted i.e. bath or shower Timescale of 30.10.06 not met. The home’s adult protection policy and procedure must be updated to include local information to ensure that the correct procedure is followed. All new employees must DS0000018245.V321094.R01.S.doc 29/01/07 29/01/07 29/01/07 12/03/07 29/01/07 12/03/07 09/04/07 09/04/07 12/03/07 29/01/07 12/03/07 Page 24 Dorothy House Version 5.2 18 OP22 19 OP19 20 OP19 21 22 23 OP19 OP19 OP29 24 OP31 25 OP33 26 OP33 undertake adult protection training. 23 The bathroom must be made fit for purpose and available for residents. Timescale of 30.10.06 not met 16, 23 A rolling programme of redecoration and refurbishment must continue with priority given to bedrooms. 16, 23 Damaged furniture and fitments must be repaired or replaced, i.e. radiator guards, bedroom furniture. 16 Provide head boards to beds for the comfort of residents 13, 16, 23 Dining chairs must be audited to determine their stability and replaced as necessary. 13 Staff files must include all relevant documentation including evidence of enhanced CRB and POVA disclosures to ensure that residents are fully protected. 9 Application must be made to the Commission for Social Care Inspection for a suitably qualified and competent person to be registered as the manager. Timescale of 13.11.06 not met 24 An effective quality assurance and monitoring system that includes audits of the environment, systems and care practices within the home, and seeks the views of residents and their representatives, must be implemented to ensure that the home is run in the best interests of residents. Timescale of 13.11.06 not met 26 The registered provider must visit the home and produce a written report each month as required by Regulation 26 of the Care Home Regulations. A copy of the monthly report must be sent to the CSCI. DS0000018245.V321094.R01.S.doc 12/03/07 29/01/07 12/03/07 12/03/07 12/03/07 29/01/07 12/03/07 09/04/07 29/01/07 Dorothy House Version 5.2 Page 25 27 OP35 13 28 29 OP38 OP38 16 13, 23 30 OP38 13 Timescale of 30.10.06 not met. Accounting and auditing procedures for residents’ finances must improve to ensure that residents’ finances are safeguarded. Appropriate facilities for communication by facsimile transmission must be provided. Mandatory health and safety training including moving and handling, basic food hygiene, infection control, fire awareness, first aid, adult protection must be provided to ensure that all care staff are up to date with current practice. Timescale of 30.10.06 not met All systems and equipment within the home must be serviced and maintained in line with the relevant regulations and their timeframes. Timescale of 30.10.06 not met. 29/01/07 29/01/07 12/03/07 12/03/07 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. 2. Refer to Standard OP35 OP38 Good Practice Recommendations All financial transactions on behalf of residents should be countersigned to reduce accounting errors. A training matrix would enable easy reference of staff training Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Dorothy House DS0000018245.V321094.R01.S.doc Version 5.2 Page 27 - 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!