Inspection on 30/10/07 for Dungate Manor Care Home

This inspection was carried out on 30th October 2007.

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 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 12/05/06

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 Lisa Johnson Unannounced Inspection 08:55 30 October 2007 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 Dungate Manor Care Home DS0000066321.V353237.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. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 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) dungatemanor@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited vacant post 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.V353237.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th May 2006 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 £600- £700 per week. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The visit was unannounced and took place over nine hours commencing at eight fifty five am and finishing at six pm. Mrs. L Johnson Regulation Inspector carried out the visit. We spoke with five people who live in the service to gain their views on the care received. Four surveys were received from people who use the service, eleven from relatives and two surveys were received from health care professionals and comments are reflected throughout this report Prior to this visit the acting manager supplied information in an Annual Quality Assurance Assessment (AQAA), which is reflected throughout this report. During the site visit a tour of the premises took place. Care plans; staff training and recruitment records, and policies and procedures were sampled. We also spoke with four members of staff We would like to thank the people living in the service and staff for their time, assistance and hospitality during this visit. What the service does well: During this visit people living in the service were provided with well balanced and presented meals and people spoken with said that they enjoyed their meals. Comments received included “the meals are good”; “The food is excellent” and “the chef is very helpful if the main meal is not to my liking” The home provides a warm, welcoming and relaxed atmosphere and comments received included, “The home creates a cheerful environment and the home has an atmosphere of friendliness and caring which extends to relatives and helps create a real home”: “the staff are very friendly and marvellous” and “Staff spend a lot of time chatting with residents and treating them as individuals”. During this visit staff were observed to be talking to people with courtesy and respect and a number of positive comments were received about the care provided including, “ The home does very well in all aspects of care and puts the residents needs first” and “I think the care and support is outstandingly high”. A number of bedrooms were viewed during this visit, which were clean and comfortable, personalised, and some have ensuite showers. A relative Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 6 surveyed said, “ My relatives room and the home in general is clean and well kept”, and People spoken with during this visit said that that enjoyed the nice views from the home across the countryside and the local golf course. What has improved since the last inspection? What they could do better: During this visit two out of three individual care plans had not been signed by people using the service and or their representatives therefore it is required that individuals and/or their representatives are consulted about their care and support needs. It is advised that life histories be obtained, as there were some gaps. Permission for the use of bed rails must be gained from people living in the service and or their representatives, which must be recorded on the risk plan. It is recommended that the home follow good practice guidelines in respect of the administration of medication. The home is advised to consult with people who use the service about their preferred activities and review the present suitability of the activities for people with dementia. It is recommended that where meal choices are available this should be recorded on the homes menu. It is recommended that staffing arrangements be reviewed during mealtimes ensuring that people who require support with eating are supported and that they are also provided with condiments with their meals. It is recommended that the contact details of the Commission must be included in the homes complaints procedure which must be made available to people using the service and their representatives. In consultation with people using the service written records must be documented of their personal property and valuables, as there were gaps in some individuals records ensuring their protection. Information must be made available to the Commission for the timescales of the redecoration programme in the home ensuring people living in the home have a comfortable and well maintained home to live in. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 7 All staff application forms must record the applicants past work history ensuring that the safety and wellbeing of people living in the service is protected. It is recommended that the appointed manager submit an application to register with us Feedback surveys must be updated to gain the views of people living in the home and their representatives ensuring that that the home is run in their best interests. The driveway must be resurfaced ensuring the health and safety of people living in the home and visitors. During this visit a freestanding heater was observed in the conservatory, which had not been, risk assessed. This matter was responded to during this visit. 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. Dungate Manor Care Home DS0000066321.V353237.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 Dungate Manor Care Home DS0000066321.V353237.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): 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that each person is provided with a written contact. Pre admission assessments are completed prior to admission to the home. The home does not support people for intermediate care. EVIDENCE: The home has an admission policy in place. Pre-admission assessments are conducted and these were sampled for three individuals. Although there was evidence of a community care assessment and health reports two out of three pre- admission assessments were not available and it was recommended that copies of these documents are placed with individuals files for viewing. The pre- admission assessment viewed for a third individual covered all areas of care and support. Prospective people moving into the service are able to visit the home and stay for a meal. People using the service are issued with a contact detailing the terms and conditions of the home. Two contracts were sampled which had been agreed Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 10 and signed by people or their relatives and by the home. The home admits people for short term respite care but does not provide intermediate care Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Each person is provided with an individual care plan, which details the individual’s health, personal, emotional and social needs. People’s health care needs are met, although one matter was identified needing attention. People living in the service protected by the homes medication policy and they are treated with respect and their right to privacy is respected. EVIDENCE: Three individual care plans were sampled during this visit. Each person had a completed plan, which contained a photograph, and it was evident that monthly reviews are completed. A new person had a completed six monthly review. Plans were based on assessment covering physical, health, emotional and social needs and clear goals and objectives were recorded. Daily records were sampled which were appropriately recorded and detailed. Life histories are recorded for individuals but there were some gaps in acquiring this information and the home is advised to complete these. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 12 Six out of eleven relatives say that the home meets the needs of their relatives and five said usually. Six out of eleven relatives say that the home keeps in touch with them, four say usually and one said sometimes. Comments received in respect of this matter included, “The home keeps me informed of major changes but does not keep me informed of minor incidents: “ “I don’t get enough information about my relatives and how their needs are being met” and “the home did not contact me when my relative was ill”. During discussion with the acting manager and from records viewed some relatives have not been invited to review meetings and two out of three care plans sampled had not been signed or agreed by people living in the service and/or their relatives to confirm that they had been consulted, therefore it was required that people using the service and/or their representatives are consulted about their care plan and that plans must be signed by them to confirm their agreement. People living in the service are registered with a GP and specialist health care professionals are accessed through the practice including district nurses. During this visit one person received a visit from a physiotherapist and the GP was carrying out consultations. Four out five people surveyed said that they received the medical support that they require and one person said usually. Health care professionals surveyed stated that specialist advice given is incorporated into the care plan and one person commented, “Since the new manager has taken over care provision has improved again to a satisfactory level”. The health needs of people were documented in their care plan this included evidence that dependency levels, pressure ulcer, nutritional, and moving and handling is recorded. Risk plans were in place for individuals identified at risk of falls, which was incorporated into the care plan, which are reviewed monthly. Two individuals were identified as having high care needs. Weight records were regularly recorded and where individuals were identified as having poor dietary and fluid intake monitoring charts were in place. Individuals identified at risk of developing pressure areas are provided with specialist equipment such as pressure relieving mattresses and cushions with Regular links are maintained with district nurses who also keep records in the home. One individual was observed to have bed rails in place and a risk assessment had been completed, although this had not been signed by the person and or their representatives to gain their permission, therefore a requirement was made that this matter is attended to. During this visit staff were observed to speak to people with respect and courtesy and they were observed knocking on bedroom doors. One person spoken with during this visit said that staff respect his privacy but on the odd occasion this has not happened and he has raised this with the person concerned at the time. A survey received from a relative stated that their Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 13 female’s relative had been supported by a male member of staff with having a bath. It is advised that people using the service are consulted about their preferences for assistance, which should be recorded in their care plan. During this visit the laundry area was viewed with people being provided with their own-labelled laundry basket for their laundry and we were told that all individuals have their own clothing, which is either labelled, by the home or by relatives. One relative surveyed said that on occasions their relative had worn clothes that did not belong to her. This matter was raised with the acting manager. During this visit people living in the service were appropriately dressed and clean. One individual said that staff assisted her with putting on her makeup which she enjoys wearing. A relative surveyed commented, “ The staff look after my relative well and she is always clean and well dressed”. Two health care professionals surveyed state that they are to visit their patients in private. Five people spoken with during this visit said they were happy with the care and attitude of the staff and comments included, “helpful”;” very caring and “Kind”. Relatives surveyed comments included, “ staff spend time chatting with people and treating them as individuals”;” the staffs caring attitude is excellent” and “the home creates a cheerful environment and has an atmosphere of friendliness and caring and this extends to relatives and creates a real home”. The home has a medication policy in place. Photographs were available with individual’s medication administration records and a list was maintained for all staff that are trained and authorized to administer medication. Records were maintained for the receipt and disposal of medication. One person had chosen to self medicate and a risk assessment had been completed. The medication arrangements in place were mainly satisfactory although it is recommended that where staff hand transcribes medication on to the medication record this should be checked signed and dated by two members that follow good practice guidelines. Staff receive training both internal training and training provided by the local chemist. Records were sampled for controlled medication, which were appropriately maintained. Medication was stored appropriately and temperature records were maintained for medication stored in the fridge. Dungate Manor Care Home DS0000066321.V353237.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 is able to demonstrate that people using the service have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. People using the service are supported to make choices and individual preferences and they receive well-presented and balanced meals. EVIDENCE: The home has an activities programme in place and activities organiser is employed who was not available to speak to during this visit. Activities provided include painting, exercises, quizzes, and classical music with occasional entertainers visiting. During this visit one person was attending to leave for day services and a pets for therapy dog was visiting. A hairdresser was visiting the home and a mobile library attends the home. One person spoken with said that he goes for walks in the local area and visits the shop and another person spoken with said that he goes out in his car. A forthcoming firework celebration had also been organised. The home facilitates Holy Communion, which meets the religious needs of people currently using the service. Information supplied in the AQAA states that all cultural and religious Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 15 beliefs would be respected. A relative surveyed said, “Staff take care to find out what peoples interests are”. Two positive comments were received about one member of staff who is helpful in providing necessary journeys for example going to the bank. People spoken with during this visit said that they were satisfied with the activities on offer. Although responses from surveys received from four people using the service were mixed including, “more trips” and limited activities for people with physical limitations and a relative commented, “ More could be done to provide physical and mental stimulation”. The home supports a number of people with dementia and the manager is advised to review the activities provided and to gain feedback through providing up to date surveys from people using the service and gaining their views ensuring that the current activities meets their needs and preferences. The manager has identified that that the home would benefit from having access a minibus to increase community contact. People maintain contact with their relatives and friends. During this visit relatives were seen visiting the home. Two people spoken with said that they are able to see their visitors in private. One person spoken with said that he drives to see his family. People moving into the service are provided with the opportunity to bring in their own furniture and possessions, which were seen during a tour of the home. A care plan sampled documented where choice making was supported for example choosing clothes and people are supported to vote in the elections. The home provides four weekly menus and nutritional records are maintained. We spoke with the cook who said that she visits and discusses menus and preferences with people living in the home on a daily basis. Fresh meat, vegetables and fruit are acquired and the chef stated she has attended appropriate training and qualifications in food hygiene and nutrition. Choices are accommodated, although it was recommended that this should be recorded on the menu. Five people spoken with during this visit said that they were satisfied with the meals provided comments received included, “the food is excellent” and “the chef is very helpful when the food is not to my liking”. The lunchtime meal was well prepared, well balanced and nutritious. One person was observed to have a sandwich, which met their preference. A hot meal is served again for supper. Breakfast is served on trays in bedrooms and a cooked breakfast can be provided if requested. The meal was served in the dining room, which creates a pleasant, relaxed, homely environment, and tables were nicely laid with condiments and refreshments. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 16 The lunchtime meal is served in two sittings ensuring that sufficient numbers of staff are available to provide support to people who require assistance with eating. Staff were observed to provide appropriate support by sitting and interacting with people, although one person had been left unattended and was using the wrong utensil to eat her desert, which was bought to the attention of the manager who was advised to review the staffing arrangements at mealtimes. It was also recommended that people who require assistance with their meals be offered condiments with their meals ensuring their choice and preferences are accommodated. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement is needed ensuring that people living in the service and their representatives have access to an effective complaints procedure and that their views are listened to and acted upon. Policies and procedures are in place, which in the main protects people from abuse with one matter identified needing attention. EVIDENCE: The home provides a complaints procedure, which is available with the service user guide and displayed in the reception area, which did not document the contact details of the Commission therefore it is required that this information is recorded should any individual wish to contact us. Since the previous visit we have received no complaints. One complaint has been received by the home, which was recorded and appropriately responded to by the manager. Two surveys received from people living in the home say that they know whom to approach if they have any concerns and two say usually. Two people spoken with this visit said that staff respond promptly if they raise any matters. Two relatives surveyed commented, “”Approachable for any enquiry or request” and “nothing is to much trouble for them and they will always listen to worries and concerns”. A health care professional surveyed said that he received some complaints but this has been discussed with the of the home and measures have been taken to rectify these matters. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 18 Five out of eleven relative surveys received stated they do not know about the homes formal complaints procedure and a relative surveyed commented, “I have never been given a complaints leaflet or information” therefore it is recommended that this document is reissued to relatives should they wish to raise any concerns. Safeguarding adults from abuse policies and procedures were present in the home, which are bought to the attention of staff. Staff training records sampled confirmed that staff were receiving appropriate training. Staff spoken with during this visit were clear as to their responsibilities if they ever witnessed any abuse taking place. Since the previous visit no referrals have been made under the local authorities policies and procedure. It was observed that two out of three service users inventories had not been fully completed on admission documenting their personal possessions. Therefore it was required that this matter is attended to ensuring that people using the service are protected. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some matters were identified for improvement in ensuing that people live in a well-maintained safe environment. People using live in a clean and hygienic environment EVIDENCE: A tour of the premises was conducted. The home is a large converted mansion house situated in its own grounds, which requires regular ongoing maintenance and redecoration. There is large lounge, which was well maintained and furnished, and a separate conservatory and dining room. The home also has a separate hairdressing salon. It was observed that a number of communal areas require some improvement to the paintwork and the staff office needs redecorating, therefore it is required that a programme outlining when this work is to be completed must be provided to us ensuring that people living in the home have have a comfortable and well maintained home to live in. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 20 The staff rest room has been relocated to another area in the home, which was viewed as unsuitable due to its position and size, and the company is advised to review this arrangement. The home has accessible gardens that provide pleasant views of the countryside and local golf club and seating is provided in this area. Bedrooms viewed during this visit were comfortable and well furnished and some have ensuite facilities. Handrails were provided throughout, two lifts were available and call bells are in place to assist people living in the home. There are three assisted bathrooms and since the previous visit two shower rooms have been installed to meet the preferences of people. A bath panel was observed to be in need of repair, which was brought to the attention of the acting manager. During this visit the home was cleaned to a good standard and was hygienic with no pervading odours present. The home employs ancillary staff and cleaning schedules were in place. There was a separate laundry and appropriate washing methods were being used and the laundry attendant spoken with during this visit said that she had attended infection control training. Infection control procedures were in place and appropriate handwashing equipment was available. The home has also received a visit from environmental health where one matter was identified which has been actioned. A relative surveyed said, “My relatives room and the home in general is clean and well kept” Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of people living in the service. One matter was identified needing attention to ensure that people are protected by the homes recruitment policies and procedures and were in the safe hands of the staff that were competent and trained to do their jobs. EVIDENCE: The staff duty rota was sampled during this visit. During the day there are five staff in the morning including one senior carer, in the afternoon there are three carers plus one senior and three carers are provided at night. We were informed that these levels are increased when occupancy increases. There are currently three carer vacancies and a recruitment process is in operation. The majority of the staff are female and are of mixed ethnicity. Two comments received stated that the language barrier has hindered communication but this was not observed during this visit”. The home has a key worker system in place and three members of staff spoken with were clear about their responsibilities. Three people spoken with during this visit said that staff are available when they are required for assistance. The home also employs a cook, ancillary staff person and an administration member of staff. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 22 Information supplied in the AQAA stated that over fifty percent staff either hold or are completing National Vocational Qualifications (level 2) or above. Staff receive induction, which is based on the Skills for Care core induction standards. Training records were examined for three members of staff which confirmed that they have receive up-to-date statutory training in fire safety, food hygiene, moving and handling, control of harmful substances, health and safety, infection control and safeguarding adults from abuse. Four members of staff have completed this recently. Four members of staff have completed training but arrangements are being made for these staff to receive up dates. It was advised that all staff must complete this training. Progress has been made in arranging for staff to attend training in dementia awareness and the manager has identified that improvement is needed in ensuring that staff attend training in the care of the elderly. Other training that staff have attended identified included pressure area care, nutrition and care planning. One person surveyed commented, “ I think the staff are exceptionally well trained to respond and support residents and to interact with them”. Out of eleven relative surveys received six say that staff have the right skills and experience and five say usually. Two members of staff spoken to felt their training and development needs were supported. Staff recruitment is conducted using an equal opportunities policy and three staff recruitment files were sampled with contained application forms, although work history not been completed for one person therefore it requirement was made that full work histories must be obtained of prospective employees ensuring the well being and safety of people living in the home. Each file contained two written references, enhanced police checks and POVA first checks, although it was it was advised that the Criminal record Bureau checks should not be retained in the home. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager is able to demonstrate that he has the appropriate qualifications and experience to manage the home, although one matter was identified for improvement. Further improvement is needed in ensuring that the home is run in the best interest of people. The financial interests of people are protected. The health, welfare and safety of residents is mainly protected with one matter identified needing attention. EVIDENCE: Currently there is an acting manager in post and the home has been without a registered manager for a number of months, which has resulted in managerial changes. The company has advertised this post and interviews are Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 24 commencing shortly, therefore it is recommended that an application to register a manager be submitted to the Commission. A relative surveyed stated, “As there has not been a manager for some time things have suffered slightly”. The acting manager is a qualified mental health nurse and has had past management experience. During this visit he was observed to have an open approach and was accessible to people living in the service. A relative surveyed said, “The home does very well in all aspects of care. It is a well run home which puts the needs of residents first” Staff spoken with stated that the acting manager is supportive and approachable and regular staff meetings are held. The company carries out monthly quality visits, which were available for viewing, these were observed to be detailed and comprehensive and included service user consultation. Annual quality assurance surveys for people using the service and their relatives to gain their views have not been completed for over a year, therefore it was required that this is updated ensuring that the home is run in their best interests. The home has held past consultation meetings with people living in the service but again these have not been updated and the manager was advised that this matter is pursued. The Commission for Social Care inspections report was also available for visitors to view in the homes reception area The company carries out a range of quality audits and evidence seen included medication and home audits. Up to date policies and procedures are in place which are bought t the attention of staff and supplied in handbooks and read and sign systems are in place. The home has a policy in place for the protection of resident’s finances. The home does not maintain monies on behalf of people, which are either managed by themselves or by their relatives. The home uses an invoicing system to charge relatives for items such as hairdressing, newspapers and chiropody and receipts were maintained for this expenditure. A number of health and safety procedures were in place. Policies and procures have been updated. Substances hazardous to health were stored securely. Information supplied with AQAA indicates that regular servicing and maintenance of equipment is up to date. The manager provided evidence to confirm that us that regular water temperature monitoring takes place. Fire maintenance records and checks were recorded and evidence provided that regular fire drills are conducted. During a tour of the premises it was observed that the driveway into the home and is a safety hazard to people living in the home as it was in a poor condition, which was uneven and had potholes. It was required that this matter is addressed ensuring the safety and wellbeing of people living in the Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 25 home. It was also observed that there was a freestanding heater placed in the conservatory. No risk assessment had been completed. The manager stated that this is used rarely and took appropriate action during this visit. Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 26 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 3 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15(1)(2) (a)(b) Requirement People living and /or their representatives in the service must be consulted about their individual care plans and their written agreement is to be obtained. Agreement must be obtained from individuals and/or their representatives for the use of bedrails Records must be maintained of individual’s personal property and valuables. Information must be supplied to the commission in respect of the homes refurbishment plan The homes employment application forms must record the individuals past work history The annual quality assurance surveys for people using the service and their relatives must be updated. The driveway into the home must be resurfaced Timescale for action 30/01/08 2 OP8 12(2) 13(c) 13(6) 23(2)(b)( d) 19(1-5) Schedule2 24 30/11/08 3 4 5 6 OP18 OP19 OP29 OP33 30/12/07 30/12/07 30/11/07 30/01/08 7 OP37 23(2)(b) 13 (4)(a)(b) (c) 30/12/07 Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 28 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 OP3 Good Practice Recommendations It is recommended that copies of pre- admission assessments are maintained with individuals records for viewing It is recommended that the home follows good practice medication guidelines It is recommending that the staff support required at mealtimes is reviewed It is recommended that the choices of meals provided by the home are recorded on the menu It is recommended that condiments be provided to people who require assistance with their meals. The home should consider re- issuing the amended complaints procedure to people using the service and their relatives It is recommended that an application is submitted to the Commission for the appointed manager to be registered by us 2 3 4 5 6 7 OP9 OP15 OP15 OP15 OP16 OP31 Dungate Manor Care Home DS0000066321.V353237.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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