Inspection on 27/02/07 for Dunkirk Memorial House

This inspection was carried out on 27th February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dunkirk Memorial House 09/11/05

Dunkirk Memorial House 26/07/05

Dunkirk Memorial House 06/01/05

Dunkirk Memorial House 10/08/04

Dunkirk Memorial House 23/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Dunkirk Memorial House Minehead Road Bishops Lydeard Taunton Somerset TA4 3BT Lead Inspector Kathy McCluskey Key Unannounced Inspection 09:30 27th February 2007 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 Dunkirk Memorial House DS0000040169.V312927.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. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunkirk Memorial House Address Minehead Road Bishops Lydeard Taunton Somerset TA4 3BT 01823 432407 01823 433083 pshields@britishlegion.org.uk 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) The Royal British Legion Mrs Pauline Shields Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 30 places for Nursing care within the overall number of 60 registered places A Registered Nurse to be on duty at all times To accommodate three named individuals under age 65 for General Nursing Care. 9th November 2005 Date of last inspection Brief Description of the Service: Dunkirk Memorial House is a home owned by The Royal British Legion. As such the admission criteria limits admissions to those who have served in the armed forces and/or their spouses. The main building has been has been purpose built and the home sits in its own well-tended grounds with ample parking. The home is close to and in walking distance of the village of Bishops Lydeard and approximately eight miles from Taunton. The home is registered with the Commission for Social Care Inspection to provide nursing (max 30) and personal care for up to a maximum of 60 older persons. The registered manager is Mrs Pauline Shields. The building is on three floors with the basement being used as the service area. All floors are linked by passenger lifts and there is disabled access throughout. Bedroom accommodation is provided in single rooms with en suite facilities, although couples can be accommodated in some of the larger rooms. In addition there are assisted bathing facilities. Immediately outside the home there are a number of seating and walking areas that include a large pond with carp, a sensory garden and greenhouse facilities. Residents also have the use of a mini bus. The home’s current fee range is between £480 & £685 per week, though fees are due to be reviewed/increased on 1st April 2007. Additional charges are met by service users for hairdressing, chiropody, newspapers and toiletries and taxis. For long journeys/trips, service users are asked for a 50 contribution where the home’s transport is used. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. This unannounced Key Inspection was conducted over one day (7.5hrs) by CSCI inspectors Kathy McCluskey and Barbara Ludlow. At the time of this inspection 55 service users were living at the home, which consisted of 29 receiving nursing care and 26 receiving personal care only. The registered manager Pauline Shields was available throughout the inspection. The inspectors were given unrestricted access to the home and all records requested were made available. The inspectors met with the majority of service users and were able to speak with ten at length. Staff on duty were also spoken with and the inspectors were able to meet with a relative who was visiting the home. As part of this Key inspection, the Commission sent comment cards to a number of service users, relatives, healthcare professionals and G.P’s. At the time of this report, 14 comment cards had been received from service users and 5 from relatives. Comments were positive and have been incorporated throughout the report. The inspectors would like to thank service users, staff, relatives and the registered manager for their time and cooperation with the inspection process. The inspectors were made to feel very welcome. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Dunkirk Memorial Home provides a very comfortable, clean and well adapted home for service users. The home has been purpose built to meet the needs of service users. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 6 Service users are treated with respect and are supported to maintain an independent lifestyle as far as possible. The home takes appropriate steps to ensure that the needs and aspirations of prospective service users can be fully met prior to a placement being offered. Service users are then able to ‘test drive’ the home so that they can be sure that they wish to remain there. The needs of service users are met by an appropriately qualified and trained team of staff and the home is managed by an experienced manager who promotes an open and inclusive style of management. The home’s arrangements for ensuring the assessed needs and preferences of service users are met is very good. A selection of care plans were examined at this inspection and were found to be very detailed and up to date. Healthcare needs are clearly identified and service users have good access to a range of visiting healthcare professionals. Service users spoken with at this inspection were very positive about the care they received and all commented on the kindness of staff. This was also reflected in completed comment cards. Some of the comments included; ‘The carers are nice and look after us well’, ‘The nursing and care staff are very supportive of my needs’, ‘This is outstanding in all aspects’. Relatives commented that they were ‘delighted with the care and nursing given’. The home offers an extensive range of activities. An activities programme is available at the home. Designated activity staff are employed and a range of volunteers provide additional input. Service users were extremely positive about the activities programme and informed the inspectors that ‘there is always something going on’, ‘we have excellent activities people’. In completed Commission comment cards, relatives also indicated that they were impressed by the activities available, ‘The home provide an excellent range of activities for everyone’. The home has a chapel where regular services take place and the home holds special functions and suppers where the service users can invite guests. Meals at the home and dining facilities are of a high standard. The inspectors were able to observe lunch being served in the dining room (restaurant). This was a pleasurable and social experience for service users. Choices are available and special diets and requests are catered for. The chef makes himself available for service users. The home has a licensed bar and during lunch service users could choose from a range of drinks including alcoholic beverages. Service users were very positive about the meals and choices available, ‘always good’, ‘two choices for main dishes’, ‘outstandingly good’. Relatives/visitors may also stay for a meal. A charge is made for this. One relative was observed enjoying lunch during the inspection. A comment from a relative was that ‘the food is excellent and varied’. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 7 On the day of this inspection the standard of cleanliness at the home was high and the laundry area was very clean and well organised. Domestics and laundry staff are employed. Positive comments were made by service users. In completed commission comment cards, all stated that the home was ‘always’ fresh and clean. ‘Cleaning very good also laundry excellent’, ‘spotless and very comfortable’. Appropriate procedures are followed to ensure the reduced risk of the spread of infection. Staff have also received training in infection control. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors to the home. What has improved since the last inspection? 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 Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 9 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 Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 10 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): 1, 3, 4 and 5. Standard 6 is not applicable as the home is not registered to provide intermediate care. Quality in this outcome area is Good. Appropriate information is available to ensure that prospective service users are able to make an informed choice about moving to the home. The home takes appropriate steps to ensure that it is able to meet the needs and aspirations of service users. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide which provides information about the home and services offered. These documents are made available to service users, prospective service users and their representatives. Copies were also seen to be displayed in the reception area of the home and included a copy of the home’s last inspection report. The inspectors were informed that the Statement of Purpose had recently been reviewed and an updated version has been forwarded to the Commission. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 11 Service users spoken with during this inspection informed the inspectors that they had been provided with sufficient information to enable them to make an informed choice about moving to the home. To ensure that the home can meet the needs and aspirations of service users, all prospective service users are fully assessed by the home. Assessments from other professionals are obtained where available. Evidence was seen in the care plans examined. Prospective service users and their representatives are encouraged to visit the home prior to making a decision to move there. Admission is offered on an initial trail basis to ensure that all parties are satisfied the assessed needs and aspirations of service users can be met. The inspectors were able to see that the home had a good supply of specialist equipment in place and the home has been designed to provide easy access for service users with mobility difficulties. Ramps, grab rails and a call bell system are available throughout the home. Staff at the home are suitably trained to meet the needs of service users. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 12 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 and 10 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The home has appropriate systems in place to ensure that the assessed needs and preferences of service users are met. Appropriate procedures are followed for the management and administration of service user medication. Service users are treated with respect and their right to privacy is maintained. EVIDENCE: The inspectors examined four service user care plans in depth. The inspectors were also able to meet with these service users, view their bedrooms and speak with the relative for one of the service users. Care plans were found to be very well maintained and up to date. Assessments had been appropriately incorporated in to the plan of care and care needs were Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 13 clearly identified. Details on how needs should be met gave clear instructions for staff and included, as appropriate, the preferences of the individuals. The home’s procedures for meeting healthcare needs were good. The inspectors were able to see evidence that appropriate procedures were being followed relating to the management of wound care. Other specialised nursing interventions were clearly written. Care plans identified the individual’s contact with appropriate healthcare professionals and the registered manager confirmed that the home received very good support/input from GP’s and other healthcare professionals. Service users are weighed monthly and any concerns are incorporated into the plan of care. Care records were found to be up to date and are reviewed at least monthly. Five relatives completed comment cards for the Commission and all confirmed that the home kept them of important matters. A comment received was ‘we are delighted with the care and nursing given’ A relative spoken with during the inspection was very positive about the care and attention that their relative received. Fourteen service users completed comment cards for the Commission. Eight stated that they ‘always’ received the care and medical support they needed, six responded ‘usually’. Other comments made included; ‘the carers are nice and look after us well’, ‘The nursing and care staff are very supportive of my needs’, ‘This is outstanding in all aspects’, ‘This is meticulous though communication between nurses on different shifts could be improved’. Approximately ten service users were spoken with during the inspection. All but one confirmed that they felt that their needs were being met by the home and were satisfied with the care they received. All commented on the kindness of staff. ‘I am very happy’, ‘Excellent’. Registered nurses at the home administer prescribed medication to those service users receiving nursing care. Appropriately qualified care staff are able to administer medication to those service users receiving personal care only. The inspectors observed part of the lunch time ‘medicine round’ and observed that correct procedures were being followed. The home uses the monitored dosage system and medicines are securely transported around the home in lockable medicine trolleys. One of the company’s representatives informed the inspectors that they had just completed a full audit on the home’s procedures for the management and administration of medication. Medicines were found to be appropriately stored with no excess stocks. Creams and eye drops in use had been identified with a date of expiry. Records had been appropriately maintained. Throughout this inspection, the inspectors were able to observe staff interacting with service users. Service users were spoken with in a kind and Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 14 respectful manner. Service users spoken with by the inspectors confirmed that they were treated with respect and that their dignity was maintained. Where service users had chosen to remain in their bedrooms, staff were observed knocking on doors before entering. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 15 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 and 15 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from an excellent range of activities. The home supports service users to maintain control and exercise choice over their lives. The provision of meals at the home and the mealtime experience for service users are excellent. EVIDENCE: Service users living at Dunkirk benefit from an excellent range of activities, functions and events both within and outside of the home. The home has wheelchair accessible minibuses where a 50 contribution to the cost is charged for long trips. A full and vast programme of activities is available at the home. The home employs additional staff for activities covering a total of 52.5hrs per week. There is an extensive network of volunteer support, staff also support service Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 16 users on trips out, in their own time; this collective input is of valuable benefit to the social lives of service users. On the day of the inspection, service users had enjoyed an ‘armchair travel’ session and a visit from a local choir. The home has a chapel and services are held each week. A shop is also available and items are taken around the home in a trolley three times a week for those service users with mobility difficulties. Service users spoken with during the inspection were extremely positive about the range of activities and events available to them. ‘There is always something going on’, ‘I keep very busy, lots going on’, ‘we have excellent activities people’. Service users confirmed that they choose how and where to spend their day. As appropriate, staff support service users to maintain an independent lifestyle as far as possible. Visitors are made welcome at the home at any reasonable time in line with the wishes of individual service users. Service users choose where they would like to see their visitors and can use the privacy of their own bedroom if they wish. Service users and one relative spoken with confirmed that visitors were always made to feel welcome and are offered refreshments. Visitors can enjoy a meal at the home with their relative if they wish. One relative was observed utilising this facility at the time of the inspection. A charge is made for this. The quality and choice of meals at the home are excellent. All meals are prepared and cooked at the home by the chef. Service users confirmed that they could speak with the chef at any time and that special requests/special diets are always catered for. During the inspection, the inspectors were able to observe lunch being served. The majority of service users appeared to enjoy going to the home’s ‘restaurant’ for lunch. The dining room (restaurant) is spacious, airy and comfortably furnished. Tables were attractively laid with table cloths and linen napkins. A range of condiments were available and a menu was in place on each table. Service users are offered a range of drinks including choices from the drinks trolley which holds a variety of alcoholic beverages. Where an alcoholic beverage is taken, service users sign for this (just as you would in a hotel) and a small charge is made each month. Staff were observed serving meals in a very professional and unobtrusive manner. Choices were offered. It was very apparent that meal times were a pleasurable and social occasion for service users. Comments regarding the food were very positive and included; ‘always good and a choice of two main dishes’, ‘Outstandingly good’ Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 17 The home has a very comfortable and well equipped licensed bar at the home and many service users informed the inspectors that they enjoyed visiting the bar just as they would have done when living at home. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 18 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 and 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 satisfactory complaints procedures in place. Systems are in place to reduce the risk of harm or abuse to service users though staff recruitment procedures need review to ensure that they comply with current legislation (refer to standard 29). EVIDENCE: The home has produced a satisfactory complaints procedure which is displayed in the home and is also available in the Service User Guide. The registered manager provided the Commission with pre-inspection information which indicated that one complaint had been investigated since the last inspection. This was responded to within the agreed timescale and had not been substantiated. No concerns have been raised directly with the Commission. Fourteen service users completed questionnaires for the Commission and all confirmed that they knew how to make a complaint. This was also confirmed by the service users spoken with during the inspection. ‘We are always listened to’ ‘I would not hesitate in raising concerns if I had any’. Five relatives, in the Commission’s comment cards, stated that they had never had to make a complaint. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 19 One relative spoken with during the inspection informed the inspectors that they did not have any concerns and that they would feel comfortable in raising concerns if they had any. The inspectors met with a service user who had been appointed ‘residents spokesperson’. They informed the inspector that the views of service users were encouraged. The home has policies in place relating to the protection of vulnerable adults. These were not examined at this inspection. Staff spoken with felt confident in raising any concerns. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 20 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, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from a very comfortable, clean environment, which offers a range of communal areas. Furnishings and décor are of a high standard and promote a homely feel. Service users have access to a range of aids and adaptations which assist them to be more independent. The home follows appropriate procedures relating to infection control. The laundry and cleaning services are excellent. EVIDENCE: Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 21 During this inspection the inspectors viewed a selection of bedrooms and all communal areas. The temperature with the home was very comfortable and all areas seen were very clean. No malodours were noted. The home has vast grounds, which have been beautifully landscaped. Gardens were not fully viewed at this inspection. Bedrooms seen were comfortably furnished and had been personalised by the individual service user. Specialised equipment was seen to be in place. This included such items as profiling beds, pressure relieving equipment and hoists. 56 bedrooms have en-suite toilet and bathing facilities. In addition to this, the home has two assisted communal bathrooms. Communal toilets are conveniently situated around the home. Service users can choose from four communal lounge areas. All were found to be very comfortably furnished. Furniture and décor were noted to be of a high standard and although Dunkirk is a large home, all areas seen promoted a ‘homely’ feel. Service user accommodation is arranged over two floors. Shaft lifts provide access to the first floor. Grab rails are appropriately situated throughout the home. All areas have been fitted with a nurse call system. An automatic door has been fitted to the dining room to aid service users. The home also has a chapel and a hairdressing suite. Service users spoken with during the inspection were very positive about the homes environment and all stated that they liked their bedrooms. The home has appropriate systems in place to reduce the risk of the spread of infection. Staff have received training and staff have access to a good supply of protective equipment. Appropriate hand washing facilities and cleansing gel are situated throughout the home. The home has a large well-equipped laundry which is situated on the lower ground floor. The laundry was found to be very clean and well organised. Given the comments from service users and the observation of the inspectors, the laundry staff should be commended for the services they offer. Laundry staff ensure that personal laundry is washed, dried, ironed and returned to the service users within the day. Service users were very positive about the laundry service; ‘the laundry service is excellent’, ‘they are marvellous’. The cleaning staff should also be commended. As previously mentioned, all areas seen by the inspectors were noted to be very clean and free from malodours. Some comments received by service users included; ‘Cleaned daily and beds changed’, ‘Cleaning very good’, ‘Spotless and very comfortable’. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 22 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 and 30 Quality in this outcome area is Adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from a staff team who have been appropriately trained. The home’s procedures for staff recruitment would benefit from some improvement. EVIDENCE: The registered manager informed the inspectors that the home has sufficient numbers of staff on duty to meet the needs of current service users. On the day of this inspection, the following staff were on duty; 2 registered nurses, head of care, 8 care staff, 2 activity co-ordinators, 4 domestics, kitchen, and administrative staff. During the inspection, the inspectors spoke with staff, service users and relatives and no concerns were raised about staffing levels at the home. Five relatives completed comment cards for the Commission and, in the response to the question, ‘Do you feel there are always sufficient numbers of staff on duty?’ 4 responded ‘Always’ and 1 ‘Mostly’. Staff spoken with indicated that they did not experience any difficulties in meeting the assessed needs of service users. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 23 The inspectors noted that the atmosphere in the home was relaxed and unhurried. The registered manager informed the inspectors that staffing vacancies were currently being covered by agency staff. The home makes efforts to ensure that the same agency staff are used where ever possible as this ensures continuity of care for service users. Care staff are supported to undertake National Vocational Training (NVQ) in care. Pre-inspection information provided by the registered manager identified 53 of the care staff as having achieved a minimum of an NVQ level 2 in care. This is in excess of the 50 recommended in the National Minimum Standards. The inspectors examined the home’s procedures for staff recruitment. Three staff recruitment files were examined. All required documentation was in place, which included enhanced CRB and POVA checks. The inspectors discussed the need to ensure that POVAFirst checks are obtained where a member of staff commences employment pending a CRB. In these cases, a risk assessment should also be completed and a supervisor should be identified for that staff member to ensure that they do not work unsupervised until the full CRB check is received. The registered manager was advised to obtain a copy of the Department of Health’s Guidance on Safeguarding Vulnerable Adults. It has been required that up to date photographs of employees are obtained on employment and maintained in their staff file. In one of the files examined, no employment history was provided. It has been recommended that the home ensures that a full employment history is provided by all future staff to ensure that any gaps in employment can be explored. The registered manager ensures that staff receive appropriate training relevant to the job they perform. Since the last inspection, training has included; NVQ, moving and handling, continence, fire safety, reminiscence, dementia, health and safety, venepuncture, clinical updating, nutrition, medication and use of syringe drivers. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 24 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, 32, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed by an experienced registered manager who promotes an open an inclusive style of management. Appropriate systems are in place to safeguard service users financial interests. The home has procedures in place which seek the views of service users and other stakeholders. Systems are in place for the supervision of staff though these could be further improved on. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager is Pauline Shields. Pauline is an experienced registered nurse who has been managing the home for over 5 years. The registered manager promotes an open and inclusive style of management which was confirmed by staff, service users and relatives. Regular meetings are held for all staff in all departments. Service users also benefit from regular meetings and the home has regular house committee meetings. Typed minutes are readily available for all meetings. A representative from the British legion visits the home on a regular basis. As required by the Commission under Regulation 26, monthly quality audit reports are completed. These were available to view by the inspectors. The home displays an appropriate and up to date employers liability insurance certificate. At the request of service users, the home will manage small amounts of money on their behalf. Records were examined at this inspection and were found to be well maintained. Receipts were available. The home does not act as appointee for service users. The manager confirmed that all staff receive regular meetings and one to one sessions but as yet, systems are not formalised. It has been recommended that a documented system is introduced which will demonstrate that all staff receive formal supervision at least six times a year. Staff informed the inspectors that they felt very well supported. Records pertaining to staff and service users are appropriately stored in accordance with the Data Protection Act 1998. At the time of this inspection, the home is taking appropriate steps to ensure the health and safety of service users, staff and visitors. This was ascertained on examination of records, tour of premises and discussion with staff and service users. FIRE SAFETY – The home conducts weekly checks on the home’s fire alarm systems. Monthly checks are made on the emergency lighting. Systems were serviced by external contractors on 15/01/07, next due 2008. The last recorded fire drill was 05/02/07. Records indicated that 14 staff were due fire safety training updates. The registered manager stated that this was in the process of being addressed. Progress will be followed up at the next inspection. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 26 ELECTRICAL SAFETY – Annual checks on the home’s portable appliances were last conducted in October and December 2006. The home has an up to date electrical hardwiring certificate dated 23/06/06. GAS SAFETY – The home’s annual servicing was found to be up to date. Servicing last took place on 13/06/06. HOT WATER – To reduce the risk of scalding, hot water outlets have been fitted with thermostatic controls. Outlets are checked monthly to ensure that temperatures do not exceed safe upper limits. A selection of bath hot water outlets were checked by the inspectors and no concerns were noted. ACCIDENTS – The home maintains appropriate records relating to all occurrences of accidents. The inspectors were able to see evidence that the registered manager looks at these records and lists them monthly. It has been recommended that a more formalised system is introduced which will clearly identify any traits and action taken to prevent reoccurrence. EQUIPMENT SERVICING – Records indicated that 6 monthly servicing of equipment was last carried out in October 2006. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 27 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 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 4 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 28 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 OP29 Regulation 19 & Schedule 2 Requirement The registered person must ensure that robust recruitment procedures are followed which will reduce the risk of abuse to service users; Along with all other required documentation, a POVAFirst check must be obtained where a staff member commences employment pending a CRB. An up to date photograph of employees must be maintained in their recruitment file. Timescale for action 10/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations The registered person should ensure that prospective employees provide a full employment history so that any DS0000040169.V312927.R01.S.doc Version 5.2 Page 29 Dunkirk Memorial House 2. 3. OP36 OP38 gaps in employment can be explored. The registered person should formalise staff supervision sessions to ensure there is documented evidence that staff receive formal supervision at least 6 times a year. The registered person should ensure that systems for analysing accidents clearly identify any traits and any action to reduce the risk of reoccurrence. Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Dunkirk Memorial House DS0000040169.V312927.R01.S.doc Version 5.2 Page 31 - 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!