Inspection on 27/11/07 for Dunsfold

This inspection was carried out on 27th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dunsfold 15/09/08

Dunsfold 31/01/07

Dunsfold 09/06/06

Dunsfold 08/12/05

Dunsfold 07/07/05

Dunsfold 24/01/05

Dunsfold 18/05/04

Dunsfold 20/10/03

Dunsfold 19/05/03

Dunsfold 17/12/02

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

CARE HOMES FOR OLDER PEOPLE Dunsfold West End Road Herstmonceux East Sussex BN27 4NX Lead Inspector Debbie Calveley Key Unannounced Inspection 27th November 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dunsfold DS0000021089.V350548.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. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunsfold Address West End Road Herstmonceux East Sussex BN27 4NX 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) 01323 832021 Mr Paul Hughes Mrs Indra Hughes Mr Paul Hughes Care Home 20 Category(ies) of Dementia (20) registration, with number of places Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty (20) Service users must be aged sixty-five (65) years or over on admission Service users with a senile dementia type of illness only to be accommodated 31st January 2007 Date of last inspection Brief Description of the Service: Dunsfold is registered to provide a home for twenty older people with dementia. The home is a large detached property situated in the small village of Herstmonceux. The home is set within its own grounds and is approximately half a mile from the main road, which includes local amenities such as shops and local transport links. Resident accommodation consists of twelve single rooms and four shared rooms. Some of the room sizes are below the New National Minimum Standard and there is not level access throughout the home although the home is exempt from these regulations as it was first registered before April 2002. Communal areas comprise of a lounge, dinning room and library/second dining area. There are three bathrooms and five additional toilets in the home. The home welcomes pets and some residents keep cats in their rooms. The external grounds include a large rural garden, and a large parking area, including courtyard tables/chairs. An alarmed gate separates the garden from the road and allows residents freedom of movement as well as ensuring their security. The home does not provide level access internally or externally and there are some steps out to the garden from some exits. The home is better suited for those without mobility needs particularly as upstairs rooms are only accessible by stairs. Information on the range of fees charged was confirmed in the pre-inspection questionnaire prior to the inspection with fees approximately ranging from around £366 to £410 per week with extra changes for personal items. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Dunsfold Care Home will be referred to as ‘residents’. The information contained in this report has been compiled from an unannounced site visit undertaken over 7 hours on the 27 November 2007 plus information gathered about the home since the previous inspection. This includes discussion with stakeholders involved in resident’s care, records submitted to CSCI, which have included an Annual Quality Assurance Assessment (AQAA) and the notification of accidents and incidents. Six surveys were received and the comments received are reflected in the report There were 18 residents living in the home, of which five were case tracked and met with. During the tour of the premises a further four residents of both sexes were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including care plans, medication records, training records and recruitment files. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspectors would like to thank the residents, staff and management for their assistance and hospitality during the visit. What the service does well: There is a combined Statement of Purpose and Service Users Guide that gives prospective residents the information required to enable them to make an informed choice about where they live. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard residents’ finances. Staff provision is well maintained with a robust recruitment practice being followed and appropriate numbers of suitably trained staff working in the home. The atmosphere of the home is pleasant with good interaction seen between residents and staff. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 6 There are attractive grounds surrounding the house with safe access particularly to the front of the house. There is an experienced and consistent management team that are knowledgeable about the residents that live in the home. The menus evidence a well thought out balanced diet with a varied choice of food in line with resident’s preferences. What has improved since the last inspection? What they could do better: Whilst there is evidence of improvement in the pre-admission documents, there is still the need to improve on the information recorded so as to ensure that they can meet the needs of the residents. The care plans continue to improve, but still lack guidance for staff to follow to ensure that a consistent and person centred approach is maintained. In particular those relating to independence in personal care, communication and behaviour. Activities should be an important part of life to the residents of Dunsfold so as to encourage and promote social independence and mental stimulation; therefore it is identified as an area that requires development to meet all the residents’ social needs. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 7 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. Dunsfold DS0000021089.V350548.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 Dunsfold DS0000021089.V350548.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): 1, 2, 3, 4 and 5. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives with a satisfactory level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission. EVIDENCE: The Statement of Purpose and Service Users Guide are in a brochure format and contain information about the home and the services it provides. It also contains information and photographs regarding the nearby sister home. Copies of these are available in the front entrance of the home. A social care professional that had recently visited the home confirmed that relevant information was provided to a prospective resident. Contracts were seen and were written in plain English. There is a copy of the terms and conditions of residency included in the Information pack. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 10 A review of the care documentation confirmed that pre-admission assessments are completed by the manager or the deputy manager. The format of the preadmission document was seen to be concise and relevant. There has been an improvement in the pre-admission process, However the three assessments seen were brief and did not detail who was involved in the process. This was discussed in full. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representatives are involved. As previously mentioned a recommendation of good practice is that the venue and all the people involved in the assessment are documented. Dunsfold DS0000021089.V350548.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 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst care plans provide a good framework for the delivery of care, they need to give clear guidance to care staff to meet the identified needs in a consistent manner. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. Procedures and practices in the home allow for the safe administration of medicines and on the whole the privacy and dignity of residents to be promoted. EVIDENCE: Since the arrival of the new proposed manager in March 2007, a new care planning system has been introduced. Four care plans were seen and in the main were satisfactory with evidence of regular review. Although there have been improvements since the last inspection, as discussed during the inspection feedback, there is still a need for the care plans to provide detailed guidance for staff to follow in meeting the resident’s individual Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 12 needs to ensure continuity and consistency of care. It is acknowledged that this is a continued ‘work in progress’. There are risk assessments in place to assess and monitor the health needs of the residents and these include: a nutritional tool, a skin monitoring tool and moving and handling tool. These were found completed and evidenced regular review. However the nutritional tool needs to be adapted to assess residents weight by other means as well as weighing. Records indicated that residents are weighed weekly/monthly in order to monitor any weight loss or gain, however the records available evidenced residents not being weighed consistently due to the difficulty in weighing some residents. Not all care plans viewed included a continence care plan and how the staff encourage independence and support residents in this area. From reading the documentation in the care plans there is evidence that the home access relevant healthcare support when necessary. There are clear records recording the visits in each individual care plan. As found at previous inspections that due to the level of dementia of most of the residents, it was not possible to gain information and the views of the residents from verbal conversation therefore direct observation was the main tool used. From direct observation the residents were seen to be supported in a discreet and dignified manner with their mobility and nutritional needs being met appropriately. There are policies and procedures in place for the storage, administration, disposal and receipt of medication and there is evidence that they are regularly reviewed. The medication administration records were viewed and were in the main completed competently. The introduction of a document that staff complete on receiving any verbal changes from the General Practitioner alerts all staff to the changes and is a good tool to use. The storage of the medication was seen to be secure and it is kept closed at all times, thus ensuring the safety of the residents. Since the last inspection the manager has contacted the Pharmacist regarding the identification of the tablets dispensed and the description of each tablet is now on the rear of the medication (nomad) box. There are plans to use a medication trolley, which will improve the dispensing and storage of medication in the near future. From direct observation the residents were treated with respect and their dignity and privacy was maintained. The staff demonstrated an understanding of some of the behavioural traits of the residents and managed them effectively, discretely and with patience. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by residents at this time does not always match their expectations, choice or preferences. Meals remain good in respect of both quality and variety that meets the majority of residents’ tastes and choice. EVIDENCE: Dunsfold do not have a daily activity programme in place and from the knowledge they have of their residents the staff stated that have found that one to one sessions are more beneficial. Outside entertainers visit the home and a Christmas pantomime is arranged for the near future. There were no separate care plans in place for activities and from discussion it was said that staff write the one to one interaction in the daily notes, however there were no entries found and this will be followed up by the manager. Activities should be an important part of life to the residents of Dunsfold so as to encourage and promote social independence and mental stimulation; therefore it is identified as an area that requires development to meet all the Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 14 residents’ social needs. It was discussed in full with the manager during the inspection. Residents are facilitated to maintain their independence for as long as they are able and again this needs to be reflected in their individual care plans. There are no restrictions on visiting times as long as consideration is shown to all the residents. Trips out are arranged occasionally, and information received from staff and from their care plans, their religious and cultural needs are discussed with the resident if possible and their representatives. One resident goes to the local church service every week and receives the church newsletter. Two residents have their pets with them, a dog and a cat and the staff support the residents in caring for them. It clearly states in the Statement of Purpose that staff will support residents in ensuring that their lifestyle choices will be met. This needs to be reflected in their individual care plans. The residents and their families are now consulted on admission of their choices concerning the gender of their carer and it was confirmed that a key worker system is soon to be introduced. Pen profiles of residents were seen to be in place for most residents and it was confirmed that these can take time to complete due to lack of information and communication problems of the residents living in the home. It was observed during the inspection that the routines at the home are flexible and there are no time constraints to meal times. Breakfast service was seen to be staggered and flexible. Residents were not hurried and allowed to finish their meal in their own time. Residents are able to spend time wherever they want in the home and were seen moving freely between the communal areas and corridors. Residents’ rooms are homely and residents, their family and friends are encouraged to personalise it with their own items. However again from direct observation during the inspection, it was not evident that residents are offered choices of beverages, or if they would like music or the television on and not all residents were offered any activity book or paper. There are two dining areas that are used for meal times and residents were seen sitting where they choose, residents also eat from small tables in the lounge. From direct observation staff were seen supporting and assisting residents with their meals. The menus are worked out on a weekly basis and demonstrated a varied and nutritious range based on the residents known preferences. One main meal is prepared, but alternatives are offered at every meal. A blended version of the meal is prepared for those that require it. A recent environmental health assessment took place in October, with no requirements. The cook completes the recommended ‘safer food’ diary daily. The kitchen was clean and well Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 15 organised and cleaning rotas were seen to be in place. Also employed are a weekend cook and supper cook, both of whom have a relevant qualification and an up to date food and hygiene certificate. The cook has worked in the home for eight years and is knowledgeable regarding the residents dietary needs and was able to discus their likes and dislikes. The staff are keeping accurate fluid and food charts for frail residents when required, one was seen during the visit. At present there is no daily record kept of resident’s food consumption and it was discussed that this would be beneficial in identifying residents eating trends and being seen as being proactive. Following discussion with the cook and staff, staff immediately started designing a record sheet. The home staff use a nutritional assessment tool to identify any residents with special dietary needs, including monthly weights, however as previously mentioned an action plan needs to be in place for those whom have been identified as at nutritional risk. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 16 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 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a formal complaints system with evidence that residents feel that their views are listened to and acted upon. Staff receive training to protect residents from abuse. EVIDENCE: The complaint policy and procedure is clear and uncomplicated and a copy of this is readily available in the home and the Service Users Guide. A system of recording complaints was demonstrated to the inspector during her visit to the home. The home has not received any complaints since the last inspection. Relatives and residents spoken with confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has the relevant guidelines on the protection of vulnerable adults and there was evidence that staff have received appropriate training. Those that haven’t are included in the forthcoming training programme. The management team have a clear understanding of adult protection guidelines and are aware of how to initiate an investigation if required. There is a copy of the Multi- Agency guidelines in the home to refer to. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst the residents’ benefit from having an environment which provides a choice of communal space and evidence of an on-going refurbishment and redecoration programme, not all areas of the home at this time were clean and homely. EVIDENCE: The home continues to follow an improvement programme that will benefit the residents and visitors to the home and will when completed, provide a welcoming and comfortable environment. The tour of the home evidenced that work is on-going. The entrance area and library area has been redecorated and is clean and bright. The lounge décor remains unchanged, but the quality of furniture has improved. There is a need Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 18 to improve the quality of furniture throughout the home, and it was discussed that this needs to be included in a written refurbishment plan with achievable timescales set. There are sufficient communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. However the bathrooms are not attractive and inviting and are in need of redecorating. This was discussed in full and will be addressed by the refurbishment programme. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, ramps to provide levelling of steps and wheelchairs. Call bells are provided in all areas. The lighting in the home is of domestic quality and the temperature in the home was comfortable. All radiators were found appropriately covered and the open fire is kept under constant monitoring and has the appropriate fireguards in place to ensure the residents safety. Water temperatures are controlled, monitored monthly and a record kept. There are systems in place for monitoring safety issues such as fire checks, fire drills, PAT testing, electrical tests and gas and boiler checks and all the rooms are routinely checked for safety and maintenance issues. Certificates asked for were provided. The records in the home confirmed they were up to date. The tour of the home confirmed that staff are aware of the fire safety policies, no doors were found inappropriately wedged open. Polices and procedures for infection control are in place and are updated regularly. The home was free from offensive odours on the day of the inspection, however whilst the majority of bedrooms were found clean, the standard of cleaning in the lounge needs to be addressed, especially the ramps and staff are to be reminded of the necessity to ensure chairs are clean following the meal service. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. The laundry area was found untidy and not particularly clean, a lot of unused equipment is stored under the boiler and this needs to be addressed. The floor needs to be replaced/ repaired in certain areas. Some comments highlighted in surveys received by CSCI and also the home’s surveys identifies that the laundry service needs to be improved. It was noted that some cardigans of residents were deeply creased as a result of tumble-drying and this also needs to be addressed. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 19 Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 20 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 and 30. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in place to protect residents, and staff training ensures they are aware of their roles and are able to provide the support and care the resident’s need EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Care staff spoken with said that the levels of staff on duty were sufficient to give the care required; they also said that the manager helps out with the residents. The surveys received did not express any concerns regarding the staffing levels. A selection of staff recruitment files were viewed and demonstrate that a robust recruitment process has been maintained to protect residents and contained all the relevant information required. There was evidence of health questionnaires, Criminal Record Bureau checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept within a locked room. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 21 The induction programme is now in place and has been introduced for all new staff. Files seen confirmed this. Discussion with the management team confirmed that all staff are supported and encouraged to complete a National Vocational Qualification (NVQ), the AQAA stated 50 of staff have an NVQ with a further 35 currently working towards an NVQ. One new member of staff talked about her induction to the home and that it was beneficial. Staff spoken with said that training opportunities at the home are good and they are well supported by the management of the home. Staff and the training list seen confirmed that compulsory training such as manual handling, adult protection, first aid and fire safety are being undertaken. The manager has introduced a training matrix, which identifies the staff training status and prompts required updates. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 22 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, 36, 37 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect residents. EVIDENCE: There has been a change in the managerial structure of the home since the last inspection with the recruitment of a deputy manager whom will be working alongside the provider/manager with the plan to become the Registered Manager in the near future. The proposed manager has experience in managing care homes for people with dementia and has the necessary skills and experience. She has the Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 23 Registered Managers Award and continues to attend training to update her knowledge. The staff were complimentary regarding her management style and she was seen to be knowledgeable regarding the residents living in the home, she was also observed working alongside the staff when required. She is working hard to meet the National Minimum Standards and is able to share her plans of improvement structures in place. The management team are sending out quality assurance surveys to residents, families, representatives and stakeholders. The surveys results are then audited and action taken when appropriate. A recommendation of good practice is that outcomes are also documented. Resident meetings are not beneficial in this particular home, but one to one interaction takes place. Relative meetings are poorly attended and this will be reviewed as to ways of encouraging participation. Residents’ financial interests are safe guarded by robust policies and procedures. The staff have no involvement with the residents personal allowances. Staff supervision was discussed and staff supervision has been commenced and is documented. Staff spoken with confirmed that they receive supervision and a plan of the year’s supervision sessions seen. At present all staff have received the mandatory training in moving and handling, health and safety and fire safety and there is evidence of a rolling plan of training. The manager confirmed that all new staff are appropriately supervised until they have received the necessary training and induction. The homes policies and procedures are reviewed regularly and for the purpose of this inspection, two policies were chosen for viewing, death and dying and medication procedures, both were comprehensive and evidenced recent review and are accessible to all staff when required. The accident book was reviewed and there is evidence of a trips and falls audit, which highlights repetitive falls/injuries of specific residents and this was then seen to be reflected with appropriate action detailed in individual care plans. Good practice was observed throughout the inspection in respect of the safe moving and handling of residents. The staff were aware of fire precautions, and due to recent incidents the security of the home has been reviewed and all exits and gates are alarmed. Several residents have challenging behaviour and this sometimes put other residents at risk, these are being managed effectively by staff at this time, and care plans reflect actions to be taken. This was fully discussed with the management team. Staff receive training in managing challenging behaviour. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 24 Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 3 X 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 Requirement That the Registered Person ensures that the pre-admission assessment has sufficient detail to ensure the home has the necessary facilities and skills to meet the prospective needs. That the Registered Person ensures that care plans must more clearly identify what action staff need to take to meet the needs of residents. (Timescale of 01/04/07 not met.) Timescale for action 01/02/08 2. OP7 15 01/02/08 3. OP12 16(m) & (n) 4. OP14 12(2) That the Registered Person 01/02/08 ensures that activities must be individually tailored to meet the needs of each resident to provide a stimulating and interesting environment. (Timescale 0f 01/04/07 not met.) That the Registered Person 01/02/08 ensures That residents’ must be consistently provided with greater opportunities for choice, such as beverages, daily life choices and activities. DS0000021089.V350548.R01.S.doc Version 5.2 Page 27 Dunsfold 5. OP19 OP21 13(4)(a) That the Registered Person 01/02/08 ensures that a written programme of refurbishment and redecoration is in place with realistic time scales. That the bathrooms are redecorated to provide a comfortable environment for bathing. That the Registered Person ensures that the premises are clean. That the laundry floor is repaired/replaced to prevent spread of cross infection. That all unused/broken equipment is stored appropriately. That the laundry service provided is monitored. 6. OP26 OP24 13 (3) 01/02/08 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 OP37 Good Practice Recommendations That photographs of residents are regularly updated. Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dunsfold DS0000021089.V350548.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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