Inspection on 17/01/07 for Dovers

This inspection was carried out on 17th January 2007.

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

Dovers 13/11/08

Dovers 20/11/07

Dovers 29/11/05

Dovers 11/08/05

Dovers 06/12/04

Dovers 09/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

Thorndene

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Dovers Dovers 9 Doversgreen Road Reigate Surrey RH2 8BU Lead Inspector Deavanand Ramdas Unannounced Inspection 17th January 2007 10:00 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 Dovers DS0000013630.V325412.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. Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dovers Address Dovers 9 Doversgreen Road Reigate Surrey RH2 8BU 01737 244513 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) Field Lane Foundation (The) Mrs Terry Christina Newton Care Home 39 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (5), of places Physical disability over 65 years of age (5) Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/ age range of the persons accommodated will be: OVER 65 YEARS One bed in the category DE(E) may be used to provide respite care. The age range of one named service user is AGED 60-65 YEARS Date of last inspection 29th November 2005 Brief Description of the Service: Dovers is a care home registered to provide accommodation and care to thirty nine service users over the age of sixty five years. The home is located in a residential area close to public amenities and other facilities. Accommodation is on two floors accessed by stairs or a lift and comprises of an office, lounges, kitchen, laundry, bathrooms, showers, toilets and single bedrooms some with en-suite facilities. The home has mature gardens which are well maintained and accessible to service users. Private parking is available. The range of fees charged by the home is £724.50 to £850.00 per week. The registered manager is Mrs. Terry Christina Newton. Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes site visit as part of the key inspection process by the Commission for Social Care Inspection henceforth referred to as the CSCI and carried out by Mr. D. Ramdas regulation inspector. The inspection commenced at 10:00 hrs and finished at 15:30 hrs and included a tour of the premises, interviews with staff and service users, and a review of documents and care records. The inspector noted some service users have mental health needs and require support with communication. In the absence of verbal feedback judgements were made about them based of their mood, behaviour and information given by staff. The inspector would like to thank the operations manager, registered manager, deputy manager, staff, service users and relatives for their contribution to the inspection. What the service does well: The home has an experienced registered manager who has the RMA (Registered Manager Award) qualification and provides management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘the home is managed very well, the manager is good and also very fair’’. The arrangements for assessing the needs of prospective users are excellent with good policies and procedures. A relative commented ‘‘I had lots of written information and made three visits, the final one with a friend. Nothing was too much trouble to assist me in the decision making process’’. Activities are well planned and organised and the home employs dedicated staff to provide activities in the home and community. A relative commented ‘‘mum takes part in walks, senior exercises, singing and memory games’’ and ‘‘my mother can take part in activities deemed to be appropriate, for example, outings to the garden centre and to the theatre’’. The home values equal opportunity and diversity with person centred plans reflecting the needs of individual service users. Further evidence confirmed staff have value based training including privacy and dignity and a relative commented ‘‘experienced staff treat every person as an individual and endeavour to find ways to make their lives interesting and fulfilled’’. The complaint process is good with one complaint made about the home which was investigated with appropriate management action taken. A relative commented ‘‘we have no problems at all with Dovers – Reigate’’. Further evidence confirmed no matters pertaining to safeguarding adults were recorded about the home since the last inspection by the CSCI. Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 6 Meals at the home are excellent and offer variety, choice and healthy eating options. A relative stated ‘‘I have always been able to have a meal with my mother, tasty food, good and varied menu’’ and ‘‘staff are very good, they take time to see people eat and drink properly’’. Observations confirmed service users enjoying their lunch, happy and smiling. Care planning is good with individual care plans and person centred plans. Evidence confirmed care plans are regularly reviewed and updated to reflect the changing needs of service users. A relative remarked ‘‘all aspects of my mother’s care are discussed with me and I am able to have as much input as I wish. I feel listened to’’. The environment is clean and hygienic and a relative commented ‘‘a beautifully presented home. Spotlessly clean. Always fresh and airy’’. The arrangements for meeting the health care needs of service users are good with access to a local GP (General Practitioner), district nurses and other health care professionals as required. A relative stated ‘‘all medical needs are met fully’’. Staff training in National Vocational Qualification henceforth referred to as NVQ is good with twenty nine carers having the qualification equivalent to over sixty percent of the staff team to ensure service users are in safe hands at all times. The company has an IIP (Investor in People Award) which indicated commitment to staff training and development. During discussions a member of staff stated ‘‘I do quite a lot of training, the deputy manager did my induction’’. Quality assurance at the home is good with regular Regulation 26 (monitoring visits). A relative commented ‘‘the staff always have a highly visible presence and are always available for informal chats, telephone conversations and formal meetings’’. What has improved since the last inspection? What they could do better: The home needs to have a development and refurbishment plan with timescales to outline improvements to the premises to ensure that service users continue to have a well maintained, safe and pleasant environment in which to live. The home needs to ensure staff recruitment files have a recent photograph of the employee and copies of the GSCC (General Social Care Council) code of conduct should be given to staff to safeguard the welfare of service users. Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 7 The home must consult the local authority environmental health department regarding undertaking a legionella risk assessment to promote the health and safety of service users. Recommendations have been made in the area of medications and induction training to promote good practice. 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. Dovers DS0000013630.V325412.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 Dovers DS0000013630.V325412.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): 3&6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing needs are excellent ensuring the needs of prospective service users are assessed before admission to the home. EVIDENCE: The home had a statement on assessing needs and the deputy manager commented that prospective service users are admitted to the home on the basis of an assessment of needs. Further evidence confirmed the home had a day care assessment form and a service user assessment form which covered personal care, health needs and social support. The inspector noted senior staff have responsibility for doing assessments and a relative stated ‘‘I had lots of written information and made three visits, the final one with a friend. Nothing was too much trouble to assist me in the decision making process. The deputy manager stated the home did not offer intermediate care and this standard was not assessed. Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 10 Dovers DS0000013630.V325412.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&10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning are good reflecting the health, personal and social care needs of service users. The systems for health care are good ensuring service users have access to health care services to meet assessed needs. Medication management is good and promote health and protect the welfare of service users. The arrangements for privacy and dignity are good ensuring service users are treated with respect and their right to privacy upheld. EVIDENCE: The deputy manager stated the home had person centred plans and individual care plans based on an assessment of needs. The inspector sampled care plans that sets out in detail action to be taken pertaining to health, personal and social care needs and included risk assessments on mobility and the prevention of falls. Further evidence confirmed care plans were regularly reviewed, dated and signed by service users’ representatives and key workers. A relative commented ‘‘staff seem to liaise well with the GP and visiting nurses’’. Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 12 The home had arrangements to meet the health needs of service users who were registered with a local GP (General Practitioner) with input from a community psychiatric nurse, district nurse and other professionals as appropriate. Further evidence confirmed the home had approved assessments for nutritional screening and pressure sores to promote the health of service users. The inspector noted service users accessed the local PCT (Primary Care Trust) for emergency health care and a relative commented ‘‘all medical needs are met fully’’. The deputy manager remarked the home had a policy on medications and a review of staff training records confirmed staff have training in medications to promote health. Further evidence indicated the home had a service level agreement with a local chemist and kept a record of medications received by and disposed of by the home to prevent mishandling of medications. Observations confirmed the home had adequate storage of medications and medication record sheets had a recent photograph of service users and were dated and signed by staff. Following discussions with the deputy manager a recommendation has been made for hand written prescriptions on medication record sheets to be dated, signed and witnessed by a second member of staff to promote good practice. The home had a policy on privacy and dignity and this area was included in the home’s structured induction programme. Observations confirmed staff addressed service users by their preferred names and the deputy manager knocked on doors before entering bathrooms and bedrooms. A relative commented ‘‘experienced staff treat every person as an individual and endeavour to find ways to make their lives interesting and fulfilled’’. Dovers DS0000013630.V325412.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): 12,13,14&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for social contact and activities are good and satisfy the social and recreational interests of service users. Community contact is good ensuring service users maintain contact with family and friends as they would wish. The systems for autonomy and choice are good helping service users to exercise choice and control over their lives. Meals at the home are excellent and offer variety and choice. EVIDENCE: The operations manager remarked the provision of day care has been reviewed and the outcomes evaluated to ensure all service users in the home have meaningful person centred activities to meet their needs. The manager stated the home employed dedicated staff to provide daily activities for service users and a review of records confirmed the home employed three staff and had a daily activity programme which includes art, music, life skills training, cooking and reflexology to satisfy the social and recreational interests of service users. Observations confirmed staff engaged service users in group activities in the lounge and a relative stated ‘‘Dovers management and staff have a real Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 14 commitment to providing appropriate events for the people living at Dovers – regardless of their dementia or disability’’ and ‘‘mum takes part in walks, singing, senior exercises and memory games’’. The home had a visitor’s policy and service users are able to receive visitors in private. Further evidence confirmed relatives visited the home to maintain family links and service users participated in community activities. A relative commented ‘‘my mother can take part in all activities as deemed appropriate, for example, outings to the garden centre and to the theatre’’ to promote community links and social inclusion. The deputy manager commented service users have choices and are able to bring personal possessions to the home. Further evidence confirmed service users handle their own financial affairs for as long as they wish to and one service user had a named advocate to promote choice and rights. Observations confirmed service users had personal possessions in their bedrooms for their enjoyment. The home employed a head chef to plan and prepare meals with the involvement of service users. The catering and development manager stated the home had written menu plans which reflected variety, choice and healthy eating options. Observation confirmed mealtime was relaxed and unhurried with meals nicely presented. Further evidence indicated staff had training in nutrition with fresh fruits, snacks and hot and cold drinks available throughout the day. A relative commented ‘‘I have always been able to have a meal with my mother, tasty food, good and varied menu’’ and ‘‘staff are very good they take time to see people eat and drink properly’’. Dovers DS0000013630.V325412.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): 16&18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints process is good ensuring that service users complaints are listened to and acted upon. The arrangements for protection are good safeguarding the welfare of service users. EVIDENCE: The manager stated the home had a complaints policy and kept a record of complaints made about the home. Information at the CSCI confirmed one complaint made about the home which was investigated and appropriate management action taken. Further evidence confirmed staff were aware of the complaints policy reflected in the home’s induction programme and a relative stated ‘‘we have no problems at all with Dovers – Reigate’’. The home had a policy on safeguarding adults and a whistle blowing policy to protect service users from harm. A review of training records confirmed staff have training in safeguarding adults, dementia awareness and behaviour that challenges to ensure that verbal and physical aggression by service users is understood and dealt with appropriately. Information at the CSCI confirmed no safeguarding adult matters were recorded about the home and a relative commented ‘‘all aspects of my mother’s care are discussed with me and I am able to have as much input as I wish. I feel I am listened to’’. The inspector noted the home had a copy of the local authority (Surrey County Council) procedures on safeguarding adults to protect service users from harm. Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 16 Dovers DS0000013630.V325412.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): 19&26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the environment needs strengthening to ensure service users have nice facilities. The systems for hygiene are good ensuring the home is clean and hygienic for service users. EVIDENCE: The home is suitable for its stated purpose and is accessible and homely. Observations confirmed the grounds are kept tidy, safe and accessible to service users. Further evidence indicated the home had a fire safety risk assessment and a visit from the local authority (Surrey County Council) environmental health officer with appropriate management action taken to safeguard the welfare of service users. The inspector noted the management is committed to improving the environment and areas of the home have been redecorated and refurbished to Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 18 make the home nice for service users. Following discussions with the manager a requirement has been made for the home to have a programme of renewal with timescales to improve the bathroom and toilet areas of the home. On the day of the inspection the home was clean, well presented and free from mal odour. Further evidence confirmed the home had a service level agreement with an approved contractor for the disposal of clinical waste, a policy on infection control and staff have training in infection control linked to the home’s policies and procedures. Observations confirmed the home employed a laundry assistant and had adequate laundry facilities including an industrial dryer and washing machine with a sluicing facility. The inspector noted staff practised infection control measures by washing their hands regularly to prevent the spread of infection in the home and promote health. A relative commented ‘‘a beautifully presented home. Spotlessly clean. Always fresh and airy’’. Dovers DS0000013630.V325412.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): 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. The arrangements for staffing are good ensuring adequate numbers of staff are on duty to meet the needs of service users. Training and development is good ensuring service users are in safe hands at all times. Recruitment and vetting practices need strengthening to safeguard the welfare of service users. Induction training is good ensuring staff are trained and competent to do their jobs. EVIDENCE: The manager stated the home is adequately staffed and employed a registered manager, deputy manager, senior carers, carers, catering staff, laundry and domestic assistants, activity co-ordinators and maintenance staff to meet the needs of service users. Further evidence confirmed the home had written staff rosters which were sampled and reflected the numbers of staff on duty including six carers during the day and four carers at nights. The inspector noted the home employed four domestic assistants to ensure the home is maintained in a clean and hygienic state and a relative commented ‘‘the manager and her deputy are always around’’. The operations manager stated the home is committed to staff training and development and a review of records at the home confirmed twenty four staff Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 20 have NVQ training equivalent to sixty percent of the staff team to ensure service users are in safe hands at all times. The operations manager remarked the home had a policy on staff recruitment and recruitment documents have been reviewed and updated. A review of records confirmed the home had staff recruitment files which included completed application forms, references, terms and conditions, job descriptions, equal opportunities questionaire, education and training records with CRB (Criminal Record Bureau) disclosure information available in the home. Following discussions with the manager a requirement has made for all staff files to include a recent photograph of the employee and it was recommended that staff have a copy of the GSCC (General Social Care Council) code of practice to safeguard the welfare of service users. The operations manager commented the company employed a training and development manager and the home had a structured induction programme. During discussions a member of staff stated ‘‘I do quite a lot of training, the deputy manager did my induction’’ and further evidence confirmed induction records were dated and signed by the employee and supervisor. The inspector noted the home had an IIP (Investor in People Award) which reflected the company’s commitment to staff training and development. Following discussions with the manager a recommendation has been made for the home’s induction programme to reflect Skills for Care common induction standards to promote good practice. Dovers DS0000013630.V325412.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): 31,33,35&38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The day to day management of the home is good ensuring the home is run by a person fit to be in charge of the home and the systems for quality assurance ensure the home is run in the best interests of service users. Policies and procedures are good safeguarding service users’ financial affairs. The arrangements for health and safety need strengthening to safeguard the welfare of service users and staff in the home. EVIDENCE: The home has a registered manager who has the RMA (Registered Manager Award) qualification and provides management stability, leadership and direction to the staff team. Further evidence confirmed the home had an organisational structure with clear lines of communication and accountability in the home. During discussions a member of staff stated ‘‘the home is managed Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 22 very well, the manager is good and also very fair’’ and a relative commented ‘‘all staff are very friendly and make you feel welcome’’. The operations manager stated the home had a policy on quality assurance and a review of records confirmed the home had regular monitoring visits with appropriate management action taken. Further evidence confirmed the home had met requirements made by the CSCI to improve practice at the home and policies and procedures have been updated to include service users involvement in the staff recruitment process. The operations manager confirmed the home provided opportunities for consultation with relatives and service users by having a quarterly meeting or through the home’s open door policy. A relative commented ‘‘the staff always have a highly visible presence and are always available for informal chats, telephone conversations and formal meetings’’. The home had a policy on service users’ money and provided secure facilities for the storage of money and valuables. The inspector noted the home kept a written record of financial transactions which were sampled and correct. Further evidence confirmed the home employed an administrative assistant with responsibility for service users’ money and the manager has ensured service users’ personal allowances are individualised with receipts kept to safeguard the financial interests of service users. The home had a policy on health and safety and staff have training in health and safety, fire safety, manual handling, food hygiene and thirty nine staff have a current first aid certificate. Further evidence confirmed the home had a policy on COSHH (Control of Substances Hazardous to Health) with products appropriately stored in a locked cupboard to promote safety. A review of records confirmed the home had a current gas safety certificate and service inspection records pertaining to fire equipment, emergency lighting, hoists and emergency call systems were up to date and valid. The kitchen appeared clean and hygienic with appropriate food storage and practices in place. Following discussions with the manager a requirement has been made for the home to consult with the local environmental health department for advice regarding a legionella risk assessment to safeguard the welfare of staff and service users in the home. Dovers DS0000013630.V325412.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 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Dovers DS0000013630.V325412.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. 1 Standard OP19 Regulation 4(1)(b) Requirement The registered person must ensure the home is well maintained and in good repair and implement a development and renewal plan with timescales to reflect the decoration of the home and the upgrading of bathroom and toilet facilities for the enjoyment of service users. The registered person must ensure staff recruitment files have a recent photograph of the employee to safeguard the welfare of service users. The registered person must after consultation with environmental health undertake any necessary actions in respect of a legionella risk assessment to safeguard the welfare of staff and service users. Timescale for action 01/04/07 2 OP29 7,9,19 Schedule 2 12(1)(a) 01/03/07 3 OP38 01/03/07 Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 25 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 OP9 Good Practice Recommendations The registered person should consider ensuring handwritten prescriptions on medication record sheets are dated, signed and witnessed by a second member of staff to promote good practice. The registered person should consider ensuring staff have copies of the GSCC (General Social Care Council) code of conduct to promote good practice. The registered person should consider ensuring the home’s induction programme reflect Skills for Care common induction standards to promote good practice. 2 3 OP29 OP30 Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Dovers DS0000013630.V325412.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!