Inspection on 12/05/06 for Dungate Manor Care Home

This inspection was carried out on 12th May 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

Dungate Manor Care Home 21/10/08

Dungate Manor Care Home 30/10/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

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 Dungate Manor Care Home Dungate Manor Flanchford Road Reigate Heath Surrey RH2 8QT Lead Inspector Mavis Clahar Key Unannounced Inspection 12th May 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 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. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dungate Manor Care Home Address Dungate Manor Flanchford Road Reigate Heath Surrey RH2 8QT 01737 244149 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) Ashbourne (Eton) Limited Mrs Daksha Mistry Care Home 45 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (45), Physical disability over 65 years of age (5), Sensory Impairment over 65 years of age (5) Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 Brief Description of the Service: Dungate Manor is a care home for up to forty-five people. The home is situated in a peaceful, semi rural location, a few miles outside the town of Reigate and is next door to a golf course. Car parking is available to the front of the home. The home is a large Edwardian building set in extensive gardens to the front and rear. The building has been extended in the past to provide additional accommodation, and now offer a selection of bedrooms, the majority for single occupation and some with en-suite facilities. A small number of shared bedrooms are also available. The accommodation is arranged over three floors served by a lift and a basement. A choice of communal rooms, including a large lounge, a conservatory and a spacious dining room are provided on the ground floor. Fees at this home are in the range of £300.00 to £603.00 per week. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to March 2007 This unannounced inspection was carried out on the 12th May 2006 by Mrs Mavis Clahar and lasted seven hours. The home has been and still is undergoing major refurbishment. The first part of the inspection was spent touring the home and speaking with service users, observing carers interacting respectfully with service users, and speaking with carers. Service users said they were contented in their homes and that they had freedom to choose what they wanted to do. It was evident that service users and carers had a good relationship and this was confirmed when one service user was observed sharing a joke with her care worker. Time was spent with the Chef, reviewing the menu, discussing the nutritional needs of the service users and observing the preparation of the day’s mid-day meal. Time was also spent with the Activities Coordinator, discussing activities arranged for the service users, followed by time spent with the service users during their activities. A tour of the grounds was undertaken. Service users have good access to the beautiful grounds and some service users informed the inspector that they have daily walks weather permitting. The second part of the inspection was spent reviewing service users care notes and sampling care workers records. Some policies and procedures were also reviewed, in order to substantiate documented practices. The home has a good policy on receiving, storing, administering and dispensing of medication. It was noted that one carer was using her “pet” name to sign the Medication Administration Record sheet. An immediate requirement was issued for this practice to cease instantly The final part of the inspection was spent giving feedback about the inspection to the manager. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? Random sample of service users files demonstrated that assessments are fully completed to allow adequate care plan to be drawn, from which service users care needs are identified and met. Service users assessments of care needs are now being kept in their care files along with risk assessments, which are signed and dated either by the service user or their representative. The new company has replaced the Whistle blowing Policy with an up to date version. The home has purchased new bedspreads for all forty-five beds. The staff room on the first floor has been fitted with new carpets and the ceiling has been redecorated. The old dishwasher has been removed along with some cupboards and a new breakfast bar with high chairs is now in place. The home has purchased a new food mixer, a new robot coupe (which liquidises, grates and slices food) and a new meat slicer. The dining room has been refurbished. The laundry has also been refurbished with two new washers and two new driers. A new stand aid hoist has also been purchased. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 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. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 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 Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information was obtained from prospective service users prior to them being admitted to the home. This allowed for carers and service users to make informed decision regarding the planning and delivery of care. Standard 6. The home caters for service users within this range but on the day of inspection there were no service user in this category. However, the home has demonstrated that they are able to fulfil the assessed needs of these service users. EVIDENCE: Random sample of service users files, care plans and daily work sheet, along with selected case tracking has demonstrated the homes ability to assess service users needs. This was supported by discussion with the manager, the key worker and the service users themselves. Discussions with carers have shown care workers had the knowledge suitable to meet the care needs of the service users in their care. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now has a good and clear care plan in place for service users. This care plan also includes appropriate risk assessments. This forms the basis for sound care based on the agreed care needs of the service users. The home’s medication Policy on receiving, storing administering and return of medication was in place, but this has not been fully adhered to. EVIDENCE: The randomly selected care plans were clear and easy to read, identifying potential and actual risks to service users. The daily work sheet along with discussion with service users demonstrated that service users care needs are fully met. No service user at the time of inspection was responsible for their medication, but the manager was knowledgeable about what to do should this situation arise. Good clear records are kept of medication receipts, storage, Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 11 administration and returns. It was noted that one carer used her “pet” name to sign the medication records. A requirement was issued on this standard to cease this practice immediately. There were no visitors to the home to speak with the inspector, but service users spoken to, rated the personal care they receive at the home as very good. Most of them said they were contented, they had enough to eat and can do as they like. They said the staff are very friendly and “this is a good place to be.” Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. 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. Service users spoken to were complimentary about their home, the care they receive and their life styles within the home and community, and the choice and variety of meals. EVIDENCE: The home employs two Activities Coordinators who provide a full programme of activities on a one to one basis, in small groups of two to four and in larger groups. This allows every one to have a choice in what they want to do. The day of the inspection was a very busy day. Some of the ladies were at the hairdressers, whilst others were busy with their painting. The inspector spent a longer time with the painting group, as it was easier to speak with these service users than those under the drier. Service users said they were satisfied with their activities and that they choose what to do. Some said they look forward to the church services and some said they tried to go out with their family on a weekly basis to keep up with the outside world. One service user drives herself to the shops and to visit her friends and family. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 13 The inspector did not sample the food, but the service users said the food is good, and plentiful. In discussion with the Chef, it was apparent she was knowledgeable about the dietary needs of the service users and prepared their food to their tastes. The Chef operates from a four-week menu with the summer menu being discussed with service user now. There is always a choice of two hot meals per day at mid-day, or salad at mid-day or the service user can choose their own food e.g. omelette etc. The evening meal is always soup followed by hot meal or sandwiches filled with service users choice. There were ample amount of fresh fruit, dry food and frozen food available in the home. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints policy and procedure with evidence that service users views are listened to and acted upon. Robust POVA policies are in place to protect the service users from abuse. EVIDENCE: The random sample of staff training files and discussions with staff evidenced that staff are being trained on recognising and reporting acts or suspicion of abuse. The new whistle blowing policy is now in place, and staff are signing it as they read it. Complaints received in the home are logged with their outcomes. This demonstrated that service users and relatives complaints are taken seriously and are dealt with within the company’s time frame. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 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 in this home is satisfactory. A programme of refurbishment and maintenance is in progress. EVIDENCE: Although there is continuous refurbishment and maintenance in progress at the home the service users are not in any danger. The home presents as comfortable with lovely gardens back and front, which are well maintained. There is good access to the gardens from various parts of the home. Some service users informed the inspector that they try to go out daily to enjoy the garden weather permitting. Adverse weather would not stop service users enjoying the garden, as the windows are low enough to allow service users to view the gardens from their armchairs in the lounge, conservatory and dining room. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 16 The manager informed the inspector that she is now waiting for a date and time for the engineers to deliver and install the sanilav pump for the toilet in the first floor bathroom. Generally, the home presents as clean, pleasant and hygienic. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. 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 standard of vetting and recruitment practices are good with appropriate checks on the suitability of staff being carried out thereby ensuring service users are being protected and their needs can be met. The staff rota for the month showed the number of staff on duty day and night and in what capacity; ensuring that service users are in safe hands over the twenty-four hour period. The manager ensures that staff are trained and updated regularly to meet the assessed needs of the service users. EVIDENCE: The staff rota demonstrated the number and grade of staff on duty for any twenty-four hour period, Currently the home employs over 50 of carers with National Vocational Qualification (NVQ) Level 2 and above in care. There are a number of care workers currently undertaking the NVQ course. No staff providing personal care to service users is under the age of twenty-one years. Domestic staff and maintenance staff are employed in sufficient numbers to ensure the safety of service users in this home. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 18 Recruitment of staff to the home is through a process of equal opportunity, and in accordance with the code of conduct and practice set by the GSCC. All staff are CRB and POVA checked prior to commencing employment and they are in receipt of terms and conditions of employment, as evidenced in their randomly reviewed personal files. There was evidence in staff’s personal files that they are supervised on a one to one basis, and new member of staff have completed an induction programme. The homes training programme for care worksers for the year 2006/2007 was discussed. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. 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 manager fosters an atmosphere of openness and respect in which service users and staff all feel valued and that their opinions matter. The home does not become involved in any aspect of service users finance. Service users are consulted about their health and personal care, interests and preferences. EVIDENCE: The manager has demonstrated that she has kept herself updated on issues relating to care of the service users and staff in her charge. She has attained the Registered Managers Award and also the National Vocational Qualification Level 4 in care. In discussion with the manager it was evident she was knowledgeable about the care needs of the service users and the training Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 20 needs of the care workers to meet these identified needs. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. The yearly Quality Audit was not yet been completed for this year. However, documentation was available to show that service users are encouraged to give their opinions on the running of the home. Service users whilst speaking with the inspector further supported this. The home does not become involved in service users finance Random sample of care workers training files demonstrated that up to date and relevant training were carried out by care workers to protect service users health and welfare. In discussion with care workers it was good to hear they had an understanding and implementation of appropriate procedures to safe guard service users. Further more, they spoke about their understanding of promoting safe working practices based on their health and safety training. The manager ensures the health and safety of service users and carers by securing safe storage and disposal of hazardous substances, regular servicing of boilers and central heating systems, which is under contract. All incidents of illness, accidents and injuries are recorded and reported to CSCi in a timely fashion. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 21 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 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 X 3 X X 3 Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 22 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) Requirement The Registered person ensures that staff adheres to the home’s policy on recording of medication. Pet names should not be used when recording medication. Timescale for action 12/05/06 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 OP33 Good Practice Recommendations The registered manager is to place a copy of the most recent inspection report in the carers station, to allow carers to see how their work is reflected. Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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 Dungate Manor Care Home DS0000066321.V294775.R01.S.doc Version 5.1 Page 24 - 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. 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