Inspection on 11/01/05 for Dorriemay House

Care Homes For Adults (18 ­ 65)Dorriemay House23/27 Eaton Road Margate Kent CT9 1XBAnnounced Inspection11th January 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Dorriemay House Address Dorriemay House, 23/27 Eaton Road, Margate, Kent, CT9 1XB Email address Tel No: 01843 292616 Fax No:Name of Registered Provider(s)/company (if applicable) Mr David Barrie Mirsky Mrs Jacqueline Ann Mirsky Name of Registered Manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 25Category(ies) of registration, with (number of places) Learning disability (25) Registration number H050000231 Date first registered 20th August 2002 Was the Home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 20/07/04 If Yes refer to Part CDorriemay HousePage 1 Date of inspection visit Time of inspection visit Name of Inspector Name of Inspector Name of Inspector 1 2 311th January 2005 11:00 am Mrs Sue GaskellID Code081981Name of Inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr David MirskyDorriemay HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementDorriemay HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Dorriemay House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Dorriemay HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Dorriemay House provides residential care to up to 25 people who require varying degrees of assistance as a result of their learning disabilities. Whilst the Home does not purport to provide specialist services, it has access to all necessary specialist services within the community. The Home comprises a terraced property adjacent to the sea front in a residential area of Margate. The Home is within a short distance of amenities such as rail and bus services, health centres, shops and churches, a library and a concert hall. Staffing comprises one of the Registered Owners, a Head of Care, Care and Ancillary staff. Although the Home has a pleasant back garden, the premises lack access for people with impaired mobility and this may have to be addressed at some stage in the future.Dorriemay HousePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the Inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The Inspector was pleased to see that several new systems have been introduced which have improved the level of care planning and daily recording. Pre-admission assessments were seen to have been carried out recently but care must be taken to ensure that any identified issues are fully investigated and that appropriate risk assessments and guidelines are prepared and circulated to staff. Although the improved system of daily records refer to healthcare needs, and appropriate referrals to Community Nurses, Physiotherapists, Consultants, G.P.s dentists, opticians etc, care needs to be taken to ensure that the daily records and handover sheets are regularly monitored to ensure that staff are aware of the outcome of any specific needs and whether further action is required. The Inspector was also pleased to see that there has been a relatively low turnover of care staff but noted that the files of some recently recruited lack evidence of 2 written references, verification of references, CRB checks and evidence of staff identity. The residents in the Home were seen to be cheerful and relaxed with staff and informed the Inspector that the Home is a nice place to live in. All areas of the Home were seen to be clean, comfortably furnished and well maintained.Dorriemay HousePage 6 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Dorriemay HousePage 7 Dorriemay HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The registered person can demonstrate the Homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the Home. (Any identified issues 28.02.05 must be fully investigated and appropriate risk assessments and guidelines prepared and circulated to staff) The registered person ensures that the healthcare needs of Service Users are assessed and recognised and that procedures are in place to address them. (Daily records and handover sheets should be regularly monitored to ensure that staff are aware of the outcome of any specific needs and whether further action is required.) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of Service Users. (Ensure 2 written references, verification of references, CRB checks and evidence of staff identity are retained for all staff)114YA3214YA1928.02.05317YA3428.02.05Dorriemay HousePage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the Registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The Inspector noted that since the Post Office no longer operates savings accounts, not all residents currently have a savings account. Whilst the Inspector acknowledges that the Home has made enquiries about this, this matter should be progressed as soon as possible.1YA7* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with Service Users Individual discussion with Service Users Group discussion with staff Individual discussion with staff Discussion with management Service User survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Dorriemay House YES YES YES YES YES NO NO NO YES YES YES YES YES YES NO NO NO YES NO YESPage 10 Number of Service Users spoken to at time of inspection Number of relatives/significant others the Inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding Managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)4 0 0 NO NO YES YES 13 0 11/01/05 11:00 4.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Dorriemay HousePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective Service Users have the information they need to make an informed choice about where to live. Prospective Service Users individual aspirations and needs are assessed. Prospective Service Users know that the Home they choose will meet their needs and aspirations. Prospective Service Users have an opportunity to visit and to `test drive the Home. Each Service User has an individual written contract or statement of terms and conditions with the Home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the Home, its services and facilities and terms and conditions; and provides each Service User with a Service Users guide to the Home. The statement of purpose should clearly set out the physical environmental standards met by the Home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the Service Users guide. 350 350 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Hairdressing chiropody 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Standard 2 (2.1 ­ 2.8) New Service Users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective Service User, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The Inspector was pleased to see that pre-admission assessments had been undertaken for recently admitted residents.Dorriemay HousePage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the Homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the Home. 2 Key findings/Evidence Standard met? Residents care plans were seen to include a life history, a pre-admission assessment, guidelines for staff on how to meet individual aims and objectives, risk assessments and supporting information from other professionals. However care must be taken to ensure that any identified issues are fully investigated with appropriate risk assessments and guidelines are prepared and circulated to staff.Standard 4 (4.1 - 4.5) The Registered Manager invites prospective Service Users to visit the Home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The Inspector was informed that prospective residents would be invited to visit the Home for trial visits in order to see the Home and meet staff and other residents. Residents confirmed that they had been to visit the Home prior to moving in on several occasions, including overnight stays. Unplanned placements would be avoided, as they are not in the best interest of the resident or the Home.Standard 5 (5.1 - 5.5) The Registered Manager develops and agrees with each prospective Service User a written and costed contract/statement of terms and conditions between the Home and the Service User. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Dorriemay HousePage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service Users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service Users make decisions about their lives with assistance as needed. Service Users are consulted on, and participate in, all aspects of life in the Home. Service Users are supported to take risks as part of an independent lifestyle. Service Users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The Registered Manager develops and agrees with each Service User an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the Home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Care plans were seen to have been prepared which include residents life history, care needs, aims and objectives, likes, dislikes and what they see as important. The Inspector acknowledges that it would not be meaningful for all of the current residents to sign their care plans, but the Inspector was satisfied that the Home makes every effort to ensure that residents are consulted as much as possible. Care plans were seen to have been reviewed regularly and/or according to the changing aims and needs of residents.Standard 7 (7.1 ­ 7.7) Staff respect Service Users right to make decisions, and that right is limited only through the assessment process, involving the Service User, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The staff confirmed that residents are encouraged to make their own decisions and were seen to respect residents wishes during the course of the inspection. The responses of residents indicated that this is normal practice. The Inspector noted that since the Post Office no longer operates savings accounts, not all residents currently have a savings account. Whilst the Inspector acknowledges that the Home has made enquiries about this, this matter should be progressed as soon as possible.Dorriemay HousePage 14 Standard 8 (8.1 ­ 8.5) The Registered Manager ensures that Service Users are offered opportunities to participate in the day to day running of the Home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The Inspector observed that residents are given every encouragement to make their views known, either through daily contact with staff or through regular House meetings.Standard 9 (9.1 ­ 9.4) Staff enable Service Users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the Service Users individual Plan and of the Homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Entries in the daily records and in other records, such as the Homes accident recording book, indicate that residents are still able to participate in activities where there may be an acceptable degree of risk. The Inspector was informed that for some residents, activities, such as going out in the community, would be carried out with assistance. The Home was seen to have prepared written risk assessments, complete with guidelines on how to minimise risk, but care should be taken to ensure that any new issues are identified and addressed.Standard 10 (10.1 ­ 10.6). Staff respect information given by Service Users in confidence, and handle information about Service Users in accordance with the Homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the Service User. 3 Key findings/Evidence Standard met? The Home has a written confidentiality policy, which is issued to staff at the commencement of their employment and included in the staff handbook. The Inspector was informed that the Registered Owner is currently in the process of applying for registration under the Data Protection Act 1998.ed for data protection.Dorriemay HousePage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service Users have opportunities for personal development. Service Users are able to take part in age, peer and culturally appropriate activities. Service Users are part of the local community. Service Users engage in appropriate leisure activities. Service Users have appropriate, personal, family and sexual relationships. Service Users rights are respected and responsibilities recognised in their daily lives. Service Users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable Service Users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Standard 12 (12.1 ­ 12.6) Staff help Service Users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Dorriemay HousePage 16 Standard 13 (13.1 ­ 13.5) Staff support Service Users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Standard 14 (14.1 ­ 14.6) Staff ensure that Service Users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? The daily records and written day care programmes indicate that residents have access to as wide a range of leisure activities as possible.Standard 15 (15.1 ­ 15.5) Staff support Service Users to maintain family links and friendships inside and outside the Home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The Inspector was informed that residents are encouraged and assisted with maintaining contacts with families and friends, who are made welcome at the Home. The Registered Owner informed the Inspector that every effort is made to include families. The Home has a quiet room, which would be available for residents to meet guests in private.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Although there are routines in the Home these were seen to be flexible according to the individual needs of Service Users. The atmosphere in the Home was seen to be relaxed and revolve, as far practicable, around the wishes of the Service Users. Residents were seen to be addressed by the name of their choice.Dorriemay HousePage 17 Standard 17 (17.1 ­ 17.9) The registered person promotes Service Users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The main meal is served at lunchtime and residents sometimes help prepare meals. Dietary needs are taken into consideration, and fresh fruit was seen to be available. The menu record book indicated that the food provided to Service Users is varied and nutritious.Dorriemay HousePage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service Users receive personal support in the way they prefer and require. Service Users physical and emotional health needs are met. Service Users retain, administer and control their own medication where appropriate, and are protected by the Homes policies and procedures for dealing with medicines. The ageing, illness and death of a Service User are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise Service Users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The Inspector was informed that residents rising and bed times are flexible according to their wishes, and bathing is according to Service Users needs or wishes. None of the residents currently require a high level of assistance with personal care. Staff confirmed that there is always a balance of male and female staff if residents require support or advice and that a female staff member undertakes the lead role. One resident confirmed that residents choose their own clothes and how they have their hair styled. All residents were seen to be dressed appropriately for their age and for the activity.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of Service Users are assessed and recognised and that procedures are in place to address them. No. of incidents where Service Users have been taken to Accident & Emergency during last 12 months No. of Service Users with pressure sores at the time of inspection (from information taken from care notes) 402 Key findings/Evidence Standard met? As much choice as possible is given over which G.P. is visited. The Inspector acknowledges that it is generally appropriate for staff to remain with Service Users during consultations with the G.P. or Community Nurse. Although the improved system of daily records refer to healthcare needs, and appropriate referrals to Community Nurses, Physiotherapists, Consultants, G.P.s dentists, opticians etc, care needs to be taken to ensure that the daily records and handover sheets are regularly monitored to ensure that staff are aware of the outcome of any specific needs and whether further action is required.Dorriemay HousePage 19 Standard 20 (20.1 ­ 20.14) The Registered Manager and staff encourage and support Service Users to retain, administer and control their own medication, within a risk management framework, and comply with the Homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The Inspector acknowledges that there are currently no residents for whom it would be appropriate to store and administer their own medication. All records and procedures relating to the collection, storage, administration and disposal of medication were seen to be in order. Medication is stored and administered from monitored dosage packs. There are sound procedures and safe storage for medication, and staff have regular training to ensure that procedures are complied with.Standard 21 (21.1 ­ 21.8) The Registered Manager and staff deal with the ageing, illness and death of a Service User with sensitivity and respect. 3 Key findings/Evidence Standard met? Although this standard was not observable, the Inspector was informed that some staff have had training in assisting Service Users to cope with bereavement and loss.Dorriemay HousePage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service Users feel their views are listened to and acted on. Service Users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that Service Users know how and to whom to complain. No. of complaints made to the Home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X X X 3 Key findings/Evidence Standard met? The Home has a written complaints procedure, which is included in the Service User Guide, with a book to record any complaints. Residents confirmed that they would feel comfortable if they had to make a complaint to the owner or staff.Dorriemay HousePage 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that Service Users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The Home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The Inspector was informed that senior staff have undertaken Adult Protection awareness training and have passed this on to the other staff.Dorriemay HousePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service Users live in a Homely, comfortable and safe environment. Service Users bedrooms suit their needs and lifestyles. Service Users bedrooms promote their independence. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement Service Users individual rooms. Service Users have the specialist equipment they require to maximise their independence. The Home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The Homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet Service Users individual and collective needs in a comfortable and Homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The Inspector was satisfied that the Home appears Homely, comfortable and generally well maintained. Most of the residents have their own bedrooms and screens have been provided in shared rooms. Bedrooms were seen to be individually furnished and decorated and communal areas were seen to be appropriately decorated and furnished.Dorriemay HousePage 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each Service User with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing Homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO NO YES 16 3 4 0 15 1X X X 40 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Dorriemay HousePage 24 Standard 26 (26.1 ­ 26.4) The registered person provides each Service User with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Standard 27 (27.1 ­ 27.6) The registered person provides Service Users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Dorriemay HousePage 25 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the Homes stated purpose and the individually assessed needs of all Service Users. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the Home. 3 Key findings/Evidence Standard met? All areas of the Home were seen to be clean and hygienically maintained. There are separate kitchen and laundry facilities and there are procedures in place for the handling of laundry. Staff interviewed expressed a high level of awareness of health and safety, food hygiene and COSHH requirements.Dorriemay HousePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service Users benefit from clarity of staff roles and responsibilities. Service Users are supported by competent and qualified staff. Service Users are supported by an effective staff team. Service Users are supported and protected by the Homes recruitment policy and practices. Service Users individual and joint needs are met by appropriately trained staff. Service Users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The Registered Manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Staff confirmed that they are issued with job descriptions. Any important information to be communicated is done so in writing and there are clear handover procedures at each change of shift. The Head of Care confirmed that staff sign to acknowledge having received and read important information.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet Service Users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? At the time of the Inspection there were 25residents residing in the Home. Staffing during the waking day comprises the Head of Care, and adequate support staff. Night staffing comprises 2 awake staff. The Registered Owner, or a senior member of staff, are always on call in the event of an emergency.Dorriemay HousePage 27 Standard 33 (33.1 ­ 33.11) The Home has an effective staff team with sufficient numbers and complementary skills to support Service Users assessed needs at all times. Staff numbers/hours relating to the needs of Service Users are based on guidance recommended by the Department of Health. Personal Care No. Service Users High needs No. Service Users Medium needs No. Service Users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 0 0 25 X 3 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X303 Key findings/Evidence Standard met? The Inspector noted that staffing levels are currently adequate for residents needs but this should be constantly reviewed as residents needs change.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of Service Users. 2 Key findings/Evidence Standard met? The Home was seen to have sound recruitment policies and procedures, which include references to equal opportunities and non discriminatory practices. However, although staff confirmed that written and verbal references are obtained, and there were copies of some of these references in the staff files, the Inspector noted that the files of some recently recruited lack evidence of 2 written references, verification of references, CRB checks and evidence of staff identity.Dorriemay HousePage 28 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the Home and meet the changing needs of Service Users. 3 Key findings/Evidence Standard met? Staff confirmed that all staff have completed an induction training, carried out over a period of several weeks. The training records indicated a satisfactory level of training, ranging from basic health and safety issues to behavioural needs, and NVQ training.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff confirmed that there are individual supervision/discussion sessions between staff and the Head of Care, and regular appraisals. Staff interviewed commented that there is a high level of support for staff from the Owner and Head of Care.Dorriemay HousePage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service Users benefit from a well run Home. Service Users benefit from the ethos, leadership and management approach of the Home. Service Users are confident their views underpin all self- monitoring, review and development by the Home. Service Users rights and best interests are safeguarded by the Homes policies and procedures. Service Users rights and best interests are safeguarded by the Homes record keeping policies and procedures. The health, safety and welfare of Service Users are promoted and protected. Service Users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The Registered Manager is qualified, competent and experienced to run the Home and meet its stated purpose, aims and objectives. Registered Manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? Although the Registered Person has maintained the Home for many years and demonstrated a high level of knowledge of individual residents and of the needs of that particular client group, he lacks the qualifications necessary to meet this Standard.Standard 38 (38.1 ­ 38.6) The management approach of the Home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The staff were seen to relate well to the Registered Owner, Head of Care and each other, and to make suggestions regarding residents care needs. Residents were seen to be relaxed and cheerful with the Manager and staff. All questions from colleagues or residents were responded to by the Owner and Head of Care in a friendly positive and constructive manner. The Home has an equal opportunities policy and there was no evidence to indicate that this is not taken seriously.Dorriemay HousePage 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of Service Users, are in place to measure success in achieving the aims, objectives and statement of purpose of the Home. 0 Key findings/Evidence Standard met? Since there have been no significant changes, this Standard was not assessed on this occasion.Standards 40 (40.1 ­ 40.6) The Homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The Homes written policies and procedures and day to day operating systems were seen to comply with current legislation and with the recognised National Minimum Standards for Younger Adults.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of Service Users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? All records (apart from some staff details) required to comply with legislation or good practice were seen to be clearly recorded and up to date. The records were seen to be stored in an appropriate location, clearly worded and easily accessible for staff and Service Users.Dorriemay HousePage 31 Standard 42 (42.1 ­ 42.9) The Registered Manager ensures so far as is reasonably practicable the health, safety and welfare of Service Users and staff. 3 Key findings/Evidence Standard met? Systems and procedures relating to the health, safety and welfare of residents were seen to be clearly worded, current and easily accessible. Written risk assessments were seen to have been prepared for areas and activities relating to the general daily routines and management of the Home, and for individual residents. Regular maintenance was seen to be carried out. All records required to ensure compliance with current Health and Safety legislation, eg the Fire alarm testing record, Accident recording book, and maintenance certificates were seen to be in order.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the Home) ensures the effectiveness, financial viability and accountability of the Home. 0 Key findings/Evidence Standard met ? Since there have been no significant changes, this Standard was not assessed on this occasion.Dorriemay HousePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceDorriemay HousePage 33 Lead Inspector Second Inspector Regulation Manager DateSue Gaskell William Wallace 27/01/2005Signature Sue Gaskell Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Dorriemay HousePage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 11th January 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Amendments to the report were necessary Dorriemay House NO Page 35 Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The Inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 24th February 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Dorriemay HousePage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Dorriemay House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Dorriemay House am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: David Mirsky D Mirsky Proprietor 14/02/2005Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Dorriemay HousePage 37 Dorriemay House / 11th January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000023391.V196746.R01© This report may only be used in its entirety. 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