Inspection on 08/12/05 for Dunsfold

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 Jason Denny Unannounced Inspection 8th December 2005 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.V269330.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. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 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.V269330.R01.S.doc Version 5.0 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 7th July 2005 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. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced routine inspection [second of two planned before April 1st 2006], which took place between 9am and 2pm. The Inspection found that 6 of the 19 National Minimum Standards inspected, had been fully met with some nearly met. Discussions with Residents, staff, and management, took place along with looking at paperwork records. The inspectors focused on new Residents and those at a higher risk of falling or having high needs. Care, accident records, and other paperwork such as Complaints records, and health care was looked at. At least 8 residents were spoken with, along with others observed, although their varying level of dementia affected their participation. Two staff, manager, and owner/manager were spoken with. This report should be read in conjunction with the inspection, which took place on July 7, 2005, which like this inspection involved two inspectors and covered areas not covered here such as food, medication, staff induction and staff supervision. Comment cards were sent to the home prior to the inspection for circulation to residents, relatives, and professionals. Three comment cards completed by relatives were received with the comments being positive. Less positive comments have been received from district nurses with them concerned that the home cannot meet the needs of a resident who they assess to need a nursing home. This discussion is currently ongoing with the home. What the service does well: What has improved since the last inspection? The home was found to be much cleaner since the last inspection. A resident who was deemed to need a advocate outside the home to take an independent interest in her welfare and support her in the community has been organised much to her satisfaction. Although progress is slow the care-plans are starting to develop into a more suitable format. The owner of the home plans to redecorate further bedrooms, along with attending to the front exterior paintwork including window frames. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 6 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 DS0000021089.V269330.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 Dunsfold DS0000021089.V269330.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): 1,3 & 4 The home needs to update and review the information it provides to prospective new residents [service users]. The home is potentially placing people at risk by moving people in with high mobility needs into an unsuitable environment. Prospective new residents need to be adequately assessed before they move in with evidence of this assessment available in the home. Shortfalls in the home records make it difficult to assess if the home is meeting needs. EVIDENCE: The home has collected most documents needed for a service user guide into a lever arch box. The home’s 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. The box contained the most recent inspection reports. The homes statement of purpose was not found in the Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 9 guide. This was rectified during the inspection. This statement was found to need updating to include information such as the qualifications of staff. The home’s brochure was also found to need correcting such as the minimum age on admittance, which is 65 not 55 years of age. The home’s management were asked to be clearer about what type of home they are as they continue to provide services for those who cannot weight bear without two people. This is particularly relevant to the two most recent admittances who had high mobility needs on admittance. The home is not registered to provide nursing care. The home never admits anyone without doing their own assessment although written assessments and admittance dates did not exist in the home for everyone. A written assessment of a new resident was not found in the home although staff confirmed that the homes owner had discussed that persons needs with them. This person was also found to be without a care-plan despite being in the home for 3 weeks. The home’s management did find a one page hospital discharge sheet [with some useful information] which had arrived a month after the person moved in. The home have discovered since the person moved in that they have a history of falls with high number already recorded in the home during that person’s first few days. The home was found to have liaised with the resident’s GP and subsequently found out about a history of urinary infections. More recently falls have reduced in frequency since 19/11/05. None of the action taken by the home was found to be recorded. This new resident was observed to need 2 staff to assist them in walking although the home is not designed or suited to people with high mobility needs on admittance. Along with another new resident, both persons confirmed to inspectors that they liked the home and felt supported with their care needs. It was not possible to evidence whether the home was fully meeting assessed needs due to shortfalls in assessment information and care-plans stored in the home. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 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 the following standard(s): 7,8 & 10 Care plans were found overall, to be poor with little progress made over a number of inspections. The home now has a good care-planning format but needs to transfer information into it to show assessed needs will be met in practice including the whole needs of the person whether it be social, personal, or occupational. It is not possible to assess if health needs of residents are being fully met due to shortfalls in the care-plans. Residents benefit from being treated with dignity and respect by caring staff. EVIDENCE: The Inspectors examined 5 care-plans including two of newer residents. The inspector saw the new care-planning books where information from old care-plans is being transferred over. The manager who deals with the care plans openly stated that she had not had time to attend to care-plans as fully as she needs to, citing cooking duties and other non –management tasks which she has to perform. The two newer residents did not have fully detailed assessment information, Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 11 one had none, which had led to their care-plans being basic. One of these residents had no care-plan and had accidents due to falls form the 19/11/05 but whose daily recording notes did not start until 28.11.05 which indicate unsteadiness on their feet. The care-plan relating to the other new resident did not have most sections of the care-plan filled in and only a very basic personal profile. Her care-plan did identify the need to encourage her to use a Zimmer rather than a wheelchair although no mention of this was found in daily notes. She was observed to use a wheelchair during the inspection. Neither person had a date of admission into the home. A number of established residents had not had their information transferred into the new care-planning format to show how the home planned to care for them. A number of plans are not being reviewed monthly. The format of the new plans is useful as more information can be entered and they are easier to follow. One resident was found to have more detail in her plan and identified needs, although fuller information on how these needs are being met was lacking. A plan of someone who cares for a pet was looked at with no information recorded to show how a difficult situation which is potentially harming the resident [due to the informed choices she is making], is being managed. Similarly the plans lack information on how the frequent falls of a new resident were or are being managed. Shortfalls in recent assessments such as the lack of written assessments in the home meant that was not possible to fully assess if resident’s health needs were being fully met. The home was found to record when health professionals visited the home. It was evident from observation and talking to those residents who could elicit a response that staff treat them with respect and are attentive to those needs they are aware of. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 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 the following standard(s): 12,13 & 14 The home needs to show that residents are provided with a reasonable range of stimulating activities based on their preferences, and which occur at regular intervals. The home supports residents to maintain existing relationships with a freedom of movement afforded to them based on needs. Residents are supported to make some choices. EVIDENCE: The inspectors are yet to find any activities planned to be taking place during the last 4 inspections 3 of which have been unannounced. Throughout the inspection most residents [at one point 16] were in the lounge with the television on in the background. A daily activity schedule is displayed in the home but is not followed. Some residents indicated that they would like more to do. There is one regular activity, which take place involving a keep fit person who visits fortnightly [Extend]. The home does sometimes record when residents take part in activities however for one resident there was no entry after 10/11/04 [a year before this inspection]. Given that new residents have moved in and the low level of stimulating activities the home is advised to review and record what residents would currently like to do in terms of activity and then record when activities are participated in, or declined. It is evident that this area needs more focus whatever the varying needs are for Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 13 those with dementia. One resident did indicate that she continues, with a friend, to organise community outings such as regular visits to church. Routines in the home are again found to be flexible such as breakfast and wake up times. The two Visitors who completed comment cards commented positively on the home one of whom is a regular visitor. Although care-plans lack full information on people’s aspirations including activities and choice, some information is recorded. Staff were observed to offer residents opportunities to make choices such as at breakfast times. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 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 the following standard(s): 16. The home 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. EVIDENCE: The management of home confirmed that no complaints had been made to the home since the last inspection. The last formal complaint, which was communicated directly to the Commission, which was found to be upheld, occurred 18 months 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. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 & 26 Dunsfold has a homely and well-appointed feel throughout. 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 as evidenced in accident records. The cleanliness of the home was found to be much improved since the last inspection. EVIDENCE: Both inspectors toured the home including an inspection of all bedrooms, communal areas such as the lounge, dining rooms, kitchens, and bathrooms. All areas of the home were found to be clean and free from offensive odours. Carpets in the extension area were found to have recently been steam cleaned. One resident was found to have had a recent accident resulting in broken glasses after tripping on a raised step linking the lounge and a corridor. No residents had locks to their rooms or lockable storage space with this decision based on a risk assessment. One resident was again 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 Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 16 management stated that they have explained that the cat-flap works without being wedged open. The resident expressed some confusion to the inspector about this. The resident has developed arthritis but recognised in discussions that her decision was making the room cold although her concern for the pet took precedence. The home was again asked to review options, and ensure that this process is recorded as the resident’s decision could affect her welfare. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 & 29 There was sufficient numbers of staff on duty on the day of the inspection to meet care needs of resident’s. The rota needs to be more transparent to show the hours devoted to the management of the home. 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: The rota demonstrated sufficient staff for each shift. Day shifts include three staff, which includes the day [registered] manager. The patterns of work along with the role of ancillary staff such as cooks and cleaners is covered in the last report [07/07/05]. The manager [on the care-side] was found to be the cook during the inspection although this was not clearly identified on the rota. Her role currently involves being the cook two days week along with working on the care shift with one hour a week admin time insufficient to attend to the range of such management tasks. The owner of the home was not on the rota but was described as being in the home Monday to Friday and some weekends between 9.30 and 3pm where he attends to maintenance and the business. 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, with two night persons due to start. Although the home Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 18 is not close to meeting the Government target that of least 50 of staff having at least level 2 by April 2005. Some new staff has been employed since the last inspection although recruitment records were not available for inspection being stored in another home. In addition the management present during the inspection were not clear if POVA Firsts had been carried out on those staff who have started without their CRB coming back clear. They believed that the other homeowner may have carried these out. The home was advised to send the Commission evidence of this and also ensure that they are familiar with changes to law effective from July 2004. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 & 38 Insufficient time is being devoted to the management of the home affecting the quality of care planning and overall quality assurance. There is therefore insufficient evidence to show whether the needs of residents are being properly met. The manager of the home will benefit from devoting and being given time to keeping up to date with the requirements of a managing a care-home and best practice advice. The recording of accidents requires immediate improvement along with the monitoring of falls. The home is required to ensure that staff have appropriate Moving and Handling training to meet the needs of residents. EVIDENCE: The main conclusion of this inspection is that the manager and the owners of the home are not sufficiently showing that they are meeting the needs of residents as seen in major shortfalls in the homes admin and paperwork, as Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 20 stated elsewhere in this report. The manager [on the care-side, not the owner] is expected to manage care needs but through discussion and looking at the rota does not have sufficient time to attend to this, leading to drift. The manager effectively works on shift as part of the care team. When she is on shift such as cooking there is no one then managing the home with her expected to do both jobs/tasks. The registered owner was therefore requested to send the Commission job descriptions to evidence the lines of accountability to show who is responsible for what. It was further advised that these job descriptions are linked to the rota to show how the home can receive realistic management hours. 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 Commission. The manager confirmed that she has not explored such a course and that due to working six day week including two days cooking would not have time to do such a course. 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 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 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 was advised to ensure more evidence exists of effective quality assurance systems such as closer review of care-plans, activities, and response to changing needs such as when falls increase. At present the home does not separately record and audit falls. A number of accidents were found to be recorded although it is concerning that many, had cause unknown for falls and when people were found on the floor. Not all accidents referred to in daily notes of the same type where found in the accident book. Some accidents, which in one case resulted in broken teeth, had not been reported to the Commission. This was made an Immediate Requirement. Despite advice from the district nursing team the home is not using a hoist for a particular service user preferring to use a belt with two staff supporting. Staff and manager confirmed that they had no training in this technique and recognised the need for updated Moving and Handling training as the last training took place in August 2004. A fire door in the dining room was found to close properly with the home Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 21 advised to seek appropriate advice. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 1 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X X X 1 Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 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 OP1 Regulation 6[a]& 4[1][c] Requirement Timescale for action 31/03/06 2 OP3 14 & 15 3 OP7 15[1] That the Registered Person must keep the Statement of Purpose under review and update it to ensure that all information listed in schedule 1 is included and is accurate. That this document is clearly on display in the home within the home’s service user Guide. 15/12/05 That the Registered Person must ensure that service users are only admitted once a comprehensive written assessment has taken place including all necessary and available information having been obtained. That this assessment is available within the home and forms the basis for the plan of care. That this assessment is available for inspection to show the suitability of the home to meet needs. That service users are admitted in line with the home’s Statement of Purpose. That the Registered Person must 31/03/06 ensure that the Service User [Care] Plans outline individual’s assessed needs and show how these will be met in practice. That preferences and choices are DS0000021089.V269330.R01.S.doc Version 5.0 Page 24 Dunsfold 4 OP12 16[m]& [n] 5 OP27.2 17[2] Schedule 4.7 6 OP29 CSAas Amen 1770 19Sch-2 12[1] & 17[2] sch 4.7 7 OP31.6 8 Dunsfold OP33 24 fully recorded. That all section of the Plans is completed and reflects information contained in assessments [Requirement of the last 5 inspections]. Requirement first made 2003. That the Registered Person must ensure that service users are regularly consulted as to their activity interests. That a regular programme of stimulating activites is made available. That participation is recorded to assess that such a programme continues to meets needs. That the Registered Person must ensure that the home’s rota clearly shows the capacity in which each person works. That the managers hours devoted to the administration and management of the home is clearly recorded. Where the manager is employed in nonmanagement duties that this is recorded along with who is managing the home. That the Registered Person must write to the Commission to confirm that POVA first checks have been carried out prior to persons [since 26/07/04] starting work in the home. That the Registered Person must ensure that the Registered Manager has a job description, which enables them to take responsibility for fulfilling their duties, and that the home’s rota supports this. That this job description shows the managers role along with that of the registered owner. That a copy of these job descriptions is sent to the Commission by the date shown. That the Registered Person must ensure that effective Quality DS0000021089.V269330.R01.S.doc Version 5.0 31/03/06 15/12/05 08/02/06 08/02/06 31/03/06 Page 25 9 OP38.4 18[1]&12 [1][a] 10 OP38.7 37 Assurances systems are introduced and maintained. That regular survey of service user [residents] and their representative’s views are carried out to assess the home’s success in meeting its stated aims. That the Registered Person must 31/03/06 ensure that staff have appropriate and regular Moving [Manual] and Handling training in order to meet assessed needs. That the Registered Person must 08/12/05 ensure that all Accidents such as falls are appropriately recorded and reported to the Commission. This was made an Immediate Requirement on the day of the Inspection. 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 2 3 4 5 6 Refer to Standard OP7 OP7 OP28 OP31 OP38 OP38 Good Practice Recommendations That a particular care-plan records the decision making process in relation to issues concerning the care of a Pet. That daily notes are linked to Care-planning goals. That 50 of all care staff in the home achieve at least NVQ Level 2 as soon as possible. That the Registered Manager[s] commences and completes a NVQ Level 4 in Care, without delay. 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. That the home repairs or takes appropriate advice in relation to a fire door in the dining room. Dunsfold DS0000021089.V269330.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection East Sussex Area Office 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 DS0000021089.V269330.R01.S.doc Version 5.0 Page 27 - 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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