This inspection was carried out on 9th November 2005.
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.
CARE HOMES FOR OLDER PEOPLE
Dunkirk Memorial House Minehead Road Bishops Lydeard Taunton Somerset TA4 3BT Lead Inspector
Teresa Anderson Unannounced Inspection 9th November 2005 10:00 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 Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 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.V259140.R01.S.doc Version 5.0 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.V259140.R01.S.doc Version 5.0 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. 6th January 2005 Date of last inspection Brief Description of the Service: Dunkirk Memorial House is a home owned and managed 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 house has been extensively modernised and extended and 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 to provide nursing and residential care for up to a maximum of 60 older persons. Up to 30 of those people may be in need of nursing care. 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 two mini buses. Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second planned inspection this year and this report should therefore be read in conjunction with the report produced following the inspection in July when all the necessary standards were inspected. This inspection was undertaken to review those standards which had not been met at the last inspection. Two inspectors spent approximately five hours at the home, touring the building, speaking with approximately fifteen residents and one visitor, looking at care plans and talking with staff and management. It is noteworthy that whilst residents were happy to speak with the inspectors they were more inclined to be getting on with their daily lives. What the service does well: What has improved since the last inspection? What they could do better:
During this inspection it was noted that care planning in relation to those residents with communication difficulties and records in relation to the administration of ‘as required’ medications’ could be improved. Fire risk assessments and fire plans should also be reviewed to ensure they are accurate and that adequate fire containing precautions are in place. Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 6 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. Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were inspected at the inspection in July. EVIDENCE: Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 9 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 and 9. Residents would benefit from improved care planning in relation to communication and from improved record keeping in relation to why ‘as required’ medication is given. EVIDENCE: The inspectors looked at six care plans. On the whole, these documents assist staff to provide consistent care in a way that is preferred by residents and in line with good practice. Care plans are kept in the residents bedroom ensuring that staff and the resident have access to them and promoting residents involvement in planning their own care. A number of residents have limited verbal communication. Care plans do not include plans or directions for helping these residents to communicate and to be understood and appropriately responded to. Some staff demonstrated an excellent understanding of what residents were communicating. Documenting this information would ensure consistency and shared and improved understanding. Some information was gained from relatives and it is important that such information is documented and shared amongst all staff. Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 10 The system for managing medication is sound and internal auditing has been successful in ensuring that records are kept up to date. A number of residents are prescribed medications which are administered on an ‘as needed’ basis. It would be good practice to record why this medication is given and to link administration and efficacy with care plan reviewing to ensure that the medication is doing the job it was prescribed for. Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 11 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): These standards were inspected in July. EVIDENCE: Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 12 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): These standards were inspected in July. EVIDENCE: Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 13 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): These standards were inspected in July. EVIDENCE: Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 14 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): These standards were inspected in July. EVIDENCE: Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 15 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): 38 Residents’ safety would be improved if fire risk assessments and plans contained further information. EVIDENCE: This standard was inspected and met during the last inspection. However, during this inspection the inspectors noticed that some bedroom doors do not have intermissent strips indicating they are not fire doors. This is not a problem, and such doors can be propped open, as long as other fire containing doors and precautions are in place. Because the manager was not absolutely sure about this and because many bedroom doors are being propped open she agreed to clarify the situation and to ensure that the fire risk assessment and plan are accurate. Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 16 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x 2 Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 17 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 OP38 Regulation 23(4) Requirement The registered person must, after consultation with the fire authority, make adequate arrangements for containing fire and for reviewing fire precautions. (This relates to the need to determine if the fire risk assessment and fire plan provide sufficient detail regarding bedroom doors and the use of fire doors for containing fire). Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that care plans set out in detail all aspects of the health, person and social care needs of residents and how these are to be met. In this instance care plans should provide detail relating to those residents who do not communicate verbally or who have difficulty communicating verbally. The registered person should clearly record why ‘as needed’ medication is administered. 2 OP9 Dunkirk Memorial House DS0000040169.V259140.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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