Inspection on 29/07/08 for Dover Cottage Rest Home

This inspection was carried out on 29th July 2008.

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

Dover Cottage Rest Home 07/06/07

Dover Cottage Rest Home 31/05/06

Dover Cottage Rest Home 15/12/05

Dover Cottage Rest Home 07/06/05

Dover Cottage Rest Home 08/11/04

Dover Cottage Rest Home 24/08/04

Dover Cottage Rest Home 15/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Dover Cottage Rest Home Dover Farm Close Stoneydelph Tamworth Staffordshire B77 4AP Lead Inspector Wendy Grainger Unannounced Inspection 07:45a 29th July 2008 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 Dover Cottage Rest Home DS0000004934.V369153.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. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dover Cottage Rest Home Address Dover Farm Close Stoneydelph Tamworth Staffordshire B77 4AP 01827 331116 01827 261569 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) Dr Rais Ahmed Rajput Mrs Elsa Lilli Badger Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (15) of places Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 June 2007 Brief Description of the Service: Dover Cottage provides accommodation and personal care to fifteen older people who have a primary diagnosis of dementia. The service is located on a residential estate on the outskirts of Tamworth. It is near to the A5 and M42. It is not within walking distance of any major shops. Public transport is available at the end of the main road. The service is situated at the end of a cul-de-sac. It has a small parking area at the front. The main door is located at the rear of the building. A rear garden is available at the back of the building. The premises provide two lounges. Single and shared bedrooms are offered. Only two of the shared bedrooms have an en-suite facility. Bathing and toilet facilities are available on each floor. The shaft lift or the stairs can access the first floor. The service’s Statement of Purpose and Service users Guide documents provide information and include the current weekly fee rates, which range from £388 to £398. As these fee rates applied at the time of our inspection the reader may wish to obtain more up to date information from the care service. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 2 star. This means that the people who use the service experience good quality outcomes. One inspector carried out this unannounced key inspection on one day between 07.45 and 16.30 hours. The service completed an Annual Quality Assurance Assessment (AQAA). This is a self- assessment tool, which was used as part of the key inspection. The completion of the AQAA is a legal requirement and it enables us to see how well the service focuses on the outcomes for people who use the service to make sure that their needs are being met. The AQAA gives us some numerical information about the service. The information contained in the AQAA was somewhat limited in the responses to the required outcome areas. We received completed ‘Have your say’ surveys from three people who use the service, one staff member and one relative. We collected information from these surveys and used it as part of our inspection process. We spoke to a small number of people to find their views about what it is like to live at the service. We also observed other people who use the service who were unable to communicate views. We looked around the premises to see the standard of comfort and safety. We looked at the monthly menu and laundry area to assess their standard in terms of meeting people’s needs. What the service does well: The service provides a warm comfortable place to live and relax in. People who use the service are encouraged as far as possible to live a life style of their choice. We spoke to and observed a number of people who use the service , comments were positive about the staff. People told us; “ The girls are good” “ I get up when I want”. Two people who use the service told us; “ it is not as homely as it used to be” both agreed that the care they had was “good” and the staff “help” them with things they cannot do. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 6 A survey completed by the relative told us;” The staff are always helpful and will answer questions and give support at all times” “ They listen and follow through even though they are busy and stretched to the limit” “They are polite” “I would like to say the staff are lovely and supportive and care very much for their clients” What has improved since the last inspection? What they could do better: We looked at the ‘Statement of Purpose’ displayed in the entrance, there were some elements missing, which were discussed. The cover to the display,was broken and a potential hazard to the people who use the service. The service users guide contained some out of date information, which is not relevant anymore and could be confusing to readers. The sample of the care plans that we looked at and our observations identified that there is a need to ensure that the staff receive training in the management of violence and aggression. Detailed records must be maintained concerning entertainment provided both internally and externally. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 7 We were told that the service has plans to update furnishings and fittings combined with re-decoration. When looking at the premises we saw that this work is needed. Records confirm that staff have not, received Health & Safety training. 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. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 8 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 Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 9 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): Standards 3 and 6. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who choose to move into Dover Cottage receive information to make a choice about whether or not it can meet their needs. No admission takes place without individuals having had his or her needs assessed. EVIDENCE: Information in the services AQAA says, ‘we provide a service users guide for all prospective clients,’ ‘careful consideration is taken when pre-assessing clients to ensure their needs can be met’ From the evidence seen, there remained minor adjustments required to update both the statement of purpose and service users guide. A completed survey from one person told us; “ a brochure would be useful”. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 10 The manager, prior to a placement being accepted visits people to ensure their needs can be met. Documentation seen for two people who use the service confirmed an assessment and additional information had been collated for this purpose. Staff we spoke to and observed demonstrated their commitment and good understanding of the needs of individual people. One completed survey told us;” the staff are lovely and supportive and care very much for their clients making a homely atmosphere, my grateful thanks to them all” Dover Cottage does not provide intermediate care. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Processes in place ensure that the personal and health needs of people who use the service are met. Medication management is adequate, safeguarding the people who use the service. People are treated with respect. EVIDENCE: We saw assessment documents and care plans for the last two people who have accessed the service. The care plans included; daily reports, processes to make sure that health and personal needs will be met on a daily basis, monthly reviews for one person, risk assessments and social workers assessments. The risk assessment for the male person who uses the service needs to be reviewed to incorporate behavioural management information to ensure his safety. We discussed with staff the care of this person. Staff confirmed they had not received training in aggression but had the knowledge to distract the person if and when necessary. We discussed the need for violence and aggression Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 12 training with the manager. The manager agreed to resource training programmes for this particular subject. We discussed the arrangements in place for the continued health care from other professional agencies as one completed survey told us; “ It was not the homes fault difficulties with the first GP, I complained and the GP decided they would not attend mum again. She was moved to another practice. I was not informed of the move”. We saw evidence in the care plans that health needs had been met. We discussed with the manager, the provision of other professionals attending the people who use the service. The district nursing service and community psychiatric nurse visit on a regular basis or when requested. We observed the night staff hand over to the morning staff and then morning handover to the afternoon staff. This handover process is good practice as it means that all staff on a daily basis have up to date information about each person. Medication is administered from a boxed “nomad” system. Staff responsible for the daytime medication administration confirmed they have received appropriate medication training, which is positive, as staff being trained in medication safety will help keep people who use the service safe and prevent medication errors. We identified that no people who use the service have the ability to selfadminister his or her medication because of their dementia needs. Records for the administration of medicines that we looked at and cross referenced with our case tracking processes gave us no concerns. We observed the administration of medicines; the person responsible ensured that each individual took the medication before they left them. We observed staff on all shifts, they were pleasant, respectful and helpful. They dealt with a situation we observed appropriately ensuring needs were met in a satisfactory manner. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are given choices in respect of their daily routines. Activities could be improved upon to ensure that each person has the opportunity to experience a fuller social life style. Meals provided are well received by the people who use the service. EVIDENCE: Activities take place daily with the exception of Sunday. We saw people were given the opportunity to play basketball with two members of the staff which they enjoyed very much. When sitting with people who use the service and discussing one area of activity ‘flower arranging’ on Fridays two people told us that they would like to have the choice to extend the activity by using flowers, ‘fresh or silk’’ while they re-arranged the flowers in the home it was not satisfying to them. Our previous inspection highlighted that the activity programme had been extended. The service’s AQAA states ‘we provide an activity programme that suits our service users. We have invested out time in extending the social life and entertainment for our service users’. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 14 A completed survey told us; ‘activities arranged by the home that mum can take part in “never”, no one has asked her. Another survey completed by a relative on behalf of a person who uses the service told us; “I am unsure of the activities provided, certainly there are activities, but perhaps a little more innovation could be introduced”. We discussed activity provision with the care manager who agreed records are inadequately maintained and need to be reviewed. She agreed to seek advice from other professional agencies to ensure a fuller, stimulating life style could be developed. At the side of the home there are tomato, strawberry plants and bean plants planted by a relative to give people an interest. We saw that menus are written to cover a four-week period. There is a choice for the main meal every day. Breakfast with the exception of Sundays is not a cooked one. We evidenced people coming into the dining room at different times, each were served food, this is positive as it shows that meal times are flexible to suit preferences. The main meal of the day is served at lunchtime. We saw and heard people who use the service offered an option of sausage, or a salmon or ham salad; followed by apple crumble. A much softer diet was served to one person with a medical condition. We suggested to the cook that this soft diet could be to served in a more attractive manner. Two people told us; “ I like the fact that the client group is encouraged to eat and given a choice if it something they dislike” “ perhaps on occasions, the meals are a little repetitive (supper and tea) tends to be “always” “ frequently” sandwiches and mini cheese biscuits. “ Main meal seems OK”. “Perhaps some more fresh fruit options”. We saw from the four weeks menus that on five teatimes a week sandwiches were served. Comments from people who use the service to the cook during our visit included; “lovely tell cook that was very good” “I enjoyed my salad” Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 15 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): Standards 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. While systems and training aim to make sure complaints are listened to and acted upon these could be improved upon to make sure that everyone is aware of how to make and deal with complaints. Processes are in place to protect the people who use the service from abuse. EVIDENCE: We saw that the service’s complaint procedure is displayed in the front entrance and is included within the service users guide and statement of purpose. We looked at the complaints book and saw that there had been two complaints since our last key inspection. The new care manager had addressed the issues informally and made an entry in the record. There had been a request for the main five-barred gate to be made easier for access; the provider to the satisfaction of the person had dealt with it. We have received one complaint concerning the management of this service, which was discussed with the manager during our inspection, who provided a full explanation of the situation. Survey’s we received varied in their comments regarding who and how to make a complaint. A completed staff survey told us , “I don’t know what to do Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 16 if a person raises a concern”. One people who uses the service knew how to make a complaint, two did not. The completed survey from a relative told us; “A full complaints procedure should be available with the contract or through a brochure” Staff spoken with confirmed that they were aware of the “whistle blowing” procedure for the home; they have received training in how they would deal with any form of suspected abuse. There had been no referrals to the safeguarding team. The service’s AQAA identifies that the service had not provided a formal training programme for all the staff about the Mental Capacity Act. Staff told us; they were aware of the Act but not its content or how it could be used in Dover Cottage. We discussed the need for the staff to be made aware of the Mental Capacity Act bearing in mind the registration of Dover Cottage. The manager agreed to resource training for the staff. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 17 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): Standards 19 25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Dover Cottage provides a warm, comfortable environment but action is needed to make sure that is fully safe and fully maintained. EVIDENCE: Located at the end of a cul-de-sac Dover Cottage provides accommodation to older people who have dementia. The care manager told us that the service has plans to start updating and refurbishing the environment. People who use the service spoken with told us “that it used to be different but recently it is not homely” we asked them what was the difference now; Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 18 unfortunately they were unable to explain. We spoke to the care manager about the comment. She thought it was because when the two ladies came to the home it was not fully occupied and this may be the reason for the comment. The home has a ‘homely atmosphere’, staff try to ensure the rooms are kept, tidy and clean, which we observed during the time at the home. A more homely environment will be accomplished by re-carpeting the two lounges, buying new dining room tables, and general redecoration. We saw areas that were dull in their decoration. The first floor bathroom is being used for storage rather than bathing. This means that the service is short of a bath and that people accommodated on this floor have to be taken to the lower floor to be bathed. We saw that this room was cluttered and could be a potential hazard for people who use the service. The bath seat had hairline cracks on it, which could gather, and bacteria and become a potential infection control risk. The bathroom should be cleared and used for its intended purpose to ensure the dignity of the people on the first floor is respected at all times. We looked at bedrooms and found that people who use the service are encouraged to personalise their bedrooms which is positive as having their own personal belongings can make them feel more settled and orientated. The rear of the garden is lawned. The car park is at the front and has a small seating area. We saw that there is a need to continue to monitor the large holly tree in the garden to ensure it did not encroach into the space detracting the light from bedrooms. The service provides equipment for people who use the service to increase their independence. The service’s AQAA states “we provide a record of maintenance and monthly audit and if any problems are noted we act accordingly”. We noticed in bedroom 15 the carpet was a potential hazard and required attention. The cover to the displayed documents in the front entrance was broken and a potential hazard for people who use the service. Comments in the surveys completed included; “The home is fresh and clean” one person said “never” a survey from a relative commented” I only ever see one cleaner it doesn’t seem enough my mothers room needs decorating and the floor seen to”. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service have their needs met by experienced staff. Recruitment procedures and induction training aim to protect the people who use the service EVIDENCE: Staffing on the day of our inspection consisted of the recently appointed Registered Care Manager, two care staff and the catering person. The housekeeper’s job is vacant, the service is waiting for Criminal Records Bureau clearance before someone commenced duty. Since our last key inspection of 7th June 2007 two staff have left employment one of these staff being the deputy care manager. We saw staff rotas for two weeks. Staff confirmed that they had been on duty as described on the rota showing that these rotas are true and accurate. Comments from people who use the service included; “ we like it here the ‘girls’ are nice to us” “ I like being with friends” Survey comments from relatives told us “ the staff work very hard to make the home comfortable” “it’s a pleasure to visit we always have a laugh with the staff” “ I cannot find fault with the home at all” Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 20 We observed staff engaging with people who use the service. We saw that people responded well to the staff. Staff showed a relaxed, pleasant manner, with good practice when assisting people. People who use the service surveys agreed that “staff listen and act on what they say” One staff survey completed told us “ there are never enough staff on duty to meet the needs of the people who use the service “. “ induction only partly covered things I needed to know” I am being given training relevant to my role”. Some of the comments need to be explored by the manager. We looked at three staff records and saw application forms, references, and clearance for a Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) on each file. The service’s AQAA told us that the majority of the staff have a National Vocational Qualification (NVQ) at level two or three. Staff on duty confirmed their qualification; they told us about other training they have received, which included; fire training, fire drill. Staff on duty during the day told us they were aware that renewal of their training was due in November 2008. This was confirmed from the records maintained. The care manager was aware that there remained training to benefit the people who use the service, which included; the Mental Capacity Act, Health and Safety, Violence and Aggression, Dementia for the remaining staff, and Infection Control. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 21 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): Standards 31,33,35,38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to the service. The service is managed well and operates effectively in the interests of the people who use it. Positive working practices are demonstrated by staff who are clear about their roles and responsibilities. EVIDENCE: The newly Registered Care Manager had been registered previously for another service. She has the experience to provide a good service to the people who she has responsibility for. The manager must complete the ‘Registered Managers Award’ as part of her registration agreement with us. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 22 The service’s AQAA did not refer to supervision with the staff, however the staff on duty confirmed that they received supervision; this was also evidenced from records that we looked at. . We spoke with some people who use the service, who are satisfied with the management. We observed good engagement between the manager, staff and the provider who visited whilst we were at the service. The service has improved in obtaining feedback from relatives and other interested parties. Comments included; “the staff work very hard to make the home comfortable” “ I cannot find fault with the home at all” The quality assurance system continues to be developed under the new manager, which will help make sure that the service will continued to be run in the best interests of those who use it. We were informed that the service does not take any responsibility for people’s personal finances so we did not check any money. The service’s AQAA states that records confirm that regular servicing of equipment takes place this we found to be correct. We looked at fire and training records, which we found to be satisfactory. We discussed with the manager the contingency plans and annual fire risk assessment that is required; this was being undertaken prior to the change of management. Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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. 3. 4. Refer to Standard OP7 OP12 OP24 Good Practice Recommendations To review all the care plans to ensure photographs are attached for adequate identification of people. Records should be made of activities offered to show that appropriate activities are available to meet peoples’ needs To prevent an accident and to promote the safety of people who use the service the carpet and display cover referred to in the report should be addressed. The registered person shall ensure that staff employed to work at the home receive appropriate training as referred to in the report to make sure that they are fully able to meet the needs of people who use the service. To prevent risk and make sure that people are safe development of the annual fire risk assessment is needed as are contingency plans in the event of an emergency. OP30 5. OP38 Dover Cottage Rest Home DS0000004934.V369153.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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