Inspection on 07/07/05 for Dunsfold

This inspection was carried out on 7th July 2005.

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 27/11/07

Dunsfold 31/01/07

Dunsfold 09/06/06

Dunsfold 08/12/05

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 Jason Denny Unannounced 7 July 2005 08:00 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 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 H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dunsfold Address West End Road Herstmonceux East Sussex BN27 4NX 01323 832021 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Paul Hughes Mr Paul Hughes Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (OP) 20 of places Dementia (DE) 20 Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of residents to be accommodated is twenty 2. The people accommodated will be aged 65 years or over on admission 3. The people accommodated will have a dementia type of illness Date of last inspection 24 January 2005 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 although the home is exempt from these as it was first registered before April 2002. Some of the double rooms are currently being used as single only. 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, which also contains a pony a goat 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 internaly or externally and there are some steps out to the garden from some exits. The home is better suited for those without mobility needs particulary as upstairs rooms are only accesible by stairs. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannonced routine inspection [first of two planned before April1st 2006], which took place between 8am and 1pm. The Inspection found that 15 of the 21 National Minimum Standards inspected, had been fully met with most others nearly met. Discussions with Residents, staff, management, took place along with a tour of the home, and looking at paperwork records. One inspector focused on the building including bedrooms, communal areas along with looking at medication arrangements, and health and safety. The other inspector focused on Residents and staff, looked at care records, assessed progress since the last inspection and looked at other paperwork such as staff supervisions and training. The timing of the inspection allowed another chance to observe breakfast and general morning routines. At least 9 residents were spoken with, although their varying level of dementia affected their participation. Meal arrangements were assessed along with activities. Care and staff records, along with safety documentation were inspected. The inspectors both interviewed and observed staff. At the time of the inspection the home was providing services to 17 people with one due to move in that day. The inspectors took into account the need for the home to focus on arrangements for the new person. What the service does well: What has improved since the last inspection? Over the last year there have been no formal complaints made to Commission who inspects the home, just one concern, which was found to have been resolved between those involved. The homes awareness around the mobility Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 6 needs of residents continues to develop. All staff were found to been working through formal medication training. Formal staff supervision has been introduced showing a clear record of how staff are being supported and monitored. An accurate record of visitors is now maintained. Two further staff have started a National Vocational Qualification. Five of the sixteen rooms have been redecorated with more effective flooring put in one. Two rooms previously used as double-shared rooms are now used as singles leading to positive benefits for those concerned. Some chairs have been reupholstered and a new tumble dryer installed. Risk assessments in residents care-plans were generally found to be more up to date. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 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 standard(s) 1,3 & 5 The inspector found that the home can improve the provision of information to both prospective and existing residents, to help prospective residents make a decision about the home. Prospective new residents are offered opportunities to visit the home for a test drive. The homes information leaflet is attractively presented. The way in which the home assesses prospective or existing residents ensures that it continues to meet needs. EVIDENCE: The statement of purpose is detailed and well presented along with a colour brochure, complete with photographs and details on the home. The home have collected most documents needed for a service user guide into a lever arch box. The homes guide was found on a lower shelf to the side of the homes main entrance area. It was only on looking at the front cover that it was identified as a guide. The home was found to recognise the need for the guide to be more prominently displayed but stated that some residents can move items. The home were asked to think about how they better present the guide and make sure that visitors are prompted to access it. No views of residents were contained in the guide although there was the outcome of a complaint investigated last year. The box contained the most recent inspection reports. The home never admits anyone without doing their own Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 9 assessment, which benefits from the skills and experience of the management team. The inspector has previously sampled a number of assessments and found them to be in order. The other Registered manager to the owner/registered manager stated that she had not seen the assessment of the person moving in on the day of the inspection completed by the owner/manager who was unable to produce the assessment on the day of the inspection. However he fully detailed verbally an assessment of this person and how the home could meet her needs. He had also passed this information on to his manager who was working the whole day. The inspector also observed the manager discussing her needs with the resident’s social worker who visited shortly before the new resident moved in. Although it is expected that there is a written assessment in place before someone moves in to assist staff. This omission showed no evidence of affecting outcomes. New residents are closely monitored during the trial period as their plan of care develops. The managers confirmed that the home always writes to the new residents representatives to confirm that they can meet assessed needs. Due to time constraints contracts were not inspected although the homes manager/owner confirmed that terms and conditions and a contract including the bed fee is agreed prior to admission along with confirmation of the room to be allocated. Delays in recording what social services can pay are affected by delays with funding. Evidence was seen of a continuous assessment of residents with adjustments made to their care in order to meet needs, such as organising specialist support. One resident who the home had began to assess as needed nursing had made a better than expected recovery from a stoke and was found to walk without a Zimmer frame where he had previously been assessed as requiring one. The home had also met an assessed need of a newer resident in relation to supporting her to get cataracts removed resulting in positive outcomes as she confirmed to the inspector. The inspectors observed how the staff in the home was comfortable meeting the needs of residents. The management team were seen to encourage potential new service users and, or, their representative to visit the home before deciding to move in. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 9 The management team clearly demonstrated a full knowledge of resident’s needs including changes but need to ensure that this knowledge is passed on to all through the plans of care. Care plans show some choices and preferences but not enough. Care plans though improved need to show closer evidence of Resident involvement to show how rights are being upheld. Care-plans need to fully show how assessed needs will be met in practice including the whole needs of the person whether it be social, personal, or occupational. Where changing needs are identified the plan needs to show how these will be met. The care-plans are now more regularly reviewed along with risk assessments such as those dealing with mobility needs. Medication arrangements were found to be sound with all staff now working through formal training. EVIDENCE: The Inspectors examined 3 care-plans including one of a newer resident. Some of those plans examined just showed the persons breakfast and drink choice along with whether they were vegetarian. One plan indicated that a person was experiencing increased confusion with no further comment on how Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 11 this change was being met. Some sections of the care-plans where found not to have been filled in such as health, or issues and problems. A number of sections of the homes assessments had not been transferred to the day-day plan of care. Some of the plans indicated where someone needed full assistance in a certain area such as personal care. All of the plans examined were found to have been reviewed within two months of the inspection. All plans had detailed Moving and Handling risk assessments. One care-plan showed where improvements had led to a change in the assessment. The home was advised to update the overall risk assessment. The care-plans were discussed with the manager/owner where it was agreed that front line staff needed to have the right level for information to carry out the manager’s assessments of residents. The inspectors observed staff dispensing medication to residents along with their system of recording. Staff was observed to fulfil all aspects of best practice including infection control. Staff were also found to have began formal workbook medication training organised by a London college. The managers of the home also confirmed that new staff complete the homes own monitoring assessment before they can dispense medication and go on to formal training. There was evidence that some information in the Care-plans was referenced to in the daily reporting notes. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14 & 15 The home provides a limited range of activities based on some resident preferences. Although there is not a daily programme of activities for each resident, it was evident that a number of residents were neither demanding nor wanting high levels of stimulating activity. Those residents who prefer to be highly stimulated were found to have made a number of arrangements with the home to organise this including trips into the community. Routines were found to be flexible for Residents with positive changes over the last year such as with breakfast times. It was not clear from records such as care-plans whether any residents wanted to be more involved in the home. Due to the confusion experienced by residents dementia, the home were advised to liaise with independent advocates when disputes arise. Food is good, varied, healthy, popular with Residents, and served in good portions. EVIDENCE: The home has structured activities on a Monday in the form of bingo and drafts along with other games along with keep fit by qualified instructors every other Wednesday. Occupational pursuits such as housework, or community trips are informally organised depending on individual need. The monthly review of Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 13 care-plans includes a review of Resident’s hobbies and interests. This review will improve once all choices are recorded in the plan. One of the managers informed the inspector that it was her opinion that the current group of residents were overall not interested in a lot of activity as experience had shown her. The manager was aware of the need to continuously review people’s interests particularly when new residents moved in. Staff were observed to spend time with residents and assist them to move around the home when they needed this help. Care-plan’s [Standard 7] were found to have made a start in recording residents preferred interests. The Inspectors found that when they arrived at 8.0am that around half the residents were up. Breakfast was observed to take place over a long, flexible period and was prepared at the time of eating as opposed to in advance. It is now the stated responsibility of day staff to do breakfast as opposed to night staff, which allows for greater flexibility if service users wish to remain longer in bed, and makes the whole process less hurried. Most residents were observed to be relaxing in the main lounge or their room during the inspection. The home benefits from a library and a front courtyard and back garden which some service users access. One resident was observed in the kitchen undertaking a number of occupational tasks with staff support. This resident confirmed to the inspector that she goes to church three times week and goes out with staff to purchase her cat food. This information was confirmed in records. A resident informed the inspector of being confused about her rights and how the home operated. The management of the home were found to be knowledgeable about all these issues. To protect both the residents interest and the homes vulnerability to false allegations they were advised to contact an independent advocate for this person. T he management confirmed that they attempt to ensure that social services visit each residents at least once a year. Records of food served along with menus were examined. Residents were observed eating both breakfast and lunch. The kitchen was inspected along with food stocks and their storage. More able residents had condiments on their tables, other residents were observed to receive support with eating. The vegetarian needs of one resident were found to be met. Alternative meals were found to be served on occasion to those residents declining the advertised main meal. The cook was advised to record when this takes place. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home operates in a more open manner and has not had a formal complaint or a concern upheld over the last year. This reduction in upheld complaints/concerns represents an improvement over recent years. The home maintains a clear record of complaints made. Staff continue to demonstrate a sound understanding on how to prevent and report abuse in accordance with the homes policy. The home advertises its complaint policy within the guide to the home. EVIDENCE: The last formal complaint, which was communicated directly to the Commission, which was found to be upheld, occurred over a year ago. A concern communicated to the Commission within the last year was confirmed by the joint-owner of the home to have been resolved. This concern had also involved social services who had been contacted. There was no evidence that the concern was upheld. The alleged concern related to the transparency of how the home invoices Resident families where they have a responsibility to pay for either extras or the fees. The owner of the home stated that the issue had been partly caused with delays in social services agreeing with the family what level of the home’s fees they would pay. All invoices to families or other resident representatives were described as being fully itemised. Staff interviewed at this and the last inspection including newer members was clear about how to both identify suspected abuse, and report it. The home has a written policy on adult protection and whistle blowing and has developed a new handbook over the lat year, which was issued to all staff. The joint-owner confirmed that they do not handle resident monies and invoice families or representatives for any extras, which the home initially pays for. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 15 The home has a clear disciplinary code. This area is covered during the first two weeks of induction with all staff clear who to report concerns to. The quality of care was assessed to have been good throughout the inspection. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19,24 & 26 Dunsfold has a homely and well-appointed feel throughout. The home was found to be well maintained with suitable décor. The external grounds and large rear garden are popular with some residents. The uneven flooring and no level access internally or externally posses some hazards although this risk is managed by the home with the home responding if mobility needs change. The home only offers first floor rooms to those who can easily manage stairs. The cleanliness of the home, which had improved at the last inspection, was found to have slipped creating a poor impression around hallways and in some bedrooms. EVIDENCE: Both inspectors toured the home including an inspection of all bedrooms, communal areas such as the lounge, dining rooms, kitchens, and bathrooms. A number of rooms were found to have offensive odours. Most rooms were found to be unclean and required to be vacuumed this also included some hallways. The management did state that the cleaner was on leave and that they were recruiting for an additional person to ensure that there was a cleaner working in the home 7 days a week. The homes care-staff were Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 17 described as helping with cleaning during quieter afternoons although their focus was on residents. The home accepted that more effective arrangements were needed to cover this important area at all times. The home was found to be using two rooms previously used as double shared, as singles resulting in more space for resident’s including any equipment such as hoists. Laundry arrangements were found to be sound. No residents had locks to their rooms or lockable storage space with this decision based on a risk assessment. The manager/owner showed the inspector a lockable safe, which attaches to furniture and would be offered if any resident or relative requested this. The policy of the home is to discourage new residents bringing in to the home valuables. One resident was found to have a cold draft in her room. This was due to her insistence that her cat-flap was kept wedged open at all times. The management was found to have explained and demonstrated that the cat-flap works without being wedged open. The resident expressed some confusion to the inspector about this with her view of events at a variance with the staff and management. The room reserved for the new resident moving in, was found to be well decorated and clean with arrangements made for the person to bring in her own furniture. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 & 30 There was sufficient numbers of staff on duty on the day of the inspection to meet needs of resident’s. The rota showed that all times there is sufficiently qualified staff to meet assessed need. Since the last inspection the home has ensured that staff are sufficiently experienced such as at night. Staff inductions are good and include all relevant areas. Staff training has improved in terms of enrolling staff on National recognised qualifications with the home closer to meeting targets. Residents praised the quality of the staff and gave examples of how well supported they are. EVIDENCE: On arrival at the home both waking night carers were going off duty. The manager confirmed that both staff were experienced. The rota demonstrated sufficient staff for each shift. Day shifts include three staff, which includes the day [registered] manager with the owner/manager available where necessary. There is a number of ancillary staff such as two cooks, supper assistants, and domestic general housekeepers whose duties include cleaning enabling care staff to focus on service users. Two staff who work the night-shift, receive support from 7am by the one member of the day shift, with helping service users morning routines such as getting ready for the day. The home has over the last year organised for breakfast preparation to wait until 8am for the day, as opposed, to the night staff, to organise. This was observed in practice during the inspection and seen as positive for residents. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 19 The inspector did not inspect certification but was informed that 2 staff have at least NVQ level 2 or equivalent and that the numbers on this course has increased from 2 to 4. Most staff did accredited training with a Moving and Handling specialist last autumn, which assisted staff’s knowledge in meeting residents needs. The owners have over the last year purchased training material from a TOPSS[ now Skills for Care] accredited company, which subsequently meets national training targets. The home have been obtained TOPPS style induction workbooks and consult with training bodies to get up to date advice. The home operates internal induction training, which is gradually signed off by both the inductee and supervisor and includes all policies and procedures. The inspector saw an induction book at the last Inspection that had begun for the newest member of staff. The home also runs Alzheimer specific training. The joint owner confirmed that inductions continue to be carried out in this way with staff supervisions used to assess progress. All new staff are job coached and shadowed during their initial few shifts. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36 & 38 The home continues to benefit from a well-established, management team. The owner/manager demonstrates a good understanding of the needs of people with dementia type illnesses. Management time reserved for the administration of the home has improved but can improve further. The manager lacks the recognised qualification, which needs to be addressed in a timely manner. The home needs to show evidence that they are regularly surveying residents and their representatives views to show that the home is meeting expectations. The home has introduced formal written supervision, which is occurring regularly staff. Most staff now have the relevant safety training. The home ensures that all appliances are regularly serviced and maintained. EVIDENCE: The home verified at the last inspection [January 2005] that it requires the manager to have the appropriate qualification namely an NVQ level 4 in care. This requirement has also been confirmed with recent guidance given to Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 21 Commission. The home has 2 registered managers one of whom predominantly works shifts with a couple of hour’s admin time per week, although it was explained that this can stretch to 7 hours. The other manager is the Owner. It has been repeatedly highlighted that the registered manager on the care side has needed more time for administrative areas such as careplans, and promptly meeting requirements and recommendations from Inspections. Both managers were present during the Inspection although the manager on the care-side was on shift and participated in the first half of the inspection. She completed an advanced City and Guilds in the Management of Care in 1998. The Commission’s expectation is that the home moves to having one registered manager in line with the expectations of the National Minimum standard which were effective from 2002, 4 years after the current Arrangements were put in place. The owner/manager confirmed that it would be the other registered manager who will be doing the National Vocational Qualification level 4 in Care. The owner/ manager is a Registered Mental Health Nurse. His role alongside the other owner involves managing the business and offering specialist clinical advice including the development of care-plans and assessments. The other joint owner of the home assists with some financial and resident administration and was present during the inspection. The home has developed its own questionnaire for surveying residents and their representative’s views. Some of the blank forms were found in the service user guide box. The last review was said to have taken place in September 04 although no report has yet been seen to show the results. The home confirmed their usual practice of not being involved in directly managing residents monies or finances. The joint-owner stated that any bills/invoices sent to resident’s representatives are transparent and itemised. The home was found to have introduced formal written supervision for staff. One record showed supervisions taking place in October 04 and May 05 for a staff person. The management stated that not all staff want supervision every two months. The home was advised to stick to this standard and record when staff decline. It was evident that staff have ready and regular access to management as confirmed in staff discussions. All equipment was found to have been serviced such as the boiler on 20.6.05 and fire equipment 09.04. Most staff continue to undertake health and safety training such as Moving and Handling carried out on September 04. The home was advised that all staff should undertake such training to update themselves. The home promptly report incidents such as deaths to the commission but has been advised to ensure sufficient detail. The home have developed a form for separating auditing falls based on accident records and near misses, but have yet to fill these in. The purpose of the form is to allow any patterns to be quickly spotted with remedial action taken. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x 3 x 2 STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 2 x 3 3 x 3 Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 23 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 7 Regulation 15[1] Requirement That the Service User [Care] Plans must outline individual’s assessed needs and show how these will be met in practice. That preferences and choices are fully recorded. That all section of the Plans are completed and reflect information contained in assessments [Requirement of the last 4 inspections]. That the home must be kept clean and free from offensive odours Timescale for action Timescale Extension [7/10/05] 2. 26 16[j]& 23[d] 14/07/05 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 1 Good Practice Recommendations That the Homes service user[ Residents] guide is updated and includes all necessary information such as residents views. That the guide is appropriately presented, displayed, and available in the home. That appropriate independent advocacy or contact with social services is organised for a service user [Resident] identified during the inspection. That 50 of all care staff in the home achieve at least H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 24 2. 3. Dunsfold 14 28 4. 5. 31 33 6. 38 & 7 NVQ Level 2 by December 2005. That the registered manager[s] Commences and completes a NVQ Level 4 in Care, without delay. That the home periodically produce a report based on a survey of service users and their representatives views on the home. That this report is included in the service user guide. That the home maintains a separate record of falls which is audited on a monthly basis or when required. That this record shows what remedial action is taken. Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Dunsfold H59-H10 S21089 Dunsfold V231311 070705 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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