Inspection on 20/11/07 for Dovers

This inspection was carried out on 20th November 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 17/01/07

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 Lisa Johnson Unannounced Inspection 20th November 2007 09:20a 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.V347079.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.V347079.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.V347079.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 17th January 2007 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. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The visit was unannounced and took place over eight hours commencing at nine twenty am and finished at five thirty pm. Mrs. L Johnson Regulation Inspector carried out the visit and Mrs. T Newton registered manager represented the home. ` The inspector spoke to five people who live in the home to gain their views on the care provided. Some people living in the home have mental health needs and have limited communication; therefore their direct views about their care could not be obtained. Therefore observations of interactions and body language took place. A survey was received from one person who lives in the service, eleven were received from relatives and four surveys were received from health care professionals. Their comments are reflected in this report. Information was provided by the manager prior to this visit in the Annual Quality Assurance Assessment (AQAA) prior to this visit, which is referred to throughout this report. A full tour of the premises took place. Staff recruitment, training records, care plans and policies and procedures were sampled. The inspector also spoke to three members of staff. The inspector would like to thank people living in the home and staff for their time, assistance and hospitality during this visit. What the service does well: The home provided a happy and relaxed atmosphere where staff were observed to interact with people well. The service demonstrated that it is developing a person centred approach to care. Care plans were detailed and comprehensive and equal opportunities and diversity are considered through this process. Care plans are regularly reviewed and carried out in consultation with people living in the home and their relatives. A relative surveyed said, “ I completed a life experiences questionnaire and the home has a flexible approach”. The registered manager has completed a three-month secondment to develop person centred skills. The home is also able to demonstrate that staff have receive training in dementia awareness. Detailed and comprehensive risk plans had been completed. Comments received from healthcare professionals who provide support to the home included,” staff take pride in the care of the residents”; “The home is always Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 6 quick to refer people to our care and “ there is good liaison with the community nursing service”. A number of positive comments were also received from relatives about the care and support provided “the standards of personal care are high”; “staff are respectful and caring are mindful of service users individuality”; “the staff treat service users like a big family and they spend a lot of time chatting with them and treating them as individuals” and “this seems to be a well run home”. During this visit people were observed to be maintaining their independence and skills. One person spoken with said, “I do my own washing and ironing” and other people were observed accessing the kitchen and one person was doing the washing up which meets their preference. The home is able to demonstrate that they are continually developing their activities. During this visit aromatherapy was taking place and craft sessions were being held in another area. A relative surveyed said, “the residents have a wide range of activities and are encouraged to join in but respects their wishes if they don’t” and another relative stated, “the home takes the time to find out what peoples interests are”. The home respects people’s rights to make choices and decisions. One person said” I have been told I can choose the colours for my bedroom”. Some people had chosen to have pets in the home, which included budgies and guinea pigs. Coffee and tea making facilities were available for people to help themselves to as well as bowls of fruit and sweets. People living in the home are provided with well-balanced meals, which are based on preferences and choice. During this visit two meals were taken and shown to each person enabling them to make a choice for their lunch. People spoken with during this visit said that they enjoyed their meals. People who required support with their meals were provided with appropriate support by staff who were interacting with them throughout. A relative commented, “the meals are very good and personal preferences are catered for”. What has improved since the last inspection? Since the previous visit a number of environmental improvements have been made including redecoration and refurbishment of some of the toilets and bathrooms. Staff personal files seen at this visit contained a photograph of the member of staff. The legionella certificate had now been obtained Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dovers DS0000013630.V347079.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.V347079.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 &6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that pre-admission assessments are completed prior to admission to the home. The home does not support people for intermediate care. EVIDENCE: Evidence gathered during this visit confirmed that detailed and comprehensive pre- admission assessments are conducted which feeds into the person centred plan. Assessments were sampled for three people which covered health, personal, emotional and social needs. Eight out of eleven relatives surveyed stated that they had received enough information about the care home to help them make a decision about the suitability of the home. A relative surveyed stated, “I was given a lot of information prior to my relative moving into the home”. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 10 Information supplied with the AQAA states that prospective people moving into the home are provided with the opportunity to spend a day at the home prior to admission. The home provides short-term respite care but does not provided support to people for intermediate care. Dovers DS0000013630.V347079.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person is provided with an individual care plan, which details their health, personal, emotional and social needs. The health care needs of people are met and they are treated with respect, and their right to privacy is respected. People are protected by the home’s medication policy and procedures. EVIDENCE: During this visit three individual care plans were sampled which were based on full needs assessments including health, personal, emotional, social, cultural and religious needs. The home has also developed person centred plans, which were sampled and provided a good overview of each individual’s needs and contained personal profiles and life histories. Care plans have been developed in consultation with people using the service and their representatives, although two plans had not been signed by them to confirm their agreement. The manager is currently going through this process. A relative surveyed said, “ I completed a life experiences questionnaire”. There was evidence recorded to confirm that care plans are revised on a regular basis. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 12 Peoples likes, dislikes, their preferred routines including times of getting up and preferred names were clearly recorded in their care plan. People using the service are registered with a GP and specialist health care professionals are accessed including district nurses, community psychiatric nurses, continence nurses and chiropody. It was evident that moving and handling assessments are conducted and risk plans were in place for people identified at risk of falls. Tissue viability assessments were completed and one person who was in bed was provided with pressure relieving equipment and a turning chart was in place. This person required nursing care, which was being supported, by the district nurse and required fluid intake monitoring. These charts were viewed and were appropriately recorded. Nutritional assessments have been introduced and weight charts were in place. Comments from health care professionals included, “The home is always quick to refer people to our care”; “there is good liaison with community nursing services” and “staff seem very committed and caring towards their residents”. Seven out of eleven relatives surveyed said that the home meets the diverse needs of people. During this visit people were observed to be clean and appropriately dressed and a number of positive comments were received from relatives about the care and support provided. “The residents always appear clean and well cared for”; “The home has always looked after my relative well”; “staff interact well with all of the residents and makes a point of knowing everybody’s likes and dislikes”; “staff and “the standards of personal care are high”. During this visit staff were observed to knock on bedroom doors before entering and closing doors while carrying out personal care. Staff was observed to speak to people with courtesy and respect. A number of people were supplied with door keys to their bedrooms. Comments received from relative surveys included, “the staff treat everyone with respect”; “The staff spend a lot of time chatting with residents and treat them as individuals”; staff are respectful and caring and they are mindful of service users individuality”. The home has a medication policy in place. Photographs were available with each person’s medication administration record and a list was maintained for all staff that are trained and authorized to administer medication. Records were maintained for the receipt and disposal of medication. While examining the homes incident/accident records it was observed that a medication error had occurred. The home had taken appropriate action but this incident was not reported to the Commission. Therefore it was required that any medication errors must be reported to the Commission ensuring the safety and wellbeing of people. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 13 A medication administration record that had been transcribed by staff had only been signed by one member of staff, therefore it was recommended that where medication cards are transcribed by staff this should be checked and signed by two people ensuring the safety and well being of people living in the home. Dovers DS0000013630.V347079.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 &15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people living in the home have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. Choices and individual preferences are respected and people receive well-presented and balanced meals. EVIDENCE: The home has demonstrated that they are committed to continually improve and develop their activities, which are based in line with people’s requests and choices. The home has a dedicated day care team of three members of staff. There is a designated activities room, which contains a kitchen area for people to participate in cooking activities. During this visit some people were making Christmas cards and aromatherapy was taking place. We were informed that people are assisted to go to the local shops. The home wishes to further develop community access and they have applied for bus passes. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 15 One person told us that she would like to visit the library, which was bought, to the attention of the manager who said that they are looking into this matter. Other activities provided include painting, reflexology, music therapy and social events. Due to a majority of people living in the home with dementia reminiscence sessions are provided and the home are developing memory boxes. Relatives surveyed said, “the residents have a wide range of activities and encourage them to join in but respect their wishes if they do not”;” they take time to find out what peoples interests are”; “the staff take my relative out a lot”. Two relatives however commented that they would like to see their relatives be provided with the opportunity go out more. It was positive to observe people being able to maintain their independence and skills. This was evidenced when one person said. “I do my own washing and ironing “ People living in the home are supported to enter the kitchen if they so wish and one person was observed washing up which respects her choice and preference and some people like to be involved with meal preparation such as peeling vegetables. Tea and coffee facilities were available for people to help themselves to at all times. The home has also held a fiveday dining evening where a room was transformed and created into a fine dining restaurant. This enabled people living in the home and their relatives to enjoy a positive social event. It was evident that people in the home maintain contact with their family and friends and a relative surveyed said, “ I can visit whenever I want to and I am always made to feel welcome and I am encouraged to have meals with my relative”. People moving into the service are able to bring any furniture and personal possessions with them into the home. People are provided with the opportunity to bring their pets with them, which was confirmed by the presence of budgerigars and guinea pigs. One person said, “I have been told I can choose the colours for my bedroom” and a health care professional commented, “Most residents have freedom of choice”. During this visit the homes menus were sampled and were observed to be varied and nutritious. The home is planning to introduce pictorial menus. Qualified chefs are employed and were aware of people preferences likes and dislikes and choices of meals are accommodated. The home provides fresh meat, vegetables, fruit and home made cakes. Cooked breakfast is provided if people prefer this option. Due to a number of people living in the home who have dementia they were supported to make a choice about their preferred meal by staff showing each person both meals. People who require support with their meal were appropriately supported by staff that were talking and interacting with them. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 16 The dining room provided an unhurried and relaxed atmosphere. Tables were laid with serviettes, refreshments and condiments. It was also observed that bowls of fruit and sweets were available throughout the communal areas for people to help themselves to. People spoken with during this visit said that they enjoyed their meals and a relative surveyed said, “the meals are very good and personal preferences are catered for”. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. People living in the home and their representatives have access to an effective complaints procedure and their views are listened to and acted upon. Improvement is needed to ensure that all safeguarding adult matters are reported following policies and procedures. EVIDENCE: The home provides a complaints procedure, which is available with the service user guide and was seen on display in the reception. Since the previous visit the Commission has received two complaints, which were referred to the manager of the home to investigate and evidence was provided to confirm that these matters have been attended to. No other complaints have been received by the home. Two members of staff spoken to were aware of the homes complaints procedure. Eight of eleven relatives surveyed stated that they know how to make a complaint and comments included, “there is a section on making complaints in the homes brochure”;” the home is always open to concerns relating to my relatives care”; “the complaints procedure is on display” and another relative stated, “any questions I may have been responded to fully”. The Local authority safeguarding adults from abuse procedure was available and the home also has their own procedures. Training records were sampled which indicated that staff receive training in safeguarding adults from abuse. This was also confirmed by three members of staff spoken with during this visit Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 18 who were also aware of the homes whistle blowing policy. Staff was clear as to their responsibilities and the action that they would take should they ever witness any abuse. While sampling the homes accident/incident records it was observed that an incident had occurred in the home, which was a safeguarding matter and this, had not been referred to the local authority. A requirement was made that this incident and any other incidents of this matter must be reported without delay to the local authority and a notification must be provided to the Commission ensuring the safety and protection of people living in the home. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 19 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, 23 &26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service live in a well maintained, clean, comfortable, homely and safe environment with one matter identified needing improvement. EVIDENCE: During this visit a tour of the home was conducted. Due to the age of the building continuous refurbishment, redecoration and maintenance is required. There is a maintenance programme in place. Since the previous visit some rooms have been redecorated, bathrooms and toilets have been upgraded and some flooring has been replaced. The windows of the house are old and need replacing and it is recommended that consideration is given to this matter ensuring people have a comfortable environment to live-in There are well-maintained grounds for people to access. All areas in the home are accessible by a lift and grab rails were installed. The home is spacious and provides a large sitting room, separate dining room, a pleasant conservatory, activity rooms and hairdressing salon. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 20 Bedrooms viewed were comfortable and contained personal items and belongings of people. Due to needs of people living in the home gates have been installed to the bottom of the stairs and appropriate systems and fixtures to doors and gates ensuring the safety of people. During this visit the home was observed to be clean and hygienic with no pervading odours present. There are robust infection control procedures in place and staff receive mandatory training in this area. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 21 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 numbers of staff on duty were adequate to meet the needs of people living in the home, although this should be kept under review. People are mainly protected by the homes are protected recruitment policies and procedures and were in the safe hands of the staff who were competent and trained to do their jobs. EVIDENCE: Copies of the staff duty rota were sampled during this visit. During the day there is four carers plus three-day service staff, four staff are provided in the afternoon and three care staff are employed at nighttime. We were informed that the staffing levels are changed to meet the needs of people when the occupancy of the home increases. During this visit it was observed that some individuals living in the home have high care needs and it was recommended that the staffing levels be kept under review. A relative surveyed stated, “ the staff are generally attentive, but feel there is occasional gaps at weekends in what is otherwise a good standard and sometimes it is difficult to get questions answered at the weekend”. Information supplied with the AQAA stated that out of twenty five care staff sixteen have completed National Vocational qualification (level2) or above and five people are completing the programme. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 22 Training records sampled confirmed that staff receive mandatory training which is updated including infection control, food hygiene, first aid, moving and handling, safeguarding adults, food hygiene, medication and health and safety. Two members of staff spoken with said that they had received training in dementia awareness and challenging behaviour. New staff receive induction training and the manager stated that this was based on the Skills for Care core induction standards. Nine out of eleven relatives surveyed said that they felt staff have the right skills and experience to support the needs of people living in the home. Comments included, “the home is able to meet the special needs with skill and kindness” and” I feel the staff are competent and well informed”. Equality and diversity are considered in the staff recruitment process. The home has an equal opportunities policy and the home employs staff with disabilities and people from different ethnic cultures. People living in the service have the opportunity to meet prospective staff applicants and are able to give their views. The home wishes to develop this further. The personal files for three members of staff were examined. All of the required information was available including police checks, although a full work history had not been completed for one person. Therefore it is required that these are obtained ensuring the protection and safety of people living in the service. The manager was aware of the need to obtain POVA first checks for all new staff before they commence employment in the home. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 23 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 registered manager is able to demonstrate that she has the appropriate qualifications and experience. The home is run in the best interests of people living in the home and their financial interests are protected. The health, welfare and safety of people is protected. EVIDENCE: The registered manager and holds the Registered Managers Award and demonstrated that she has the skills and experience to manage the home. Since the previous visit the manager has completed a three-month secondment to develop person centred skills. During this visit the manager was seen to be making herself accessible. Three members of staff spoken with said that they were supported by the management structure that there was good teamwork and regular staff meetings are held. A relative surveyed stated, “ Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 24 “The home seems to be well managed.” and another relative said, “The home achieves a good balance between being well managed, giving a good service and responding to a variety of needs.” The home conducts quality assurance with questionnaires, which have included catering questionnaires and likes and dislikes. The manager stated that regular consultation tales place with people living in the home and their representatives. The responsible individual completes monthly quality visits and these were available for viewing. The home has a range of policies and procedures with evidence that these are reviewed and updated. The home has a policy in place for the protection of people’s finances. The home employs an administrative assistant who overseas these records. The arrangements for records that were in place were sampled for three people. Monies held on behalf of residents were stored securely and all expenditure was recorded and receipts maintained. Information supplied with the AQAA identified systems are in place for routine service and maintenance arrangements for the environment. The home conducts environmental audits and fire records were appropriately maintained with evidence available that alarm checks and fire drills are regularly conducted. Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 25 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 4 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 X 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 3 Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) 37 13(6) 37 Requirement The registered person must ensure that all medication errors are reported to the Commission without delay. The registered person must ensure that all safeguarding adults from abuse matters are reported to the local authority without delay and written notification must be provided to the Commission. The registered person must ensure that full work histories are obtained as part of the staff employment application process. Timescale for action 20/11/07 2 OP18 20/11/07 3 OP29 19(1-5) Schedule2 20/12/07 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 OP9 Good Practice Recommendations The registered person should consider ensuring handwritten prescriptions on medication record sheets are DS0000013630.V347079.R01.S.doc Version 5.2 Page 27 Dovers dated, signed and witnessed by a second member of staff to promote good practice. 2 OP19 Consideration should be given to replacing the windows in the home Dovers DS0000013630.V347079.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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.V347079.R01.S.doc Version 5.2 Page 29 - 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!