Inspection on 09/06/06 for Dunsfold

This inspection was carried out on 9th June 2006.

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

The inspector 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 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 Jon Wheeler Key Unannounced Inspection 9th June 2006 9:00 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.V294449.R01.S.doc Version 5.1 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.V294449.R01.S.doc Version 5.1 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.V294449.R01.S.doc Version 5.1 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 8th December 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. The previous inspection report was not available to service users or their families, although the report was sent out in January 2006. 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.V294449.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors and took place between 9am and 2pm on 9 June 2006. The Commission met with the proprietors at the office of CSCI in Eastbourne on 6th April 2006 to stress the importance of making the necessary improvements and changes, to ensure the home meets the Regulations and Standards. The inspection process involved talking to the two proprietors, one of whom is now the sole manager; three staff members and conversations with eight service users. Written feedback was received from five service users, two relatives and two visiting health professionals. The inspection process also involved a tour of the premises, observing staff working with service users; reading care plans, records, policies and procedures. The storage, administration and recording of medication were viewed. The inspection found that there had been progress in meeting some of the requirements from previous inspections. There were some new requirements made as well as previous requirements either remaining outstanding or having been partially met. One complaint had been received by the service. Whilst there was some evidence that the service has begun to investigate the complaint, including informing the Commission, the process of investigation had not been thoroughly documented. At the time of the inspection, the complaint was still being investigated. What the service does well: What has improved since the last inspection? Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 6 There is now a clear line of management within the home. The service has changed its format for the care plans, which generally have improved, although some require further information. The service has had an Occupational Therapy assessment of the environment carried out, which has led to improvements to the Environment, including the provision of a ramp in the communal lounge. The service has provided a wide range of training courses for staff and staffing levels have been appropriate. 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.V294449.R01.S.doc Version 5.1 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.V294449.R01.S.doc Version 5.1 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, 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Due to incomplete information, service users are unable to make a fully informed choice about moving in to the service. Generally pre-admissions assessments identified the needs of prospective service users, although some information was not recorded. EVIDENCE: There was evidence that the statement of purpose had been updated to include the recent changes in management within the home. However, the service user guide was not complete, with the most up to date inspection report not being available, despite it being sent to the home in February 2006. There was documentary evidence of an improvement in the pre-admission assessment of prospective new service users, although there were still some gaps in information within the assessments. There was documentary evidence that as part of the pre-admissions process, the service got information from Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 9 other professional agencies and where possible from the family of prospective service users. However, as there is one service user who currently is not having her needs met, the service must ensure it can demonstrate in the preadmission assessment that it can meet all the needs of new and existing service users. The service does not provide intermediate care. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 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, 9, 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service has improved its quality of care plans, although some information had not been recorded to enable the service to fully meet the needs of service users. Generally the health care needs of the service users are met. Although the inability to consistently use the correct equipment or procedures for the moving and handling of one service user did not meet identified needs at all times. Medication had been accurately recorded but was not kept securely at all times. Whilst generally service users are treated with dignity and respect, not all procedures were carried out in privacy and therefore did not ensure service users were treated with dignity at all times. EVIDENCE: There was documentary evidence of an improvement in the care plans. Plans had more comprehensive information and there was documentary evidence of care plans being reviewed on a monthly basis. Care plans included background Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 11 information about service users; photographic identification; record of visits by health professionals; pressure area assessments; daily recordings and evidence of a basic monthly review. However, whilst the quality of care plans had improved, there were still gaps in information in some plans. Whilst it was understood that some of this information may not be available, it was suggested by the inspectors that the care plan should reflect where information is unavailable, rather than areas of the plan remaining blank. There was documentary evidence that service users are supported to access a range of health services, such as a General Practitioner, Community Nursing, and Psychiatric nursing. Service users have also accessed hospital and inpatient services where required. It was discussed that one service user with more complex needs should be reassessed to ensure all their needs can and are met at the home. Manual handling training had been provided for staff a few months prior to this inspection and it was reported by some health professionals that the service has been given input in relation to meeting health care needs of the service users, including using hoisting equipment to aid moving and manual handling of service users. Despite this, it was reported that the staff had not been following the advice given and therefore the service could not ensure the health and safety of all the service users. There was evidence that the staff were due to undertake further training to try to ensure they used appropriate equipment and techniques to lift service users and meet their health needs. During the inspection, two service users were verbally abusive to each other on a number of occasions, with no clear staff intervention to ensure the wellbeing of the service users. At the time that the unannounced inspection started, a staff member in the dining room was dispensing medication to the service users. It was observed that whilst medication was being given to individual service users, the box containing the medication was left open and unsupervised. An immediate requirement was left for the service to ensure medication was kept securely at all times. All medication had been recorded accurately, once dispensed. Staff were generally observed treating service users with dignity and respect. Staff were seen knocking on bedroom doors before entering and talking to service users in a relaxed and friendly manner. However, one staff member was observed starting to shave two service users in the communal lounge, one of whom was asleep at the time. One of the proprietors was alerted to this and asked the staff member to carry out personal care routines in the service user’s bedroom or in a bathroom. In further discussion of this incident, the proprietors accepted that this practice was not acceptable and they stated that this would be picked up in the staff member’s supervision and training. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 12 Two staff were observed offering choices to service users and asking them what they would like to do. However, one staff member was observed escorting two service users from the dining room to the lounge, without asking them their choice, or telling them where they were going. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been some improvement in the provision of activities, but they remain limited for some people. Generally service users are encouraged to make choices in their lives, although not all staff sought views and choices about the service users daily life and activities. Service users are provided with a wholesome and nutritious menu, which offers choice and meets individual dietary needs. EVIDENCE: There was documentary evidence of some activities being offered at the home, although some service users did not access these opportunities. These are not routinely offered throughout each day. Activities offered included a discussion group on current events; dance; games; puzzles; an exercise class; reminiscence sessions; painting; songs and dance; watching films and a church service in the home. During the inspection, a staff member was observed playing card games with two of the service users. However, at the time of the inspection, most service users were sat in the lounge with the television on. Some of the service users were sitting down behind a row of high-backed Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 14 chairs and were unable to see the television. One service user helps to lay out the tables for meals, tidy up and dry the washing up. There was evidence in care plans that service users are encouraged and supported, where possible, to maintain contact with their families and friends. Feedback was gained from two relatives of service users who stated that they are made welcome at the home and are encouraged to visit. There was also evidence in recent pre-admission assessments that the service seeks information about service users from their families. During the inspection, some staff were observed helping service users make choices about where they would like to sit, or what activities they would like to do. However, one staff member was observed moving two service users about the home without asking their opinion or telling them where they were going. Care plans generally reflected the preferences and dislikes of individual service users, although it was stated by the proprietors that it was not always possible to get this information depending on the level of dementia of some of the service users and if they did not have family support to help with getting information about people’s likes and dislikes. Two service users said they were able to choose what food to eat, if they didn’t like what was on the menu and they could choose if they attended the activities or not. There was evidence of a varied and nutritious diet being offered for service users. Care plans recorded any preferences or dietary requirements of the service users. There was evidence of service users having choice of food for breakfast, which was being served when the inspection started. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 15 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, 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service does not robustly record the investigation of complaints. As the service had not completed CRB checks for all staff prior to them commencing employment, the service could not ensure the health and safety of service users. EVIDENCE: The service has a complaints book, although there had been very few complaints recorded as being received. One complaint had been received and was in the process of being investigated, although there was no clear documented audit trail to show that the investigation process had been carried out effectively. Whilst the Proprietors described the process they had undertaken to investigate the complaint, there was no written response to the complaint on file, nor written evidence of letters sent to investigate the process thoroughly. The service had an adult protection policy, although not all staff were able to clearly describe the policy or process of adult protection, should an allegation be received by the service. However, staff stated that they would be undertaking more adult protection training as part of their NVQ courses. The service was not able to ensure the safety of the service users as one staff member had been employed prior to a criminal records bureau check having Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 16 been completed. The service had done a ‘POVA first’ check on the staff member, but was not providing sufficient supervision to ensure the service users were protected. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users generally live in a secure environment and homely environment, which meets their needs and provides them with their own bedrooms and sufficient communal space. The service could not ensure the safety of all service users as some fire doors were propped open. The home provides a clean and tidy environment. EVIDENCE: The inspection included a tour of the building, including 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. There was evidence of recent modifications to the building, including a ramp to eliminate a potential trip hazard between the lounge and the dining room. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 18 At the time of the unannounced inspection, the home was clean and tidy, with there being evidence of sufficient cleaning at the service. During the inspection, the cleaner described the cleaning rota, which ensured all areas of the home were kept clean and said she had sufficient time and materials to successfully undertake her duties. Service users bedrooms were homely and individually furnished to meet their needs and preferences. No residents had locks to their rooms or lockable storage space with this decision based on a risk assessment. During the inspection, some fire doors were found propped open. An immediate requirement was left to ensure fire doors remain closed. The service had fitted automatic closing devices on communal area fire doors. In a downstairs bathroom, some chemicals and prescribed medicinal creams were not secure, being stored in an unlocked cupboard. An immediate requirement was left for all chemicals and medicines to be stored securely at all times. There was documentary evidence that the service had commissioned an independent Occupational Therapy report to assess the environment within the home. The owners had addressed some of the recommendations of the Occupational Therapy report. A ramp had been fitted to provide better passage between the lounge and one of the dining areas. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 19 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, 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are insufficient staff on some shift. There are gaps in staff training, so the service is unable to ensure they can meet the needs of the service users. The lack of robust recruitment procedures does not ensure the safety of service users at all times. EVIDENCE: At the time of the unannounced inspection, there were insufficient staff on duty to meet the needs of the service users. Although there were sufficient staff numbers, one staff member was working without adequate supervision, prior to his Criminal records Bureau check having been completed. This staff member should only work under constant supervision until the CRB and recruitment process are complete. The recruitment procedures were not robust, with one staff member working who had not had a completed criminal records bureau check. The service had completed a POVA check, but the staff member was not working under sufficiently tight supervision to ensure the safety of staff. This staff member had provided one reference, which had been taken verbally by the home, although the service had not received a written reference. It was discussed with the owners that all staff must have a CRB check completed before they are able to commence employment. Guidance from the Commission’s website Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 20 was subsequently sent to the service to clarify the situation. An immediate requirement was left to for all appropriate employment checks to be completed prior to staff commencing employment. There was documentary evidence of a staff training having been done or being planned, including fire safety; health and safety; moving and handling; pressure area care; care planning; medicines training; infection control; food hygiene. It is required that all staff undertake training in dementia to enable them to effectively meet the needs of the service users. Staff stated they had done adult protection training, although not all staff could adequately describe the processes of adult protection. It was recommended that further adult protection training be carried out to ensure all staff are up to date with the policy and procedure to ensure the protection of vulnerable adults. There was documentary evidence of a comprehensive induction training process for new staff, to ensure they are informed about the needs of service users and the policies and procedures within the home. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 21 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, 35, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is now a clear management structure within the home, although gaps in procedure means the home is not always run in the best interests of the service users. Service users finances are safeguarded in the home. Whilst there are a range of checks in relation to health and safety, the service cannot ensure the safety of service users as some fire doors were propped open and some chemicals and medicines were not securely stored at all times. EVIDENCE: Since the last inspection, there has been a change in direct management of the service. Following a dialogue with the Commission, Dunsfold now has a clear line of management, with one of the owners being the registered provider and manager. This has enabled the service to have clear lines of responsibility. The Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 22 staff stated that the owners are supportive and approachable. Where service users were able to comment, their comments were supportive of the manager, as was feedback from relatives. There was evidence at this inspection that since the owner has taken over the direct management of the home, there has been some progress in meeting requirements. However, there remain some areas needed for improvement, including the recruitment processes; quality of care planning and ensuring all staff work in a way that respects the dignity of the service users. There was evidence from talking to the owner and the staff that the service has changed some of its routines to try to ensure the home is run in the best interests of the service users. They are offered some choices in their lives and where care plans have improved, they generally reflect the individual needs and preferences of the service users. However, significant gaps in the recruitment processes for new staff means the home is not always run in the best interests of service users, to ensure their well-being. One service user continues to receive leg injuries as staff are not consistently using suitable equipment or moving and handling techniques. It was reported by the service that they do not handle the finance of any service users, which done by family or in one case by a financial appointee. There was documentary evidence of a range of health and safety checks, including regular fire drills, fire equipment having been checked on 5 October 2005 and an on-going maintenance plan. There was evidence of work having been carried out, including the fitting of automatic release mechanisms on fire doors in communal areas and a ramp being fitted in the lounge. Some bedroom doors were found propped open and an immediate requirement was left for the service to ensure all fire doors remain closed, unless fitted with appropriate automatic closing devices. Whilst there was evidence of continued moving and handling training for staff. There was evidence that in relation to one service user, the correct equipment and procedures were not routinely being used. It is required that the service ensures all staff are appropriately trained and follow the guidance to ensure all service users are assisted to be moved correctly. Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 23 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 3 X 2 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 24 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. 2. Standard OP1 OP3 Regulation 5, sch 4 14 & 15 Requirement Timescale for action 01/09/06 That the Service user guide includes all required information. That the Registered Person must 01/09/06 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. (This requirement was from the previous inspection of 8/12/05). That the Registered Person must 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 fully recorded. That all sections DS0000021089.V294449.R01.S.doc 3. OP7 151 01/09/06 Dunsfold Version 5.1 Page 25 4. OP8 13(1)(b) & 13(5) 5. 6. OP9 OP10 13 (2) 12(4)(a) 7. OP12 16[m]& [n] 8. 9. OP16 OP18 22 13(6) 10 11. OP22 OP27 12(1)(a) 18 (1) (a) 12. OP29 CSAasAm en177019 Sch-2 of the Plans is completed and reflects information contained in assessments [Requirement of the last 6 inspections]. Requirement first made 2003. That all staff are aware, understand and follow all advice from healthcare professionals especially in relation to moving and handling and use of the hoist. All medications are kept securely in the home at all times. That residents are treated with respect and dignity and personal care is not provided in communal areas. That the Registered Person must ensure that service users are regularly consulted as to their activity interests. That a regular programme of stimulating activities is made available. That participation is recorded to assess that such a programme continues to meets needs. That the complaints procedure is transparent and all complaints’ investigations are fully recorded. That all staff are fully aware of the home’s adult protection policy and procedure, know what to do if they have any adult protection concerns about a resident and receive appropriate training in adult protection. That all recommendations from he Occupational Therapist’s report are completed. There are sufficient staff, who have had a completed recruitment process, on each shift. That the Registered Person must write to the Commission to confirm that POVA first checks and completed CRB checks have DS0000021089.V294449.R01.S.doc 01/09/06 09/06/06 01/09/06 01/09/06 15/06/06 01/09/06 01/11/06 09/06/06 09/06/06 Dunsfold Version 5.1 Page 26 13. OP30 18 (c) (i) 14. OP31 9 (2) (b) (i) 181&121a 15. OP38 16. 16. 17. OP19 OP38 OP38 23 (4) 23 (4) 13 (4) a been carried out prior to persons [since 26/07/04] starting work in the home. This requirement was from the previous inspection of 8/12/05). All staff should receive up to date training in relation to people with dementia type illnesses. That the Registered Manager Commences and Completes a relevant management qualification. That the Registered Person must ensure that staff have appropriate and regular Moving [Manual] and Handling training, including use of the hoist, in order to meet assessed needs. This requirement was from the previous inspection of 8/12/05). Fire doors remain closed unless fitted with approved automatic door closing mechanisms. Fire doors remain closed unless fitted with approved automatic door closing mechanisms. All chemicals are kept securely in the home at all times. 01/09/06 01/12/07 01/09/06 09/06/06 09/06/06 09/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dunsfold DS0000021089.V294449.R01.S.doc Version 5.1 Page 27 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. 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