Inspection on 26/06/07 for Dussindale Park Nursing & Residential Home

This inspection was carried out on 26th June 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dussindale Park Nursing &... 11/11/08

Dussindale Park Nursing &... 30/06/06

Dussindale Park Nursing &... 07/11/05

Dussindale Park Nursing &... 05/05/05

Dussindale Park Nursing &... 26/10/04

Dussindale Park Nursing &... 29/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Dussindale Park Nursing & Residential Home Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD Lead Inspector Mr Jerry Crehan & Hilda Stephenson Unannounced Inspection 26th June 2007 09:15 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 Dussindale Park Nursing & Residential Home DS0000044398.V344371.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. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dussindale Park Nursing & Residential Home Address Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD 01603 701900 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) dussindale@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Care Services Limited Mrs Johanna Paul Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Fifty-eight (58) Service Users may be accommodated of either sex who are aged over 65 years. From time-to-time 2 service users between the age of 50 and 65 years may be accommodated. The total number not to exceed fifty-eight (58). Date of last inspection 30th June 2006 Brief Description of the Service: Purpose built in 1994, Dussindale Park is situated in a modern residential suburb of Thorpe St Andrew on the outskirts of Norwich. The home can accommodate 58 older people with residential or nursing needs, in single and double rooms; 38 of the rooms have en-suite facilities and some of the ground floor rooms open up to patio areas. The accommodation is on the ground and first floor levels, and can be accessed by passenger lift. The second floor is used for offices and storage. The surrounding lawns and garden areas are well maintained and can be accessed by service users. There is ample parking space at the front and to the rear of the premises. The local GP practices and other health professionals support the home. The range of fees charged is £460 - £600. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. Before the inspection the Manager completed a lengthy questionnaire about the service. Fourteen comment cards were received from service users and their relatives. Records held by the Commission and previous inspection reports were checked. This key inspection compromised an unannounced visit to the home that took place over 7 hours on 26th June 2007. Opportunity was taken to tour the premises, look at care records and policies, and communicate with the home’s service users, their relatives, several nursing and care staff, and the Manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. Dussindale Park is one of several homes in Norfolk owned by the Proprietors. There has been a change in the ownership of the service since its last inspection report. What the service does well: • • • • • An assessment of all new service users is carried out and all prospective service users are invited to the home with their relatives. People’s individual healthcare needs are carefully looked after, and the home is proactive in the management of continence and pain relief. Staff are respectful and give people privacy and dignity. The home is well equipped to provide comfort and meet the assessed needs of people who use the service. There are good records of complaints, that consider corrective action to be taken and consideration for future preventative action. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: • The service must provide new and prospective people who use the service with sufficient and up to date information about the home to make an informed choice about long-term care. New service users and their relatives must have easy access to the complaints procedure so as to be absolutely clear about how they may complain if they wish to. All nursing and care staff must receive refresher training on adult protection issues, which helps to protect people who use the service. All nursing and senior care staff with responsibility for providing formal supervision must receive training appropriate to the task they are required to perform. Recommendations have been made that all staff receive refresher training in infection control, dementia awareness and that more care staff are supported to undertake NVQ training. • • • • 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. Dussindale Park Nursing & Residential Home DS0000044398.V344371.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 Dussindale Park Nursing & Residential Home DS0000044398.V344371.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): Standards 1 & 3 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The individual needs of people using the service are assessed and understood in order that the service can be sure their needs will be met. Prospective people to use the service and their representatives do not have the information they need to choose a home, which will meet their needs. EVIDENCE: The home does not have an updated ‘Statement of Purpose’ or ‘Service Users Guide’ to reflect the services provided at the home since the recent change of ownership. The home’s Manager stated that they had provided the Proprietor with the information required for these two publications, but the Proprietor has not provided the completed publications. Consequently the home’s Manager is passing on verbal information and providing prospective service users with the Proprietor’s brochure. However, this document does not contain sufficient Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 9 information for anyone to make an informed choice about long term care (See Requirement 1). The home has a well-designed assessment pro-forma (for pre-admission assessment) used by the Manager or deputy when collecting information to ascertain the level of support required by prospective service users. There is evidence of assessment for new service users seen in their files. All prospective service users are invited to the home with their relatives. The Manager and other senior staff will show people around and provide additional information about the service and its facilities. The majority of service users spoken with, or who completed comment cards prior to the inspection visit, said that they were given sufficient information about the home prior to moving there. The manager stated that she takes care to consider the impact on the service user group at the home of the accommodation of any prospective service user. At the time of the inspection visit service users seen were certainly appropriately placed, and the service user group appeared compatible. Dussindale Park Nursing & Residential Home DS0000044398.V344371.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): Standards 7, 8, 9, 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services receive good nursing and personal care that is based on their individual needs. The principle of respect for people as individuals is put into practice. EVIDENCE: A sample of service user’s care plans were thoroughly examined and found to contain clear, concise information regarding the health care needs, with the social needs of each individual currently being developed. Each of the care plans contained risk assessments in relation to their moving and handling needs, medication involvement, with indicators in place to monitor nutritional needs by assessing pressure care, weight management and the home is proactive in the management of continence and pain relief. Service users and their relatives spoken to confirmed that they were regularly kept up to date with their care needs and written aspects of the care plans with the care plans being reviewed on a monthly basis. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 11 Evidence of specialist services such as chiropody, optician, dental and palliative services were regularly sought for those who required such healthcare. Service users confirmed that the staff at the home upholds their privacy and dignity at all times, assisting them back to their rooms or the quiet lounge if they require a quiet area. Care plans seen were based on the service users assessment of their healthcare needs and on activities of daily living. The management of the home had taken into account the importance of obtaining more information regarding the service users social care needs, past hobbies and interests since its last inspection. Senior staff explained that the new format from the Proprietor includes various stages of a person’s life breaking the sections into childhood, teenage years, middle age and old age. Staff also explained that several families had taken these away to complete as comprehensively as they could, to enable the staff to have a better understanding of the person they were caring for. It is recommended that the home complete the social care needs of each service user as soon as possible to enable the staff to have a better understanding of the people they are caring for from the outset (See Recommendation 1). The care needs for some service users included clinical intervention for wound care. Appropriate risk assessments and nursing procedures were in place for these people, with regular reviews. Nursing staff had evidence of wound care training booked in July 2007 to enable them to keep up to date with current practice and trends. The home is separated into two units, with a nurse in charge to manage each. The Manager explained that she visits each prospective service user to assess their needs and to ensure that the home can meet these, and that she has to take into account other service users needs also, ensuring that service users are not placed inappropriately for the group as a whole. There are suitable safe storage arrangements for medication in dedicated rooms. The home uses a ‘Monitored Dosage System’ for administration of most medicines, and nursing staff take responsibility for administering medicines. Appropriate records are kept for the receipt of medication into the home, its administration and any medication returned to the pharmacy. Controlled drugs were appropriately stored and records corresponded with stock held. However, it was evident that care staff members who are not appropriately trained witness the administration of controlled drugs on occasions (See Recommendation 2). There is a payphone available on the ground floor, and every bedroom has a telephone point. Usually when a service user receives a call, the caller is asked to call back in a few minutes while the phone is taken to the service user, or service user brought to the phone. It is recommended that alternatives (such as a cordless telephone) to these inconvenient arrangements be made, and that alternatives ensure that service users are able to make and receive calls in private (See Recommendation 3). Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have access to a good diet that is specially prepared if necessary. Social needs and recreational activities provided at the home are adapted to suit service users individual tastes, and will be improved with the appointment of dedicated staff to this role. EVIDENCE: Many service users were too physically frail to take part in more organised activities, though it was noted that the home provides talking books, music and reminiscence discussions. Those service users with a memory impairment had photograph albums of family and friends to help jog her memories of their past life. The care plans contained life histories of service users to assist staff to raise topics with them for reminiscence topics, although this had not been completed in all cases. It was observed that staff respected those service users who did not wish to take part in activities and preferred to stay in their room, although it was noted that some staff were sitting talking with these service users at various times during the day. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 13 The manager explained the post of ‘activities coordinator’ was currently a vacant. However, one of the senior carers organises games, cards, picture bingo, singing, parties and the occasional outings, with the previous outing to a local seaside town, and a further two organised during the summer months. The home should be commended for enabling service users to continue with contact with the community. During the day of inspection, nine service users were taking part with reminiscence discussion with photographs to jog their memory to tell their own stories, all the service users evidently enjoyed this activity. Comments received prior to the inspection visit include positive statements such as ‘the home celebrates special occasions very well’ and ‘the staff interact with residents and are very kind and caring’. Discussion with frailer service users confirmed that staff visited them in their rooms at various times during the day to chat or offer to put on music, television or take them for a stroll around the home. Some service users complained of being a little bored during the day and wished they had something to do. It is recommended the home employ the activities co-ordinator as soon as possible who can specifically adapt activities for those who are frail to help relieve boredom (See Recommendation 4). The fourteen comment cards from service users and relatives/visitors to the home confirmed that the content and quality of the meals continue to be generally good. There are three well-presented dining areas providing a good ambience for service users to take their meals. The kitchen staff are able to provide specially prepared foods and for special diets. The kitchen was found to be clean and the chef was preparing lunch of steak pudding with two further alternative main courses. Staff who prepare and handle food have undertaken the food hygiene training. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people who use the services and their relatives do not have access to the complaints procedure. People who use the services are protected from abuse. EVIDENCE: Copies of the complaints procedure are available in the home’s reception area. As indicated earlier in this inspection report there has been a delay in the home being able to provide its ‘Statement of Purpose’ or its ‘Service User Guide’ to service users and prospective service users. Among other information these documents explain out how to make a complaint. It is a concern that new service users and their relatives do not have access to these documents and may not be absolutely clear about how they may complain if they wish to (See Requirement 2). Service users asked about whom they would go to with a concern or complaint indicated that they would speak with the Manager or the Nurse, and three of the four comment cards from service users indicated that they know how to make a complaint. Records of complaints are kept at the home and were seen at the inspection. They included the complaint, findings of the investigation, corrective action to be taken, consideration for future preventative action. This is good practice. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 15 The home has experience of appropriately referring matters (in the last twelve months) for investigation through the Adult Protection Protocol, for the protection of vulnerable adults living at the home. Nursing and care staff spoken with were clear about the action they would take if concerned about the possibility of abuse taking place at the home and were confident that they could deal with this appropriately. They were equally aware of the home’s ‘Whistle-blowing’ procedure and its function. Staff have received training in the protection of vulnerable adults, however, this needs to be refreshed for many staff and provided to newer staff (See Requirement 3). Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22, 24, 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment at the home is safe, well maintained and designed to support the needs of people who use the service. EVIDENCE: A tour of the building and inspection of maintenance records demonstrated that the home is well maintained and meets service user needs in a homely and comfortable way. The home’s grounds and gardens are well established, attractive and reasonably maintained. The Manager stated that additional security arrangements are currently being considered for the home. This may mean additional security at the home’s entrance with a coded keypad (or other system) for entry and exit. There are storage facilities for the variety of equipment and mobility aids keeping the general environment clear and accessible. However, some Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 17 equipment is stored in communal parts of the home. The manager stated that there are no alternative storage options for some equipment, it was therefore recommended that the Manager or other appointed people monitor the storage of equipment to ensure it does not present a risk (See Recommendation 5). The home was free of any unpleasant odours at the time of the inspection visit. There have been changes to the accommodation provided at the home. There is a reduction in the number of shared bedrooms with a view to a maximum occupancy of 48. Other changes to the environment have included the developing of a ‘memory room’ with reminders of every day things and objects. Several service users were enjoying this space at the time of the inspection visit. Accommodation for service users is well decorated and furnished. Doors to service users private accommodation is lockable and there are lockable facilities within each bedroom for money and valuables. The home is generally well equipped to provide comfort and meet the assessed needs of people who use the service. The home has had difficulty in managing service users’ laundry and the Manager has acknowledged this difficulty. Measures have been introduced since the last inspection visit to help to ensure the proper management of laundry and to ensure that service users have access to their own clothing at all times. Staff practice seen provided evidence of an understanding of good infection control practices, however, staff training records indicate that many staff require training and refresher training in infection control (See Recommendation 6). Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are generally well trained and in sufficient numbers to adequately support the people who use the service. For this outcome to be good, staff whose training is up to date should care for people who use the service. EVIDENCE: There were 41 service users accommodated at the time of the inspection visit, twenty-one people living on the first floor and 20 on the ground floor of the home. Two nursing and seven care staff cared for them (though the Manager and staff rotas indicate this is sometimes eight care staff in total). There is also domestic, kitchen and maintenance staff. Generally there is a nurse allocated to take charge of each floor of the home, supported by four care staff on the first floor, and three or four care staff on the ground floor. This was an adequate staffing allocation that met the individual and collective needs of service users at the time of the inspection visit. However, some comments from service users and relatives received prior to the inspection indicate a view that there are not always staff available when they are needed, for example ‘not always many staff on duty to deal with the numbers of patients’, and ‘sometimes you cannot get to talk to anyone because staff are no-where to be Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 19 seen or are too busy to talk to you’. The overall evidence suggests that the needs of service users are being met but some of their expectations are not. It was clear that service users need a high level of care and nursing care, with care tasks generally needing two carers at a time. Consequently the allocation of three care staff to a floor rather than four would have a significant impact on their ability to meet assessed need and to meet the expectations of service users. Effectively a nurse and carer would be responsible for the remaining twenty (or thereabouts) service users while their colleagues attended to one person. It is recommended that the Manager maintain the provision of four care staff on each floor of the home (See Recommendation 7). There are eleven registered nurses and a care staff complement of 24, of whom 5 have a minimum qualification at NVQ 2 (or equivalent). The Manager stated that this training had been applied for an additional eight care staff. This would see the home exceed the minimum 50 requirement of trained staff. (Standard met in part and ongoing, see Recommendation 8). Sample staff files and discussion with carers provided evidence that service users are protected by improved and good recruitment practices. Sample staff files seen and discussion with staff provided evidence of mandatory training and some specialist training with evidence of learning in place. Training includes fire awareness, health and safety, manual handling, infection control, basic food hygiene, and dementia awareness. It is recommended that dementia awareness training be extended to all staff (See Recommendation 9). As indicated in this report, it is recommended that staff receive training (and refresher training) in adult protection/understanding abuse, in infection control and in supervision. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager of the home is experienced and qualified. There are well established measures for monitoring the quality of the service provided to people who use the service. EVIDENCE: The Registered Manager is a first level nurse who has recently completed her ‘Registered Managers Award’; she has continued to attend a variety of other care and management training. The Manager has approximately twenty years experience of Management. Staff and service users both described her as friendly, balanced and approachable. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 21 However, the Manager stated that she has resigned from her post and will be leaving the home in August 2007. At the time of the inspection visit this was known by many people at the home and will have an unsettling effect as changes as significant as this are bound to do. It is hoped that the Proprietor will act promptly to appoint a suitable replacement at the home. There are several processes at the home for monitoring the quality of the service it provides. The Manager and the Proprietor carry out quality audits covering a range of topics, and they send monthly monitoring reports to the Commission. The Manager arranges six monthly meetings for relatives and service users to air their views and share information about the home. The home has an ‘in house’ newsletter produced about four times each year where general information about life in and around the home is shared. The Manager stated that she had incorporated satisfaction survey feedback into the newsletter. The newsletter is not circulated outside of the home and consequently will not be available to many relatives, and other ‘stakeholders’ (See Recommendation 10). It is also recommended that the Manager conduct staff meetings that are available to all care and nursing staff at the home (See Recommendation 11). This will help to ensure clear leadership and clear lines of authority and responsibility within the home, they may also be a means of quality monitoring. At present staff meetings described are smaller meetings arranged on an ‘ad hoc’ basis. Relatives or appointees manage service user financial affairs. Financial records reviewed were satisfactory, corresponded with monies held at the home and are evidently audited periodically. There is evidence of arrangements in place for formal supervision of nursing and care staff, however, supervisor’s have not received training to carry out this task. All staff with responsibility for carrying out formal supervision should receive training relevant to the task they are required to perform (See Requirement 4). It is recommended that the Proprietors should offer the Manager appropriate professional supervision and support (See Recommendation 12). The health, safety and welfare of service users are met. Maintenance and Fire records are well kept. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 2 X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 3 Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4(1) Requirement Prospective people who may use and do use the service must be provided with sufficient and up to date information to make an informed choice about long-term care. Prospective people who may use and do use the service must be provided with up to date information about how they may make a complaint. All staff must receive refresher training on adult protection issues, which helps to protect people who use the service. All nursing and senior care staff with responsibility for providing formal supervision must receive training appropriate to the task they are required to perform. Timescale for action 31/07/07 2. OP16 22(5) 31/07/07 3. OP18 13(6) 31/07/07 4. OP36 18(c)(i) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 24 No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the home complete the social care needs of each service user as soon as possible to enable the staff to have a better understanding of the people they are caring for from the outset It is recommended that all staff with a responsibility for administration of medicines have training relevant to the responsibility they are required to undertake. It is recommended that alternatives (such as a cordless telephone) are explored to ensure reasonable access for service users to make and receive telephone calls in private. It is recommended the home employ the activities coordinator as soon as possible who can specifically adapt activities for those who are frail to help relieve boredom. It is recommended that the Manager or other appointed people monitor the storage of equipment to ensure it does not present a risk. It is recommended that staff receive training and refresher training in infection control. It is recommended that the Manager maintain the provision of four care staff on each floor of the home. It is recommended that all care staff are supported to undertake NVQ 2 (or above) training. It is recommended that dementia awareness training be extended to all staff. The home’s ‘in house’ newsletter should be circulated outside of the home so that it is available to relatives, and other ‘stakeholders’. It is recommended that the Manager conduct staff meetings that are available to all care and nursing staff at the home. The manager should be offered appropriate professional supervision and support by the proprietors. 2. 3. OP9 OP10 4. 5. 6. 7. 8. 9. 10. 11. 12. OP12 OP22 OP26 OP27 OP28 OP30 OP33 OP32 OP36 Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dussindale Park Nursing & Residential Home DS0000044398.V344371.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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