CARE HOMES FOR OLDER PEOPLE
Dunster Lodge Off Manor Road Alcombe Minehead Somerset TA24 6EW Lead Inspector
Barbara Ludlow Unannounced Inspection 26th June 2007 10:30 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 Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Dunster Lodge Address Off Manor Road Alcombe Minehead Somerset TA24 6EW 01643 703007 F/P 01643 703007 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) MRS MARGARET JOAN HAYES MRS ANNE CLARKE MRS MARGARET JOAN HAYES MRS ANNE CLARKE Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To accommodate one named person under the age of 65. Date of last inspection 31st October 2006 Brief Description of the Service: Dunster Lodge is an established care home situated in a quiet part of Alcombe approximately one mile from the town of Minehead in Somerset. The care home is at the top of the hill accessed along a steep narrow drive leading off Manor Road in Alcombe. The home is set in approximately 3.5 acres of landscaped grounds with panoramic views of Minehead and the Bristol channel across to Wales. The home is registered to provide personal care for up to 19 people over the age of 65. The registered providers and managers are Mrs Margaret Hayes and Mrs Anne Clarke; both live within the grounds of the home and are hands on in the home. The accommodation is over three floors with access by stairs and a passenger lift. Accommodation is mainly single rooms with one room being a shared room at the present time. The providers intend to make this into a single room in the future. The communal rooms include two sitting rooms, a dining room and conservatory all on the ground floor and accessible for ambulant and people who use wheelchairs. Toilets are close to the communal areas. The communal rooms are spacious with comfortable seating for all people in the home. The conservatory is mainly used for group activities and provides a suitable environment for people to sit and socialise. People sitting in the communal rooms can listen to music or watch television or sit quietly and read if they choose. The current fees range from £350 to £ 500 per week. Extra charges are made for personal items, hairdressing and newspapers. The providers have established a stable staff group, many of whom live locally to the home. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. One inspector for CSCI carried out this unannounced inspection over a six and a half hour period. The manager/ proprietor Mrs Clarke was due to go off duty but chose to remain at the home for the inspection. Mrs Hayes proprietor returned to the home late morning having accompanied a service user to hospital. Two care staff; the social therapist, the handyman and the chef were on duty. Contracted gardeners were attending to the grounds. Sixteen service users were in residence. All were seen during the day. A tour of the premises was made. Time was spent with service users and daily life in the home was observed. Staff were spoken with and lunch was taken with the social therapist. Records were sampled and inspected these included serving records, staff recruitment files, medication records and care plans. Feedback was given to the proprietors at the end of the inspection day. Questionnaires were sent out to General Practitioners and four were returned. Comment cards were passed to staff and seven were returned. Comment cards to service users and relatives were sent after the inspection visit. Extra time was given to the inspection period to allow feedback to received. Analysis of the feedback is included in the body of this report. This inspection was well received and the inspector would like to thank service users, management and the staff team for their time and contributions to the inspection process. What the service does well:
The home has a welcoming and homely atmosphere; service users seemed quite relaxed and comfortable. The feedback from service users and relatives supported this view. Comment included ‘provides a friendly and homely atmosphere’, offers ‘security and a homely feeling’. The home is pleasantly situated in the grounds and has accessible outdoor space. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 6 There are well managed and varied activities on offer. These were of interest to the service users, who can chose to opt in or out as they wish. There was good level of participation during the whole day. Comments received included ‘encouragement to take part in various activities is highly commendable.’ Bedrooms are personalised with meaning, photographs are nicely presented and hung on the walls at a height that makes them appealing and easy to view. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 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 Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5. Quality in this outcome area is good. The level of information available about the home is sufficient to enable an informed choice to be made. Pre admission visits are welcomed and pre admission assessment is made to make sure service user’s needs can be met at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a brochure with photographs. There is also a small map, which will be helpful when first locating this care home. A statement of purpose and service user guide (2002) is available; this document is supported with a DVD (Digital Video Disc) to provide information
Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 9 about the care home to prospective service users and their families. The DVD was not sampled at this inspection. The home has a cat and will take small pets by arrangement. At the visit the inspector heard of one cat and one small dog being in residence with their owners. One person more recently admitted to the home said there carers made the choice. This person said they had been made ‘very welcome’ and staff had been ‘very kind to the dog’. Written feedback confirmed that information available about the home had been sufficient and contracts had been agreed. One relative commented that they were ‘pleased to have made the decision for their relative’ and this had worked out ‘Better than they had dared hope’. Care plans were examined. Pre admission assessment had been made with information where relevant, was included from the community health and social welfare care practitioners. Care plans written on admission were written in a person centred way. Care needs of the individuals were met. Property lists were completed on admission. Consistency in admission practice and record keeping was evidenced in the random selection of care plans examined. Contracts were sampled and were clear. They included what are the extra costs that may be incurred such as newspapers, hairdressing and toiletries at cost. Incontinence pads where an assessment has not been made will be charged for. There are token charges / donations for events such as ballroom dancing. There is a charge for the summer ball to cover the costs. The inspector was informed that this is not prohibitive and has proved to be a very popular annual event. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is excellent. Service users were well respected and care was delivered in a dignified manner. Care plans support an individual approach to care. Consistently well recorded evidence of social and health care needs being met was seen. Medication records were well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were up and about at the time of this visit. All looked well cared for and seemed relaxed. Staff interactions with service users were respectful and kindly. Carers were described as ‘very kind’; service users addressed many staff, by name. The service users asked said they can choose how they spend their time each day. One person said of their usual day always ‘choose what to wear ‘and ‘has
Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 11 the help they need’ with their personal care. Assistance with bathing was given at the service users request. Care plans sampled for six service users. These care plans were written in a person centred style and described care needs in an individualised and meaningful way. Information was gathered consistently. Pre admission assessments had been undertaken. Chronic ill health conditions such as diabetes were recorded in detail. It was very clear how to meet the service users care needs and what to be alert for if unwell or any instability in their condition occurred and what action to take. The care plans included risk assessments and any falls were carefully recorded. Falls and any treatments are recorded in red. Professional health care input by the G.P or district nurse is clearly recorded in the care plan record. Health Professionals allied to health care such as the chiropodist also visit the home. Feedback to CSCI from visiting health care professionals was requested in May 2007. Positive responses were received from four G.P practices. One commented that this is an ‘excellent home’. A visiting community nurse was spoken with at the inspection. They confirmed being able to see their patient in private, having access to hand washing facilities and having a good rapport with staff at the home. Pressure area care and prevention is jointly managed with access to preventative aids and care advice being agreed. One person reported to be at risk of pressure sores developing had a detailed care plan which stated the frequency of checks and interventions at night. Also it stressed the person must be handled ‘gently’ and the care plan emphasis was for tender loving care. Weight is measured regularly, evidence of healthy weight gain since admission to the home was recorded for one person. Medication records were examined. Individual photographic identification is used for the majority of service users. No gaps were seen on the medication administration charts. Two members of the senior staff check medication received into the home. Medications are counted and then signed in by one staff and countersigned as checked by another. With only two exceptions, the records of medication administration and management were excellent. Staff spoken with confirmed having received medication and manual handling training. One relative had said that if there were any concerns about their relative ‘they were informed within minutes’. Another was pleased to be given the
Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 12 opportunity to take their relative to appointments outside the home to the dentist or surgery. Comment from a service user was that the ‘care is excellent’. Written feedback from four care staff indicated that senior staff are involved with the administration of medication, also that they are clear about their roles and responsibilities. Staff indicated that they have not had to deal with situations they feel unprepared for. Staff were asked about the night care routine. Day staff work until 9pm then one staff is in the building with a senior person (manager) ‘on call’ on site. Hourly checks are made on service users unless they request otherwise. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. Service users are treated with respect. Care is individualised and meets the needs of the service users at the home. Activities are well managed, varied and supportively undertaken. Meals are sociable occasions and a good choice is offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sixteen service users were in residence. One person was attending the hospital and had been taken by Proprietor Mrs Clarke as support. Daily life at the home was observed. Service users spent their time, as they preferred, some were sitting in their rooms; others were in one of the lounges or had joined the social therapist in the conservatory to paint or knit. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 14 The Social Therapist and Service users have a’ List of 10 Great Ways to treat each other’, this, which starts with ‘use kind words’. This list of ground rules has been agreed to promote respect and tolerance between service users and with staff. Service users seemed to be very relaxed and were happy taking time to do the things they wanted to do, reading or knitting and socialising or enjoying a creative painting opportunity. An art exhibition had been held in May to exhibit some of the work produced at the home. Knitted dolls are sold to raise funds. Comment heard from service users about staff and their effect on the home included ‘staff are good’, ‘like the friendliness’. Morning coffee with biscuits was offered, other drinks were available throughout the day. At lunchtime eleven service users ate together in the dining room, others had chosen to take lunch in their bedrooms. The inspector joined the activities coordinator and had lunch in the conservatory. A well presented and tasty meal was served. One person commented that the food was ‘exceptional’ and there are a ‘variety ‘ of meals offered. The meal at lunchtime was orange or apple juice. Cottage pie, gravy, roasted and / or mashed potatoes, cauliflower and peas served from a trolley, all diners were asked if they were all right and second helpings were offered. Dessert was apple crumble and custard. Asked about the food, one person said the ‘porridge was a disgrace, on most days’. No other negative comments were heard. The social therapist has introduced ballroom dancing classes with a local instructor. This was reported to be very popular. Trips out for four or five people with the social therapist in her land rover are well supported. Journeys to the harbour at Watchet or Blue Anchor Bay for afternoon tea are arranged. In warmer pleasant weather the gardens are used and service users sit outside. There is a Summer Ball, which is held in a marquee in the garden and gives an opportunity for really dressing up and celebrating with families and friends. Books of memories are have been started for some of the service users and families and friends have been asked to contribute with photo’s and stories. The social therapist has made efforts on behalf of individuals to help them retain and rekindle contact with their families and friends. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 15 The hairdresser visits the home each Wednesday and holistic therapies can be arranged up to twice per month, at cost. Attendance at Religious services is supported. Service users currently attend a service on Tuesday afternoon and are collected from the home. The social therapist is qualified to diploma level, enthusiastic and commented that the proprietors are very supportive and encouraging which makes the work very enjoyable. The evidence seen was of a commendable range and quality of social opportunities being offered. Service users and relatives offered praise in writing for the range of activities and the ‘encouragement to take part’. The home was described as ‘friendly’ and as having a ‘homely atmosphere’ and a ‘secure, caring and lively atmosphere’. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. The home has a complaints policy. Staff are aware of the adult protection issues and the risks to the vulnerable people. Staff recruitment practice must be managed more robustly in future to reduce the risk of harm to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy and procedure is well advertised. It is included in the home’s statement of purpose and service user guide. The Commission for Social Care Inspection has not received any complaints or concerns regarding this care home in the last twelve months. No complaints or concerns have been recorded in the homes complaints book. Staff returning questionnaires and those spoken with confirmed they had received training and information about protecting vulnerable adults. They also expressed their confidence about raising concerns about poor care practices or allegations of abuse. The inspector checked two staff files to look at the recruitment procedure.
Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 17 Two staff had commenced working at the home before Criminal Record Bureau Protection Of Vulnerable adults (POVA) First checks had not been taken up. One requirement is made for all future recruitment practice. Otherwise a good level of information was gathered during recruitment processing. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,26 Quality in this outcome area is good. The home is well maintained and provides a well adapted environment for service users. It is homely and service users private space was tastefully personalised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made. There have been some improvements made to the environment. A new assisted bathroom has been commissioned since the last inspection. A special assisted bath, new toilet with hand rails and large wash hand basin had been fitted, the floor covering was specially fitted (tanked) to making it easy to thoroughly clean and less likely to leak spillages.
Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 19 Service users rooms were sampled, they were very nicely done, and pictures and photographs were at a level that made them easy to view. The personalisation of the rooms made for a homely inviting environment. One service user said that ‘it’s a lovely home’ and they are ‘very happy here’. The home was tastefully decorated and was clean and tidy. Malodour was noticed in one room and was discussed with Mrs Clarke, Where regular deep cleaning fails attention to replace the floor covering should be made. This is recommended. Environmental safety has been taken into account with hot water temperature restricted at bath outlets, potentially hot radiator surfaces were covered and first floor windows were restricted in opening. Fire alarm testing is carried out and a routine test was conducted during this inspection. The conservatory, which has a good view out to the garden, is well used and had a lot of activities equipment stored there. The chairs were comfortable and the ladies using this room had their places to sit and seemed very content. All asked made positive comments about the home and reminisced about the events they had shared at the home. The garden is extensive and the level areas are well used and photographs of the summer ball were seen, the inspector heard that the service users are fund raising for a marquee for such events. The drive has a tarmac surface making its surface more level and safer to negotiate. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. Staff recruitment practice could place service users at risk of harm. The skill mix and number of the staff on duty provides a level care sufficient to meet the needs of service users in residence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On duty at the home visit was the provider/manager, who had been on call overnight night. Mrs Clarke was due to go home but chose to remain at the home for the duration of the inspection visit. Sixteen service users were in residence; a mix of dependency was seen. Two care assistants, the chef and the handyman were on duty. Mrs Hayes, proprietor was escorting a service user to hospital for an appointment to give the service users some support. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 21 Two staff files for new starters since the last inspection were examined. Both files evidenced that the staff had commenced work at the home without the minimum of a satisfactory Criminal Records Bureau POVA First check having been received. The home has ten staff who have achieved with NVQ Level 2, and two that have achieved NVQ level 3. Staff supervision is recorded on computer and a running record is produced. This recording system was sampled and provided a regular updating of staff supervision. Staff meetings are held; the last recorded meeting was on 8.05.07 Staff spoken with confirmed that they had received induction training and had initially worked shadow shifts to be introduced to the home and the service users. These staff had received fire and manual handling training. Continence training, medication management and administration and food hygiene training were also mentioned. Supervision was described as informal. One staff commented that they ‘love it’ (working at the home). Written feedback from staff indicated that staff felt induction and supervision was adequate. That staff were aware of the homes policies and procedures. They also confirmed having CRB checks and being provided with personal protective clothing, such as gloves and aprons. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is good. Service users benefit from a service that is well managed and that is clean, comfortable and safely maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management of the home are dedicated and experienced in running the home and providing a caring service. One service user said that ‘the home is very well run and creates an environment to enable me to keep active and I am very happy they have my
Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 23 interests at heart’. Praise came from relatives who felt they had helped their relatives to make the right choice and were kept informed and up to date with the welfare of their relatives. The home has developed staff supervision since the last inspection. Feedback from staff was very positive, the inspector heard that the home is an enjoyable place to work and the proprietors are encouraging to staff offering training and ‘100 support without exception’. The home has a detailed fire policy. The medications policy was also seen. The maintenance records for the home were examined and were up to date for the fire alarm, emergency lighting and the detection equipment. Fire extinguishers were serviced in July 07. A copy of the six monthly fire training record for all staff with dates given and with planned refresher dates set was given to the inspector. Staff confirmed having received fire training. Night staff fire training sessions should be three monthly, this is recommended. The portable and bath patient hoists had been serviced, 4.10.06 and 13.3.07. The lift was serviced in February 2007. Staff supervision is recorded as a computerised running record; this was sampled for two staff. The home are currently renewing their Quality Rating with Social Services and the focus of the Quality Assurance at this time was directed towards this. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19(1)(b) (i) Requirement Staff must have a POVA First check in place before commencing work at the home, to ensure their suitability to work with a vulnerable client group. Timescale for action 25/09/07 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 Refer to Standard OP24 OP38 Good Practice Recommendations One carpet that requires regular deep cleaning should be replaced if the cleaning fails to remove the malodour. Fire training for night staff should be four times per year. Dunster Lodge DS0000016016.V341626.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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