Inspection on 20/09/07 for Dover House

This inspection was carried out on 20th September 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 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 House 13/12/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Dover House 30 Derbyshire Lane Stretford Manchester M32 8BJ Lead Inspector Helen Dempster Unannounced Inspection 20th September 2007 11:15 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 House DS0000069325.V351069.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 House DS0000069325.V351069.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dover House Address 30 Derbyshire Lane Stretford Manchester M32 8BJ 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) 01617180248 01617185125 Catherine Bernadette Conchie Mrs Patricia Carlon Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - code PC, to people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP. The maximum number of people who can be accommodated is 10. Date of last inspection Brief Description of the Service: Dover House is a care home which provides residential accommodation with personal care for up to ten (10) residents within the category of old age (OP). The home is situated in a residential area of Stretford, and is close to Stretford Arndale Centre and local public transport and motorway networks. Dover House is a large Georgian house set in pleasant grounds. The steps to the front and side of the property have blocked paving. The home has gates with an electronic security system. Car parking space is available at the front of the building and on the roadside. To the rear of the property is an extensive patio area. The grounds to the rear offer a secure external assembly area, which can be accessed via steps or a wheelchair lift from the lounge. The home has ten bedrooms, all of which are en-suite. The first floor has stair lift access. The communal rooms consist of a large lounge/conservatory style area and a designated dining area. The kitchen is open plan onto the dining area. The range of fees charged by the home are from £348:42 to £376:30 per week. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of this service, which was purchased as an existing service by the new owner and subsequently registered in May 2007. This inspection was conducted by gathering lots of information about how well the home was meeting the National Minimum Standards for Older People. This included the owner of the home filling in an Annual Quality Assurance Assessment (AQAA), which gave information about the residents, the staff, the premises and how the service is run. A resident, a resident’s relative and three members of staff also completed questionnaires about the service. The inspection also included carrying out two unannounced site visits to the home on 20th September 2007, from 11:15am to 7:45pm and on 21st September from 1:30pm to 4pm. During these visits, lots of information about the way that the home was run was gathered and time was taken in talking with residents, a resident’s relatives, a social worker, the manager, the owner of the service and the staff team about the day-to-day care and what living at the home was like for the residents. Other information was also used to produce this report. This included reports about things and events affecting residents that the home’s staff had informed the Commission about. The main focus of the inspection process was to understand how the home was meeting the needs of the people who use the service and how the staff were supported to meet residents’ needs. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those people living at the home. What the service does well: Residents’ and a resident’s relative spoke highly of the care provided and residents’ valued the respect of staff for their privacy and dignity. Comments included, “they look after us well”, “leave us in privacy”, “never leave doors open”, are “kind and respectful” and are “very good about privacy”. A social worker said that they had “no concerns whatsoever” about the actual care of residents’, which was “good”. Residents’ said that the food was “good”, that there was “always something you like” and that they “never go hungry”. One resident said that the food was “beautiful” and another said that it was “lovely always”. Residents said that they were, “very happy” and one resident said that, “everything is done for you”. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 6 Residents’ live in clean, warm, attractive and homely surroundings, which is free from unpleasant odours. Communal areas were spacious and were well furnished and decorated. Safe staff recruitment practice protected residents’. Staff were happy and one member of staff said that because it was a “small home”, staff “know the old people” and that, “when they go in hospital we miss them”. This person said that the home was a, “smashing place”, had a “homely atmosphere” and that, “everything was done with residents’ in mind”. Staff said that the new owner was “lovely” that staff could go to the owner with problems and that the owner had “peoples interests at heart”. A resident’s relative said that the owner “communicates well” was “very happy and friendly”, “very welcoming”, “nothing is too much trouble at all” was “always there for you completely” and “has the energy and enthusiasm to do the job”. What has improved since the last inspection? What they could do better: There were a number of things that the home could do better, some of which had the potential to put residents at risk. The new owner demonstrated a commitment to address these issues and had responded, in writing, to the concerns stating how they would be addressed. The concerns included the following: Care plans were not always based on the assessment of a residents’ needs, they were not fully completed and up to date. Risk asssesments were not up to date and unsafe medication practices put residents at risk. The outcomes of visits by GP’s was not recorded. Unsafe medication practice had the potential to put residents at risk and a referral was made to the Commissions Pharmacist Inspector to visit the home. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 7 Records did not meet data protection guidelines, because some were communal records, which included personal details about more than one resident. Residents’, a relative and staff thought that activities needed to improve. Staff must complete training in safeguarding adults and have a knowledge of Trafford Council’s Protection of Vulnerable Adults Policy. Doors were not fitted with locks and it was recommended that residents were offered a locked room to which they could hold the key. There was no clear system in place for obtaining the views of residents’, relatives’ and visiting professionals, and using these to identify improvements for residents. Fire safety arrangements needed to improve. 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 House DS0000069325.V351069.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 House DS0000069325.V351069.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): 1 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents health and personal care needs were assessed before their admission. EVIDENCE: The home was registered in May 2007 and, at the time of the visit; the new owner of the home was making a number of changes to policies, procedures and record keeping. The Statement of Purpose and Service User Guide were therefore under review at the time of the visit. It was recommended that when the Service User Guide has been updated, all residents’ be given a personal copy. The files of four residents’ who had been admitted to the home most recently were seen. All four residents’ needs had been assessed by a Social Worker, Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 10 and, wherever possible, the home’s staff had visited these residents’ prior to admission. One resident’s relative said that they were able to recall this assessment visit-taking place. However, the staff had not consistently record the outcome of their own assessment of need. The new owner of the home had developed a new form on which the assessment of needs would be recorded. Dover House DS0000069325.V351069.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): 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. The privacy and dignity of residents’ was upheld. Care plans and risk assessments did not contain sufficient information on how residents’ needs were being met. Poor medication practices put residents’ at risk. EVIDENCE: Care plans were in place for all residents’. One of the most recently completed care plans demonstrated good practice. This included having a detailed “resident’s profile” which noted the things that were most important to this person. These included noting that the resident, “takes great pride in (their) appearance” and “enjoys discussing what outfit to wear”. Health needs were also clearly recorded on this care plan. However, other care plans seen were not of this standard and did not address all areas of assessed need. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 12 Copies of social work assessments and assessments by health care professionals were made available to staff on some of the files seen. However, some aspects of needs referred to in these assessments were not addressed in the care plans. One example was a resident’s care plan, which was only partly completed and did not reflect a mental health assessment, which noted that this resident had “hallucinations”, was “hearing voices” and was “vulnerable”. It was of concern that this was not reflected in the care plan and that there were no risk assessments to advise staff on how to minimise risks. Another resident was said to have “digestive problems” and was “anaemic”, which had led to hospital admissions, yet there was no record of a dietician referral, or what steps needed to be taken to ensure that the diet given helped the absorption of iron. The health authority assessment for another resident noted, “all areas of life affected by loss of sight (registered blind)”, yet this was not addressed in a care plan or risk assessment. Other details of medical needs, including some issues, which might put the resident at risk, were not addressed in the care plan. For some residents’, care plans did not have any details of needs concerning foot care, mental health and cognition and diet and weight. These concerns were discussed with the new owner. The owner said that the process of drafting appropriate care plans had begun and was being addressed as a priority. The owner stated that the aim was to ensure that all the care plans were of a similarly high standard and gave staff clear guidance on meeting needs. The owner added that the first step had been to improve the content and standard of day to day records and this was evidenced through much more detailed records about social care. Staff were also recording the outcome of visits by doctors and other health care professionals in daily records. However, as these were mixed up with other information, including social care information, it was difficult to audit residents’ ongoing health needs. Risk assessments were not in place to advise staff of practical ways in which risks could be reduced. One resident’s record made reference to a fall. This resident was said to complain of their “side hurting”, the record said that this resident was “given pain tablets and glass of Horlicks” and was “checked regularly during the night”. The record also stated that a visit from this resident’s doctor was requested later that day, as the resident was in pain. However, there was no record of the outcome of this visit and no ongoing records of the resident’s condition specific to the fall in the days following the accident. A social worker was reviewing the needs of a resident at the time of the visit. This person noted improvements in the home since new owner took over. The social worker said that they had “no concerns whatsoever” about the actual care of residents, which was described as “good”. Similarly, both residents and Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 13 a resident’s relative spoke highly of the care provided. However, having “no risk assessments” was a professional concern. Medication was stored in a locked cupboard in a communal area. Medication was dispensed from monitored dosage packs. The start dates of monitored dosage systems did not correspond with the medication administration records and were very confusing. Staff had not received recent training in the administration of medication and some staff had never had training in this area of work. There were lots of examples of inaccuracy on the medication administration records (MARS). These included gaps in the records, where it was not clear whether medication had been administered or not and handwritten details of prescribed medication, which did not include administration instructions. There were no arrangements in place for storage and recording of controlled drugs. The stock levels of medication was high and it appeared that liquid medication, prescribed for two residents, was not being dispensed from their own individual bottle. Finally, the need to have detailed care plans for each resident about their support needs concerning medication administration, including in what circumstances ‘when required’ medication is given, was discussed. In the light of the above concerns about medication practice, a referral was made to the Commission’s Pharmacist Inspector. Following the inspection, the owner confirmed that an urgent meeting had been arranged with the home’s supplying pharmacist for support and advice. The owner of the home recognised that many of the records did not meet data protection guidelines, because some were communal records, which included personal details about more than one resident for example records of community nurses visits. Residents’ at the home spoke highly of the way in which their privacy and dignity was respected. Comments included, “they look after us well”, “leave us in privacy”, “never leave doors open”, are “kind and respectful” and are “very good about privacy”. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 14 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’ social needs and choices are respected, however activities should be consistently based on individual need inorder to meet residents’ diverse needs. EVIDENCE: Residents’ files did not consistently contain information on their preferred likes and dislikes. One resident’s record noted that this person was, “not a very social creature, prefers (their) own company”, “has an active mind, enjoys one to one conversations, but doesn’t like large groups”. Another resident was said to like “listening to the radio and talking”. A resident’s relative said that the only thing the staff could improve on was to provide more entertainment in the afternoon. Two residents’ who completed questionnaires said that they had activities “sometimes”. A member of staff noted in a questionnaire, “Residents get very bored which leads to aggressive moods. They need more time for chatting to people and activities to pass Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 15 time”. The owner acknowledged that this was a problem. Following the inspection, the owner forwarded a list of planned activities and explained that a member of staff was about to be recruited specifically to provide activities. Menus at the home were planned on a daily basis. Formal alternatives to the main menu were not offered, but the owner said that alternatives are offered according to residents’ preferences. Residents talked about how pleased they were with the food. Residents said that the food was “good”, that there was “always something you like” and that they “never go hungry”. One resident said that the food was “beautiful” and another said that it was “lovely always”. When asked about being offered choices, one resident said, “If you don’t like the meal they always give you something else”. Other residents’ confirmed that this was the case. The main meal was served at lunchtime. The meal was served in a relaxed and unhurried way. Residents’ care plans had details of their needs and preferences about food. Residents’ said that their families were made welcome and were offered drinks. A resident’s relative said that they were impressed that the owner took time to find out the specific needs of the family concerning drinks, which were based on their religious beliefs. Residents’ described daily life at the home, including going to the shops and sitting in the garden. Residents said that they were, “very happy” and one resident’ said that, “everything done for you”. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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’ were confident that any issue they raised would be dealt with. Residents’ were not fully safeguarded by the staffs’ knowledge of adult protection policies. EVIDENCE: Two residents’ who had filled in questionnaires, both indicated that they knew how to make a complaint. Residents’ and a resident’s relative said that they could approach the owner if they had any problems. The owner had reviewed the complaints procedure. At the time of the visits, the home did not have a copy of Trafford Council’s Protection of Vulnerable Adults Policy and staff had not had training in the implementation of the Protection of Vulnerable Adults Policy. Staff must have this information so that they know what to do in the event of a disclosure of abuse. Following the visit, the owner confirmed, in writing, that a Copy of Traffords Protection of Vulnerable Adults Policy was received on 26th September 2007 and a meeting had been arranged with a member of staff from Trafford Council’s Education and Development Department to arrange Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 17 mandatory training of staff, including training in the protection of vulnerable adults. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ live in clean, warm, attractive and homely surroundings. EVIDENCE: The home was clean, homely and free from unpleasant odours. Communal areas were spacious and were well furnished and decorated. All residents’ rooms seen were clean and tidy. Residents’ bedrooms all had en suite facilities and were personalised with photographs, religious images and other personal effects. Doors were not fitted with locks and it was recommended that residents’ were offered a locked room to which they could hold the key if they wanted this. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 19 One resident’s relative said that there had been some positive changes made to the home by the new owner. This included replacing carpets, fixing things, having more matching things and residents having their own personal bedding, towels and a toilet bag. The relative said that the new owner had made a “big difference in cleanliness and homeliness”. The standard of kitchen hygiene was high. However, the kitchen, toilets, bedrooms, bathrooms and toilets, all had bar soap and cloth towels. This carries a risk of cross infection and a recommendation was made about the need to obtain the advice of the local environmental health department about this issue. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 20 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. Good recruitment practice protects residents’, but a lack of appropriate staff training and supervision put residents’ at risk. EVIDENCE: A visiting social worker said that staff interaction with residents was “very good”. The owner demonstrated a good understanding of safe recruitment practice. Recruitment practice at the home had been reviewed to include a revised application form, record of interviews, and an interview assessment form. The owner was in the process of recruiting new staff and had a good grasp of the need to check for gaps in employment histories and obtain Criminal Record Bureau (CRB) checks. The home is staffed with a minimum of two staff to care for ten residents’ at all times. At night there was one member of staff on waking duty and another on call in case of emergency. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 21 At the time of the visit, there was no evidence to suggest that staff had up to date training in moving and handling, food hygiene, fire safety, medication administration and other issues. A member of staff stated that, “learning was ongoing through experience”. The owner acknowledged this, had audited records and noted shortfalls. As noted earlier, following the inspection a meeting had been arranged with a member of staff from Trafford Council’s Education and Development Department to arrange mandatory training of staff. Fire Awareness training for staff and residents was booked for 2nd November 2007. Two members of staff were interviewed and three members of staff completed a questionnaire. One member of staff said that they had a full induction but had not had formal supervision. Another member of staff said that they had a practical induction, but that there was no record of this. Neither of these staff had received any recent training. Both of these staff spoke highly of the home. One of them said that they were “very happy here” and that “everybody was happy”, that the home was “just perfect” and that the owner and staff were “friendly” and “helpful. The other person said that because it was a “small home”, staff “know the old people” and that, “when they go in hospital we miss them”. This person said that the home was a, “smashing place”, had a “homely atmosphere” and that, “everything was done with residents’ in mind”. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. The owner is working hard to improve the service by developing positive relationships with residents, relatives and staff. However, inadequate fire safety practice could put residents at risk. EVIDENCE: It was clear from discussions and observations that the owner fosters an open and friendly atmosphere in the home, and that residents, visitors and staff find the owner to be approachable. Staff said that the new owner was “lovely” that staff could go to the owner with problems and that the owner had “peoples Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 23 interests at heart”. Staff said that communication was “very good” and that. “everyday, everything is talked through”. A resident’s relative said that the owner “communicates well” was “very happy and friendly”, “very welcoming”, “nothing is too much trouble at all” was “always there for you completely” and “has the energy and enthusiasm to do the job”. The owner and staff were seen to interact well with residents’ and demonstrated concern for their well-being. One example was a letter seen on a resident’s file which demonstrated that the owner had been a good advocate for this resident, by writing to a hospital consultant on their behalf. There was no clear system in place for obtaining the views of residents’, relatives and visiting professionals, and using these to identify improvements for residents’. This needs to be addressed so that these peoples’ views may be taken into account in future plans. Written information provided by the owner of the home demonstrated that appliances and equipment tests at the home were up to date. However fire safety practice was poor. In particular, fire safety checks of the fire alarm were not up to date and the home was not undertaking regular checks of the means of escape and emergency lighting. At the time of the visit, staff had not received fire safety training and the home did not have an up to date fire risk assessment. The owner contacted the fire authority for advice and confirmed, in writing, that a Fire Safety Inspection was booked for Tuesday 9th October 2007 and Fire Awareness Training for staff and residents was booked for the 2nd November 2007. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 24 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 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 x 2 Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13 and 15 Requirement Care plans must address all areas of assessed need, providing specific details of how care staff assit residents’ and any actions taken. Timescale for action 08/11/07 2. 3. OP9 OP30 13(2) 13 and 18(1) 5. OP36 18(2) Risk assessments must be in place to assess all risks applicable to an individual resident, including the risk of falls. These must be subject to consistent review to take account of any changes so that residents are protected. Medication administration and 08/11/07 record keeping must be reviewed so that it protects residents. The manager and all staff must 08/12/07 have appropriate training to enable them to support and protect residents. This includes training in Moving and Handling and the Protection of Adults from Abuse. The manager must provide 08/12/07 regular supervision to all staff to support them in caring for residents’. Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 26 6. OP38 13 Fire safety checks must be undertaken in line with Fire Department Guidelines and the fire risk assessment must be a working tool, that all staff are familiar with, which is updated regularly to ensure the safety of residents’ and staff. 08/11/07 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. Refer to Standard OP1 Good Practice Recommendations It is recommended that the statement of Purpose and Service User Guide are updated and that each resident, and/or their relative, is given a personal copy of the Service User Guide and that it is adapted so that residents can access the information easily. It is strongly recommended that a care plan for the administration of “when required” medication, including Paracetamol, confirms why medication is prescribed and in what circumstances and for what conditions, medication is given. It is strongly recommended that residents be offered a locked room to which they could hold the key if they wanted this. It is strongly recommended that to protect residents from cross infection, the guidance of the local environmental health department be sought concerning hand hygiene. It is strongly recommended that a quality assurance system is developed to allow residents’ views to be heard and taken account of. 2. OP9 3. 3. 4. OP10 OP26 OP33 Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Central Registration 9th Floor Oakland House Talbot Road, Old Trafford Manchester M16 0PQ 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 Dover House DS0000069325.V351069.R01.S.doc Version 5.2 Page 28 - 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. 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