Inspection on 28/11/06 for Dowty House

This inspection was carried out on 28th November 2006.

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

Dowty House 10/04/08

Dowty House 07/02/06

Dowty House 10/08/05

Dowty House 27/01/05

Dowty House 25/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Dowty House St Margaret`s Road Cheltenham Glos GL50 4EQ Lead Inspector Sharon Hayward-Wright Unannounced Inspection 13:00 28 November 2006 th 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 Dowty House DS0000016424.V317725.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. Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dowty House Address St Margaret`s Road Cheltenham Glos GL50 4EQ 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) 01242 520713 01242 530206 Coronation Old People’s Housing Society (Cheltenham) Limited Mrs Joyce Bourne Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can take a maximum of 4 service users between the ages of 55 to 65 years. This number includes 2 named service users under the age of 65. 4th September 2006 Date of last inspection Brief Description of the Service: Dowty House is a Victorian property, which has been adapted and extended; it is situated close to the centre of Cheltenham. The home is bordered by a busy road and is sited in an area that has undergone re-development. Dowty House is a care home for older people. The accommodation is located on three floors; a shaft lift provides access to the second floor but not the first floor, which is at mezzanine level. Access to this level is achieved through a stair lift. All rooms are single occupancy and have washbasins. Bathrooms and toilets are located on each floor. The communal accommodation consists of two lounges (one is a smoking room) and a dining room. Access to and from the building is gained through the front and back doors, which are controlled by telephone for security. To the front and side of the property there are well-tended gardens with flowers, shrubs and garden furniture where service users can sit out. To the rear of the home is a new conservatory and parking spaces. CCTV monitors the rear of the property. The fee ranges for this home are from £350 to £420; per week and extras to the fees include hairdressing, newspapers and chiropody. This information was given to the inspector after the site visit. Copies of the homes Statement of Purpose and Service Users Guide are displayed around the home. Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over 2 days in November 2006. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Registered Manager was available during the inspection as were other members of the home team. A total of 28 of the National Minimum Standards for Older People were inspected. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk Service users were spoken with to ascertain their views on the care and services provided. A number of surveys were sent to the home prior to the inspection for service users, staff and visitors to the home. All had positive comments to make about the home, and these include; ‘staff at Dowty House are fantastic and treat all service users as though they are part of the family’ and ‘very impressed with the care and attention given to my relative’. The comments received from staff during the inspection all indicated they are very happy working at the home. The Registered Manager and care staff were spoken with throughout the inspection and were helpful and co-operative. All requirements issued at the last inspection have been addressed. Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has completed an audit of the home that includes the views of service users, visitors to the home and staff. Copies of this are available around the home. The home has reviewed the format used for care plans to include a long term assessment of needs and care plans with more individual information about service users. This is to provide care staff with all the information they need to meet the needs of the service user. Dowty House DS0000016424.V317725.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. Dowty House DS0000016424.V317725.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 Dowty House DS0000016424.V317725.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, 2, 3, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure prospective service users and their family/representative are given enough information to make an informed choice about moving into the home. EVIDENCE: Since the last inspection the home has reviewed their Statement of Purpose and Service Users Guide. The format has also been changed. Copies of these guides are available around the home and at both entrances. The home has also set up their own web site and is in the process of reviewing their ‘flyers’. The homes Service Users Guide and terms and conditions were examined in line with the changes to the Regulations that came into force in September 2006. Two additions are required to their terms and conditions to meet the Regulations. Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 10 Three service users who had their care examined in detail also had their contracts looked at. Two service users have their care funded by Community and Adult Care Directorate (CACD) and one of these service users pays a contribution towards the fee. One service user said they remember signing a contract when they were admitted to the home but since then Community and Adult Care Directorate deal with their fees. Another one of the three service users is self-funded but was unable to discuss this with the inspector due to their medical condition. However their records held by the home had copies of their contract and fee increase letters. Pre admission assessments were seen of a recently admitted service user completed by the home. A copy of the assessment and care plans devised by Community and Adult Care Directorate was also available as was hospital discharge information. A number of service users spoken with all said they had visited the home prior to moving in. One service user said that they had a specific request and there were not many homes that fulfil this requirement and that they had received assistance from their Social Worker. A family member had also visited the home and felt this home would meet their needs. This service user said they had made the right decision to move into this home. Intermediate care is not provided by this care home. Dowty House DS0000016424.V317725.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 adequate. This judgement has been made using available evidence including a visit to this service. Since the last inspection improvements have been made with service users care records ensuring up to date information is available for staff. Improvements are needed with the medication arrangements to ensure the safety of service users. Health services are accessed for service users. EVIDENCE: Three service users had their care examined in detail. One service user was able to speak at length to the inspector about the care they received. All three had a pre admission assessment completed by the home. Since the last inspection the home has reviewed the format used. All had a new long-term assessment of needs and care plans devised from this. The care plans were all individual to each service user. Reviews were seen on a monthly basis. The Registered Manager documents any changes in the care plans, however consideration should be given to changes being documented in the long-term Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 12 assessment of needs as well as the care plans. Evidence was seen of service users signing their care records. Risk assessments were in place for moving and handling and falls. Separate risk assessments were in place for any other risks identified; again reviews of these were seen. Care records, service users and staff confirmed they have access to medical services. One service user was due to visit the dentist the week following the inspection and had recently had day surgery at the local hospital. Care records contained details of health professional visits and the outcome. Service users confirmed they have access to a chiropodist. Medications systems were inspected. The Pharmacist Inspector for the Commission visited the home in August to provide advice and support to the Registered Manager. The Registered Manager is going to review the policy and procedure inline with the information given at this information. Records were seen of medication received into the home, administered and returned to the local pharmacy. All Medication Administration Records (MAR) were examined and a number of gaps were found in the recording, therefore it would be difficult to assess if the medications have been given or not. Several handwritten entries had been checked or signed by a second person and on one entry the dose had not been written. A number of service users are prescribed ‘prn’ or ‘as and when’ medication but the home needs to ensure care plans are in place for the use of these medications. Several service users self-medicate and consent forms were seen in their care records. Lockable facilities are provided in service users rooms. During the first day of the inspection the wheelchair lift had broken down in the main lounge therefore the staff could not get the trolley to the dining room and several service users rooms, however the member of staff ensured the safety of the medication during administration. On the second day of the inspection the lift had been repaired and the trolley could be taken to the dining room and service users rooms on this floor. The home has a lockable box for transporting medication to the one part of the home, as it is not accessible for the trolley. The home does not have any controlled medication only night sedation that is recorded in the controlled drugs register, which has been changed since the Pharmacist inspection. The home also has the correct storage facility. The home has purchased another medication cupboard for storage. Dates of opening were seen on all but two liquid medications and on stock medication. The Registered Manager orders all medication and the prescriptions are sent to the home prior to being sent to the Pharmacy. The home has an up to date drug reference book and specimen signature list. All staff that administer medication have undertaken an accredited course and training from the Pharmacy used by the home. Temperature checks are undertaken on the room and medication fridge and air conditioning has been fitted in this room. Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 13 Service users spoken with all said that the staff maintains their privacy and dignity. Service users are able to have their own telephones in their rooms if they wish. One service user said she likes to laugh and joke with the staff as it helps to pass the time. Dowty House DS0000016424.V317725.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 good. This judgement has been made using available evidence including a visit to this service. The home provides an activities programme for service users if they wish to attend, and contact with the local community is encouraged. The meals in this home are good, offering both variety and catering for special dietary needs. EVIDENCE: The home has posters around the home advertising activities planned that include outside entertainers. Activities undertaken by staff are recorded in a diary. On the second day of the inspection outside entertainers were visiting the home and the service users who were attending all appeared to be enjoying it. Service users said they could choose whether they take part in the planned activities or do their own thing. One service user has recently started computer lessons at the local college and the home now has a computer room. Several service users said they are able to go out alone and another service user was going out with their family during the second day of the inspection. The surveys received from service users prior to the inspection had a mixed response with some saying that they felt able to join in some activities but Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 15 others felt unable to do so. The Registered Manager said they ask service users what activities they like but the majority of able service users prefer to do their own. Links with the local community are encouraged and maintained; several service users are able to go out independently and staff said they take service users out to the local shops. One service user attends a day centre. Visiting to the home is not restricted and a number of visitors were at the home during the inspection. Service users confirmed they are able to make choices about their daily lives and this includes service users who need a high degree of care from staff. A service user who is visually impaired is able to make choices about where they spend their time. A number of service users smoke and the home has provided a comfortable nicely decorated lounge for them and one service user said they like to spend most of the day in this room. One service user said they like to go to bed late and get up late. Choices were offered at lunchtime for service users who do not like what is offered. Another service user said the staff make ‘special sandwiches’ for them to eat just before they go to bed. An inspection of the kitchen did not take place as the home has had a recent Environmental Health Visit and they have been awarded the ‘spa award’ for the third year running. The home has addressed the requirements issued from this visit. One service user helps to butter the bread for sandwiches most days. The cook and Registered Manager devise the menus. Service users are asked for their input on the meal and one service user confirmed that they speak to the cook about any changes they would like. Two mealtimes were observed and the inspector and Responsible Individual joined the service users for a meal on the second day. Both enjoyed the meal provided. The vast majority of feedback received from service users said they enjoy the food provided by the home. Mealtimes were seen to be a sociable event and staff offered assistance discreetly when required. Drinks were seen being offered to service users at regular intervals throughout the day and jugs of cold drinks were seen in service users rooms. Two service users were enjoying an alcoholic beverage at one mealtime, which one-service user said they enjoyed. Dowty House DS0000016424.V317725.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives can feel confident that their complaints will be listened to and acted upon. The home has arrangements in place for protecting service users from abuse. EVIDENCE: The home has not received any complaints. The Commission received an anonymous concern that was investigated and was not upheld. The home has copies of their complaints procedure displayed around the home. Results from service users surveys and from speaking to service users they all said they would approach the Registered Manager if they were unhappy about anything or if they had a complaint or concern. Relatives comments received from surveys stated that all but one have not had to make a complaint. The homes training matrix, staff and the Registered Manager all confirmed that they have received training in the protection of vulnerable adults. The home is to arrange this training for recently appointed staff. The home has policies in place for abuse, whistle blowing, aggression and harassment and the use of restraint. The home does not use restraint. No referrals have been made to the POVA list. The staff handbook is in the process of being updated and this will include several of the policies mentioned above. Dowty House DS0000016424.V317725.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, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing service users with an attractive, clean and homely place to live. EVIDENCE: A tour of the environment took place with a small number of service users rooms seen. The home has plans in place to refurbish several of the shower rooms and one has all ready been completed and they are planning to redecorate the main lounge at the beginning of next year. Service users rooms seen all had their personal belongings visible and all were very individual. A commode was seen in one service user’s room that needed to be disposed of as it was rusty in places and could be an infection control risk to the service user. The Registered Manager said this would be replaced immediately. Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 18 The majority of staff have undertaken infection control training and protective clothing is available in the home. Staff were seen wearing this when needed. Service users surveys and service users spoken with all said they felt the home is always clean and tidy. A comment received on a relative/visitors survey said the ‘home is always very clean and staff welcoming’. The home was very clean and no odours were found during both days of the inspection. Dowty House DS0000016424.V317725.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. Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. On the whole service users are protected and supported by the homes recruitment practice. EVIDENCE: The homes duty rotas were examined. The staffing numbers have not changed since the last inspection. The Registered Manager is looking to appoint a ‘general assistant’ to work from 9am – 1pm to help the care staff with bed making and giving out hot drinks each morning. Ancillary staff are also employed to assist the care staff in caring for the service users. Staff spoken with and from their surveys returned the vast majority said it was a nice place to work and they receive excellent support from the management team. One comment said there is not enough staff on nights, however the Registered Manager said the night staff do not undertake any other duties than to care for the service users. Service users all commented that the staff are friendly and helpful. The home has seventeen of their care staff with an NVQ 2 or above and three new staff about to start this training. Three staff members have just Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 20 completed the NVQ 3 training and one member of care staff is due to start this. The personnel files of three recently appointed staff were examined. All had the required checks undertaken as required by the Care Home Regulations. One staff member had left the home to work at another care home and then returned after a short period of time. The home has not undertaken another POVA/Criminal Records Bureau disclosure (CRB), however they obtained the other checks required by the Care Home Regulations and are going to get a copy of the POVA/CRB that was done at the other care home. The home must obtain a new POVA/CRB check for this member of staff due to the break in employment and supervise them until the CRB is returned. The Registered Manager said she would attend to this as a matter of urgency. The homes induction programme was examined and each new member of staff is allocated a supervisor and is supervised for up to three months. If the new member of staff has not undertaken care work before they use an outside training company’s induction as well as their own induction programme. Two recently appointed staff induction checklists were checked. The home has a good training programme for staff that includes the NVQ training and after they have completed the induction they are registered on the NVQ training. The home has a training matrix in place that lists all training undertaken by staff and when it is due again. This ensures that all staff are up to date with mandatory subjects and other training is also offered. Staff spoken with and from the surveys sent all said they are offered training. Other comments were ‘excellent training’, and ‘well trained staff’. Dowty House DS0000016424.V317725.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, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home are able to discharge their responsibilities fully ensuring the home is run in the best interests of the service users. The home reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of service users, staff and relatives. The home ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. EVIDENCE: There have been no changes to the management of the home since the previous inspection. All staff are aware of their job roles and will ask for Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 22 support. The Registered Manager keeps herself updated with training and records were seen of this. She has completed the NVQ 4 training. Service users spoken with and staff all said they could approach the Registered Manager if they had any concerns or the team of Deputy Managers. Prior to the inspection the home completed a quality assurance audit that involved obtaining the views of service users, visitors to the home and staff. An action plan has been drawn up to address these areas where improvements are needed. Copies of this report are available around the home. A monitoring form has been devised to record the areas that are audited by the staff in the home. The Registered Manager is going to devise a spreadsheet for monitoring accidents. The systems for managing service users personal allowances were examined. Records are maintained and receipts kept. Two senior staff each week check the records and monies to ensure they are correct. No issues were found. The Registered Manager is an appointee for three service users. Staff supervision records were examined and the Registered Manager has now delegated some of the care staff supervision to the Deputy Managers. The home is meeting the recommended six times per year for care staff. Records of supervision sessions of ancillary staff were seen. Records were seen of servicing of equipment to include electrical. The home has had a new boiler fitted this summer and has a contract in place to ensure they are running correctly. A Legionella check has been carried out this year. All records relating to fire equipment checks were up to date and this includes fire training. The home has completed their fire risk assessment. Monthly water temperature checks were seen and the home still needs to maintain records of when showerheads are washed out to reduce the risks of Legionella. A health and safety policy is in place and posters were seen around the home. First aid boxes are also available. Dowty House DS0000016424.V317725.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 3 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 X X X X 3 X 3 STAFFING Standard No Score 27 4 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 3 X 3 Dowty House DS0000016424.V317725.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 OP2 Regulation 5(b-bd) 1) Requirement The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include— (ba) the terms and conditions (other than those relating to fees) in respect of the provision to service users of accommodation (including the provision of food), personal care and (if available) nursing care; (bc) the arrangements in place for charging and paying for any services additional to those mentioned in sub-paragraphs (b) and (ba); (bd) a statement of Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 25 Timescale for action 01/03/07 whether any of the matters mentioned in sub-paragraphs (b) to (bc) would be different in circumstances where a service user’s care was being funded, in whole or in part, by a person other than the service user; 2. OP9 13(2) The Registered Person shall 30/01/07 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (This relates to care plans for ‘as and when needed medication’ and handwritten entries.) 30/01/07 The Registered Person shall not employ a person to work at the care home unless— Subject to paragraphs (6), (8) and (9), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. (This relates to a POVA/Criminal Records Bureau disclosure) 3. OP29 19 & Sch 2 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 OP7 Good Practice Recommendations The home should add any changes to service users longterm assessment that are also documented in the care DS0000016424.V317725.R01.S.doc Version 5.2 Page 26 Dowty House 2. 3. OP7 OP9 plans. The home should document the times service users wish to get up and go to bed in their care plans. Review the storage of some medicines for external use in bedrooms to make sure this is safe for everyone in the home. Provide refresher training about the safe handling of medicines. Review the medicine policy as advised by the pharmacist inspector. The home should document when the clean out the showerheads as directed to reduce the risks of Legionella. 4. 5. 6. OP9 OP9 OP38 Dowty House DS0000016424.V317725.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Dowty House DS0000016424.V317725.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. 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!