Inspection on 27/06/08 for Dulverton House

This inspection was carried out on 27th June 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dulverton House 15/09/06

Dulverton House 24/11/05

Dulverton House 26/04/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dulverton House 9 Granville Square Scarborough North Yorkshire YO11 2QZ Lead Inspector Ray Burton Key Unannounced Inspection 10:00 27th June 2008 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dulverton House DS0000062423.V368705.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. Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dulverton House Address 9 Granville Square Scarborough North Yorkshire YO11 2QZ 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) 01723 352227 F/P01723 352227 angelawebster@yahoo.co.uk Dr Khalid Hussain Javed Dr Mussarat Javed Care Home 22 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (22) of places Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users up to 22 (OP) and up to 5 (DE(E)) up to a maximum of 22 service users 15th September 2006 Date of last inspection Brief Description of the Service: Dulverton House is a large detached building situated in a residential area of the town. A former dwelling house and hotel, it has been adapted to provide accommodation for a maximum of 22 residents. Its location makes it convenient for access to local facilities and amenities and to the town centre by public transport. Resident’s accommodation is situated across 4 floors all served by a passenger lift. The lower ground area is use solely by staff and is where the office, kitchen, laundry and staff areas are situated. Communal rooms are situated on the ground floor together with some resident’s private accommodation. The rest of the bedrooms are located on the upper floors. Some bedrooms have an en-suite facility and there are ample communal bathrooms and toilets on each level that are accessible to residents. The home’s well-maintained garden, which has level access from the dining room and front of the house, provides sunny and shaded areas and appropriate seating for residents and visitors. Dulverton House is registered for 22 people over 65 year up to 5 of who may have a dementia type condition. Current fees are £341.00 to £372.00 a week. Additional charges are made for hairdressing, chiropody, toiletries, papers and magazines. Information about the services provided are made available in the home’s Statement of Purpose, Service Users Guide and through published inspection reports available from the home Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection covering all of the key standards of the National Minimum Standards for Care Homes for Older People. It commenced on 27th June 2008 and was completed on 10th July 2008. The inspector was accompanied for part of the inspection by a pharmacy inspector from the Commission for Social Care Inspection. During the inspection the inspector looked around the home, examined various records and spoke to the people living there as well as the proprietor, manager and members of staff. The pharmacy inspector conducted a detailed audit of the medication systems in the home. What the service does well: What has improved since the last inspection? What they could do better: There were several areas requiring improvement identified during the course of the inspection: • The storage and administration of medicines need to be improved so that there is less chance of mistakes happening. Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 6 • • • Care plans need to be further developed so that they contain all of the information necessary for the delivery of peoples care. Risk assessments need to be carried out to make sure that all areas of the home are safe. The manager needs to apply to become registered with the Commission for Social Care Inspection. 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. Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 7 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 Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 8 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, 3, 4, 5. People who use this service experience good quality outcomes in this area. Prospective residents are given information prior to admission to enable them to make an informed decision about the suitability of the home and its ability to meet their needs. The homes assessment procedure ensured no one would be admitted unless his or her needs could be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The homes statement of purpose and service users guide informed prospective residents and their families about the facilities available at Dulverton House. The manager said that a thorough pre-admission assessment was conducted by staff at the home with the co-operation and involvement of the prospective resident, his/her next of kin and appropriate healthcare professionals. Where a referral had been made by a Social Services Department a care manager’s assessment was also obtained. Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 9 Prior to admission, prospective residents and their families were invited to make one or more visits to look around the home, share a meal and meet members of staff and the people already living there. A care plan showed how, following a visit with her daughter, a prospective resident visited the home once a week for “day care”. This transition period, lasting approximately six weeks, allowed the person to get to know the home and the people living and working there and overcome the fears she had about moving into residential care. If a prospective resident were unable to visit the home the manager would visit the person in his/her own home or in hospital so that a pre-admission assessment could be carried out to determine if the home would be able to meet the persons needs. Following admission there was a trial period during which time a new resident was able to decide if they wished to continue to live at Dulverton House. The home does not offer intermediate care therefore standard 6 does not apply. Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 10 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, 11. People who use this service experience poor quality outcomes in this area. There are poor systems for the accurate administration, recording and storage of medicines. This puts people at risk of not receiving their medication safely and as prescribed. This may have an effect on their health and wellbeing. Care plans require further development so that they set out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The manager and members of staff had extensive knowledge of the social and healthcare needs of the people living in the home and were able to say how those needs were met; however that knowledge had not always been fully recorded in care plans. Examination of four care plans revealed further development was required to ensure each plan contained all available relevant Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 11 information that would help provide a comprehensive picture of the resident and assist staff to deliver support in the way that was wished by the individual. The homes recently implemented care planning document was very detailed however, of the four plans which were examined, none had not been dated or signed by the member of staff responsible for formulating the plan or by the resident to signify his/her involvement with, and agreement to, the plan. Assessments had been conducted in all areas of daily living; however these had not always been developed to show what action had been taken to meet an identified need. Risk assessments had been conducted however they were not always sufficiently detailed and did not fully explore identified risks to enable suitable risk management strategies to be put in place. It was observed during the inspection that residents were treated with respect and addressed courteously and appropriately. In conversation residents said they were very happy with the way in which support was given and felt that staff were friendly and respectful towards them and delivered care, especially personal care, in a way that ensured dignity and privacy was preserved. Policies and procedures were in place dealing with the care of residents during their final days; staff had received training in palliative care and spoke with sensitivity about the needs of people during the final stages of their lives. As part of this key inspection a CSCI pharmacist inspector carried out an inspection of the medication systems; her findings were as follows: “The current Medication Administration Record (MAR) charts were looked at. There is a list of staff authorised to administer medicines and examples of their signatures. This means it is possible to identify who was involved in administration if a query or problem occurred. There are no dividers between the MAR charts. Having dividers between MAR charts helps to reduce the risk of the medication being given to the wrong person. There is inconsistency in the recording of the quantity of medication supplied and the date received. The quantity of medication from one monthly cycle to another is not recorded on the new MAR. This means it is difficult to have a complete record of medication within the home and to check if medication is being administered correctly. The standard of handwritten entries and changes to medication was poor. One MAR chart had no dates recorded to show when the medication had been given. Another chart had medication changed from tablets to liquid form. The changes were poorly written which made them difficult to read. This means there is a risk that staff may misread the directions and give the incorrect Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 12 medication or dose. To make sure there is an accurate record the quantity supplied, the date of entry, the signature of the person making the entry and a witness signature where possible should be included. Similar requirements are needed for a change of dose or cancelled medicines. Details of the person authorising the change should also be included. This makes sure that there is an accurate record of the details for medicine administration. The standard of accurate record keeping is poor; there were a large number of gaps on the MAR charts. To demonstrate that people are getting the medication as prescribed the MAR chart should record each administration. One MAR chart had medication not given because there was no stock available. A system must be in place to make sure that medication is available to prevent people being without. There was medication found that was out of date. Medication for people no longer living at the home was also found. This means there is a risk that people may be receiving medication that may no longer be safe or work properly. This may have an effect on how their medical condition responds. A box of diamorphine ampoules was found in the trolley. This medication is known as a controlled drug and a record must be made in the controlled drugs register. The ordering of prescriptions is the responsibility of one of the senior carers. The person in charge of ordering medication must have sight of the prescriptions before a supply is made. The prescription is the authority for the staff to administer medication to the person. This also provides an opportunity to check if any new medicines or dose changes are included. Any problems with prescriptions can be addressed at this point rather than after the supply has been made. The checking of prescriptions is an important part of the management of medication.” Dulverton House DS0000062423.V368705.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. People who use this service experience good quality outcomes in this area. The routines of daily living and activities made available are flexible and varied to suit individual expectations and preferences We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: It was apparent from observation and conversation with members of staff and the people living in the home that there was a relaxed and friendly atmosphere with residents being encouraged to exercise personal choice and maintain control over their lives. Meals were served in the dining room at set times, however there was a great deal of flexibility to allow for individual wishes and circumstances; meals could be taken in the privacy of a person’s own room. Examination of the record of meals served revealed a healthy, balanced and varied diet was provided. Meals were attractively presented and alternatives were available should anyone not wish to have the dish of the day. Residents confirmed the food was good, with plenty of variety. Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 14 One gentleman told the inspector that the meals were very good with plenty of choice; he said he suffered from diabetes however he was always provided with a suitable diet. He said: “The staff are very helpful and meet my every need. The manager is very good, this is a very good place and I would not wish to be anywhere else.” The home employed the services of a diversional therapist twice a week and various regular activities e.g. quoits; indoor bowls; dominoes; quizzes; arts & crafts etc were organised. Occasional events such as concerts at a local college and a coach trip and picnic were also organised. In addition links had been made with a local junior school with children from the school occasionally visiting the home, and residents attending the school for an annual Christmas party. Whilst encouraging residents to take part in organised activities staff spoke of setting aside time each day to spend quality time with residents to encourage individual activities such as going for a walk to the local shops, providing a manicure, aromatherapy sessions or merely chatting. Some of the people living in the home had developed new interests or had continued to pursue past hobbies; one had expressed an interest in gardening and had been provided with an area of the garden where he could grow vegetables, two were accomplished water-colourists and their paintings were displayed in their rooms and throughout the home. One of the residents was a member of a local art club. On one of the days of the inspection a resident was seen to be practicing his computer skills on the office computer, assisted by the manager. Residents said they could receive visitors at any time and were able to talk with them in private. Local clergy visited so that people living in the home could take part in an act of religious worship if they wished. Dulverton House DS0000062423.V368705.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, 17, 18. People who use this service experience good quality outcomes in this area. The home has appropriate policies and procedures in place in relation to the protection of vulnerable adults and for dealing with complaints. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home had a suitable complaints procedure, stating how complaints could be made, who would deal with them, the timescale for the process and what to do if not satisfied with the way in which the matter had been handled. There had been no complaints received since the last inspection. The inspector spoke with several residents, all of whom expressed satisfaction with the general running of the home and with the way in which they were cared for. They said they did not have any complaints but would know what to do and who to see if they were unhappy about anything and were confident that any concerns they might have would be quickly and satisfactorily addressed. A residents meeting was held every two months at which people living in the home were encouraged to discuss any concerns, requests or suggestions they might have to improve the quality of life in the home. Policies and procedures were in place to ensure the safety and protection of the people living in the home and to respond to any suspicion or allegation of abuse. The manager said that 50 of staff had received “safeguarding” Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 16 training. It is important that training for the remainder of staff members takes place as soon as possible. Dulverton House DS0000062423.V368705.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, 20, 21, 22, 23, 24, 25, 26. People who use this service experience good quality outcomes in this area. The environmental standard is good, providing the people who live there with an attractive and homely place in which to live. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The internal and external fabric and décor of the building was maintained in good condition and the home was clean, hygienic and free from offensive odours. Dulverton House has been recently refurbished to a high standard and provides a very pleasant and homely environment for the people who live there, improvements include: redecorating of communal rooms, new carpets, new lounge and dining room furniture, improvements to the kitchen, new bathroom Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 18 fittings including specialist disability equipment. New fire doors fitted to each bedroom. As part of the recent refurbishment several bedrooms had been redecorated, and all were comfortably and appropriately furnished, seven had en-suite facilities and those without had been provided with a wash hand basin; all had been personalised by the inclusion of small items of furniture and other effects such as pictures, ornaments and photographs brought from the occupants own home. Sufficient suitable lavatories, washing facilities and specialist disability equipment were available and were easily accessible. All areas of the home were centrally heated and radiators had been covered with suitable guards to ensure a safe surface temperature. Hot water outlets accessible to residents had been fitted with regulators to guard against scalding; regular water temperature checks were undertaken. Health & safety documentation was up-to-date. Records showed regular checks and servicing was undertaken of all equipment. Fire safety records were properly maintained. The home has a very pleasant and well maintained garden that is easily accessible from the house via French windows; seating areas had been provided and the area provides a comfortable and congenial outside space for residents’ to enjoy. Although the general environment was good there were some areas of concern requiring the urgent attention of the provider: • The staircase leading to the basement area, which is accessed via an unlocked door in the hallway, poses a risk to any resident who is confused or unsteady on their feet; a risk assessment must be conducted and suitable action taken to ensure the safety of the people living in the home. Various windows above ground floor level had not been fitted with devices restricting the opening. Risk assessments must be conducted and suitable action taken to ensure the safety of people living in the home. The two open fires and gas fire in the communal areas must be properly risk assessed and suitable action taken to ensure the safety of people living in the home. A final exit fire door was secured by a lock, bolt and chain. The manager must consult with the fire safety officer to ensure all fire regulations are met. • • • Dulverton House DS0000062423.V368705.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. People who use this service experience good quality outcomes in this area. Staff are employed in sufficient numbers, and with suitable skills and training to meet the needs of the people living in the home. The home operates an appropriate recruitment procedure. We have made this judgement using a range of evidence, including a visit to the service This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the days of the inspection staff were employed in sufficient numbers to meet the assessed needs of the people living in the home. Staffing rosters showed appropriate staffing levels were maintained at all times. Five personnel files were examined, each contained evidence that all necessary checks, including Criminal Records Bureau (CRB), were carried out and satisfactory references obtained prior to commencement of employment. All newly appointed members of staff received induction training that met the “Common Induction Standards”. Personnel files and staff interviews revealed all received mandatory training and were encouraged to undertake further training to aid their professional development and help them meet the needs of the people living in the home. Of the twelve permanent members of care staff eight were qualified to a minimum of NVQ level 2 in Care and one was Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 20 currently working on her portfolio to achieve the award. None-care staff were also encouraged to work towards achieving qualifications; the cook was currently undertaking the NVQ level 2 in Professional Cooking and the Housekeeper was shortly to commence an appropriate course at NVQ level 2. Dulverton House DS0000062423.V368705.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, 34, 35, 36, 37, 38. People who use this service experience adequate quality outcomes in this area. Management systems and record keeping require further development and improvement to ensure the safety and wellbeing of people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Dulverton House provides a high level of accommodation and a good quality of care for the people who live there. The provider, manager and staff work hard to deliver a service that is very user focused; attention is given to individual needs and preferences and it is apparent that people living in the home are treated as individuals and encouraged to lead lives that reflect their interests and wishes. Residents told the inspector they were satisfied with the care they received and found the manager and staff very pleasant and helpful; they said Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 22 they felt Dulverton House was a good home. A quality management system has recently been introduced to help measure success in meeting the aims, objectives and statement of purpose of the home. The manager has been in post since 2005 but has not yet been registered as manager with the Commission for Social Care Inspection; an application should be submitted as a matter of urgency. Although she does not hold the required qualifications in care or in management the manager said she has recently embarked on a course of study that will lead to her becoming qualified. When interviewed, members of staff said they found the manager approachable and supportive. People living in the home were encouraged to look after their own money and valuables; however some monies were held by the home, for safekeeping. Appropriate records were kept of all financial transactions. Examination of personnel files and conversation with members of staff and the manager revealed that although some formal supervision took place it was not of sufficient frequency to meet the National Minimum Standards. Examination of record keeping showed improvement and further development was needed in some areas to ensure the safety and wellbeing of the people living in the home; particularly with regard to medication, care planning and the assessment and management of risk. The manager must ensure that environmental risk assessments are conducted, are regularly updated and any required action taken to ensure the safety of the people living and working in the home; particular attention must be paid to the issues raised in the environment section of this report. The manager and proprietor showed an eagerness to address all of the identified problem areas and were able to produce an action plan showing how they planned to undertake the work. Dulverton House DS0000062423.V368705.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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 2 2 2 Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 25 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 1 OP38 13(4) Risk assessments must be 10/07/08 conducted on the staircase leading to the basement area and appropriate action taken to ensure the safety of people living in the home. 2 OP38 13(4) Risk assessments must be 10/07/08 conducted on the two open fires and gas fire and appropriate action taken to ensure the safety of people living in the home. 3 OP38 13(4) The provider must consult with 10/07/08 the Fire Safety Officer of the local Fire Authority to ensure all fire regulations are met, in particular with regard to final exit fire doors. 4 OP38 13(4) The registered person must ensure that all fully opening 10/07/08 windows are assessed in respect to their safe use. (original timescale for action 30/09/06) 5 OP9 13(2) All medication must be stored 10/07/08 safely and administered as prescribed. Accurate records must be kept for all medicines including controlled drugs. This will make sure that people receive their medications correctly and safely. Handwritten entries and changes to MAR charts must be accurately recorded and detailed. This makes sure that the correct information and dose is recorded so a person receives their medication as prescribed. Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 26 6 7 OP31 OP36 9(b)(i) 18(2) 8 OP7 15 The manager must achieve suitable qualifications in both management and in care The manager must ensure that a system is put in place to ensure each member of staff receives a minimum of six formal supervision sessions each year Care plans must be developed to include all relevant available information that would provide a more comprehensive picture of the resident to help staff deliver support in the way that the individual wished. Risk assessments in care plans must be more detailed and include strategies to eliminate or minimise risk. 31/03/09 10/07/08 30/09/08 13(4)(c) 31/08/08 Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 27 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 Medication carried over from the previous month should be recorded on the MAR chart. This helps to know exactly how much medication is held and when checking that it has been given correctly. Regular monthly prescriptions should be seen before sending to the pharmacy. This makes sure a check can be made that all the medicines required have been listed and prevents people from being without. The quantity of medication that is used from one monthly cycle to another should be recorded on the new MAR. This makes sure there is a method of tracking how much medication has been administered and to know how much stock there is. Dulverton House DS0000062423.V368705.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Dulverton House DS0000062423.V368705.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!