Care Home: Dolphin Manor

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What the care home does well People spoken to said that they are very well looked after at the home and that the staff are “great.” It was apparent from observation that people are encouraged to maintain their independence and to do as much as possible for themselves. The home is very clean and offers a safe and comfortable place for the people who live there. People are fully included in decision making at the home. The home recognises that visitors are an important part of peoples’ lives. All visitors are made welcome and are offered refreshments to enjoy with their relative or friend. One relative said, “It is just like a family home”. What has improved since the last inspection? Staff have been made aware of what incidents at the home need to be notified to the CQC to ensure compliance with Regulation 37 of the Care Homes Regulations 2001. Since the last key inspection the home has had a new fire safety sprinkler system installed, during this time all staff included night staff have had fire warden training to make sure that people are safe at all times and staff is fully versed on fire safety. There has been some improvement in the evaluation of care plans. This means that the people at the home and the staff are clear that a care plan has been effective. What the care home could do better: The numbers of care staff on night duty should be reviewed taking in to account the dependency of the people living at the home and the layout of the home. This is to make sure that the safety and well being of staff and the people at the home is not compromised.All people receiving care in the home must have a plan of care that meets their identified care needs, This would make sure that care needs do not get missed.Dolphin ManorDS0000033250.V376317.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Dolphin Manor Stone Brig Lane Rothwell Leeds LS26 0UD Lead Inspector Valerie Francis Key Unannounced Inspection 10th June 2009 10:00 DS0000033250.V376317.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dolphin Manor Address Stone Brig Lane Rothwell Leeds LS26 0UD 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) 0113 2824942 0113 2824942 Leeds City Council Department of Social Services Mrs Sonya Williamson Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2007 Brief Description of the Service: Dolphin Manor is located in the Rothwell area of Leeds just a short walk from the shops and facilities in the town. There are public transport links with Leeds and Wakefield and parking spaces are available outside the home. The home is purpose built and all accommodation is provided on the ground floor. There is a safe garden to the rear of the building with a greenhouse, raised garden beds, fishpond and pleasant seating areas. The home is registered to provide care for up to thirty-five people who have no specialist need. Nursing care is not provided but the home is well supported by the local healthcare teams. There is generous communal space in the home providing comfortable sitting and dining areas for people who live there. There are small kitchenettes with tea and coffee making facilities as well as a specially set up “visitors’” room. There is a bar in the home and staff provide a shop for the people living in the home. Information about the service is available in a Statement of Purpose and Service User Guide as well as a brochure. These documents are reviewed regularly to make sure that the information is up to date. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is ** star. This means the people who use this service experience Good quality outcomes. From information provided on the day the current weekly fee for the home range from£102.90 to £510.30 per week. Additional costs include toiletries, hairdressing, holidays, leisure activities and clothes. More up to date information about fees can be obtained from the home along with copies of previous inspection reports. One inspector visited the home unannounced at 10 am until 5:30pm, which included talking to the staff and the care officer who was in charge at the time, about their work and the training they have completed, checking records, and policies and procedures the home have to keep. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. All this information was used to plan the inspection visit. We asked for information to be sent to us before the inspection, this is called an annual quality assessment questionnaire (AQAA). We sent surveys to people living in the home and staff. During the inspection we spent time talking with people who live in the home and relatives who was visiting. We focused on the key standards and what the outcomes are for people living in the home, as well as matters, which were raised at the last inspection. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 6 What the service does well: People spoken to said that they are very well looked after at the home and that the staff are “great.” It was apparent from observation that people are encouraged to maintain their independence and to do as much as possible for themselves. The home is very clean and offers a safe and comfortable place for the people who live there. People are fully included in decision making at the home. The home recognises that visitors are an important part of peoples’ lives. All visitors are made welcome and are offered refreshments to enjoy with their relative or friend. One relative said, “It is just like a family home”. What has improved since the last inspection? What they could do better: The numbers of care staff on night duty should be reviewed taking in to account the dependency of the people living at the home and the layout of the home. This is to make sure that the safety and well being of staff and the people at the home is not compromised. All people receiving care in the home must have a plan of care that meets their identified care needs, This would make sure that care needs do not get missed. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 8 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 Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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 information given to people is clear and it helps people to decide if the home will meet their needs. A thorough assessment process is used to identify peoples needs. EVIDENCE: We saw that people are given good information about the home and have the opportunity to visit and spend time at the home before they decide if it is right for them and can meet their needs. The home’s Statement of Purpose and the Service User Guide had recently been update, to make sure that people have access to information that is current. We saw that there was information such as the address of the local church which has links to the home. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 10 We looked at the care records of two people who were recently admitted to the home, there was evidence that an assessment was carried out by a social work professional and the home had carried out its own assessment, to make sure that it could meet the people’s needs. During people’s visit to the home before their admission an assessment is carried out by one of the management team and care staff who observes the person. This is to make sure that people fit well with others living at the home. This also gives the person the opportunity to meet with people who live in the home. From discussion with people and their visitors it was apparent that they had been involved in the assessment process. The home also gets copies of the easy care documents which we saw had current information about the person. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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’s personal and health care needs are met in a way that respects their privacy and dignity and the care records support this. However, because information is not always recorded there is the possibility for needs to be overlooked. People are protected by the home’s systems for dealing with medicines. EVIDENCE: We looked at four people’s care records to check that a plan was in place, which would help staff provide support to people according to their needs and wishes. The care plans looked at showed that people had care plans in place; two of the plans seen were for people who were on short stay at the home. The plans Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 12 did not have enough information for staff to deliver care to these people that would meet all their identified care and support needs. We saw that people had night care plans in place, which told staff how people’s care is to be delivered during the night. There were some brief notes to show that people’s care plans are evaluated monthly. The care plans showed that people and/or their representatives are involved in planning care and relatives confirmed this. Three care plans showed that people, their relatives and others involved in the person’s care were involved in the process. We saw good information where all aspect of the person’s care needs were reviewed, and any changes reflected in their care plan. People are asked to for their agreement to carry out an annual health review with their General practitioners, so that any change in their health care can be identified and the appropriate care given at the home. Risk assessments were in place dealing with all areas of risk including nutrition, falls, moving and handling. Many of the risk assessment forms have been reviewed and improved since the last inspection. All staff who administer medication have had training on safe handling of medication. The home uses an observation tool to assess staff six monthly, to make sure their practices are still safe to administer medication to people who live in the home. The home works closely with GP’s and carries out six monthly review of people’s medication. The home has an in house procedure for staff to follow when ordering and booking in and out of medication in the home. There is also a policy for administering controlled drugs. We saw that an audit of medication is carried out, and we were told that this audit is done by the manager. However, the audit report was not signed for. The medication administration file had sample signature of staff who can administer medication. Medicines are stored correctly within the home. For those people who administer their own medication the appropriate risk assessments are in place. A random selections of medicines were checked and was correct. The home was in the process of changing to a new pharmacist for their medications. A senior carer explained how medication is ordered, stored and administered and when administering medication she followed proper procedures. Dolphin Manor DS0000033250.V376317.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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 live at the home are able to exercise choice in their daily routines and their social expectations are met. People living at the home are provided with a varied and nutritious diet. EVIDENCE: People told us that they spend their day doing what they want but in the main they watch television and converse with each other. However, we did see people playing board games with staff or with each other. Visitors told us that they are always welcome at the home and were able to speak to staff. People were able to tell us the name staff who they have contact with most and does the extra things for them, like taking them shopping or buying things that they need. The home told us in the AQAA that people have access to a range of varied activities to suit individual preferences; activities are held in the home or Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 14 people have the opportunity to go out into the community, to local pubs and shops and places of interest, with the availability of a minibus fortnightly. One person told us that they had asked at the last three residents meetings for exercise equipments that were suitable for them, so that they could continue to carry on with their exercise programme, but nothing has been done about it. When we looked at the minutes for the house meeting for the past three months, this was confirmed. The officer said he would discuss the matter with the manager. Two people who were on short stay in the home, told us that the home was a nice place and staff were really friendly and helpful. When we asked people about choices they said they could make any choice, such as what day and time to have a bath, what to eat, where to go and what to do. People are encouraged and supported to keep in contact with their relatives. Daily newspapers are made available. We were told that the home aim to have monthly residents meeting which we found were well attended. We were told that relatives and friends are encouraged to use the home like it was their relative’s home. The chef has been working at the home for many years and was very knowledgeable about the likes and dislikes of the people at the home and of the needs of those with special dietary needs. We were told and we saw that meals are discussed with people at their meetings. People and their visitors have access to tea and coffee making facilities. The menus for the day are displayed on each table, showing people the choice of food on offer. We also saw that people could have an alternative to what was on offer. During the inspection of records we saw that not all people have a nutritional risk assessment carried out, this we were told is only carried out if there was a problem. However, we saw records of people’s monthly weight checks. People told us that the food was good, and you can have anything you wanted to eat as the cook was very accommodating. One person said that they had put weight on since they came to live in the home. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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’s views are listened to, taken seriously and acted upon. Staff have a good understanding of adult protection issues, which protects people from any abuse. EVIDENCE: People said if they had any concerns they would feel able to talk to the manager or another member of staff. They were also confident that any issues raised would be resolved. One person said the manager and staff are readily available to listen and to act. There is a copy of the Local Authority Social Service complaint procedure in place that includes details of the timescale within which complaints will be responded to. A log is in place of any complaints that are received that give details of the date, complaint, action taken and outcome. We were told that complaints are seen as positive and are encouraged so that they could learn from them. Staff have attended safeguarding adult training. All staff spoken to were able to detail exactly what they would do if they felt any practices in the home was not in the best interest of the people who use the service. We were told that all staff have a full CRB Criminal Record Bureau) check before they can start work, to make sure they can work with vulnerable people; this we were told is carried out every two years. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 16 The home’s management team have had training on the Mental Capacity Act Deprivation of Liberty (DOL). They plan to carry out cascade training to all the other staff in the home. The care officer told us that there is a commitment to people rights, choice and liberty. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. There is an ongoing programme of repair and refurbishment so that the environment meets the needs of the people living in the home. Infection control is well managed. EVIDENCE: The home was clean and tidy and there were no offensive odours. People told us that the home was usually clean and fresh. Bedrooms were decorated and furnished according to personal taste. Since the last key inspection the home have redecorated the main corridors, replace some of the lounge chairs and bought new coffee tables and re-carpeted ten bedrooms. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 18 The home has also had a new fire safety sprinkler system installed. The installation of the fire sprinkler system had just been completed and on the day of our visit work people were plastering areas that needed putting right. We were told that all night staff were fire wardens to make sure fire safety is not compromised. During the fire safety system installation there were three night staff, one we were told did not deliver care; their role was for fire safety in the home because the fire safety system was not in action. We observed staff adhering to infection control by wearing the right protective clothing to carry out tasks. Such as: wearing gloves and aprons, double wrapping soiled and used incontinent products, to stop the spread of infection in the home. In bathrooms and toilets we saw that there were aprons, gloves and sacks for incontinent pad and yellow clinical waste bags in bins. Liquid soap and disposable towels were seen in all areas where clinical waste was handled. People had no concern about the way in which their clothes were laundered. Generally we found that the home was maintained to a high standard. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. There are sufficient numbers of trained staff to meet the needs of the people living at the home. Recruitment practices make sure that staff are safe and suitable to work with vulnerable people. EVIDENCE: At the time of this key inspection, staffing level appeared to be enough to meet the needs of the current group of people living in the home. However, people said staff do not always have the time to take them out or carry out activities in house. We were told that there are some care staff vacancies, which are covered by agency staff or staff overtime. This, we were told is to make sure people have enough available staff to meet their needs. Staffing levels are reviewed on a daily basis to make sure there is enough staff for people’s care. We were also told that although there are three staff on nights this was only for a short time to carry out fire safety checks at night, to make sure people are safe. While the new fire safety system was installed. We have an ongoing concern about night staff levels at the home. This is due to the layout of the building combined with the numbers of people living at the home, which suggests that there may not be enough staff to make sure that people are properly supervised overnight and their care needs met. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 20 The home has 80 of care staff qualified to NVQ (National Vocational Qualification) at level 2 and all the care officers have NVQ level 3. Recruitment practices make sure that staff are safe and suitable to work with vulnerable people. We looked at three staff recruitment files which were held in the home. We found that they all had application forms with work history, two references and interview notes. All applicants have a full (CRB) criminal record bureau check. We were told that no applicant will start working until the result of a satisfactory CRB is received. All new staff have induction training and completes an induction book. We were told that night staff have and we saw that all new members of staff have had induction training. Any one wanting to work nights have an induction which involve shadowing a care officer, moving and handling, infection control, health and safety and food hygiene. We were told staff cannot undertake any moving and handling until they have had the training. The care officer said some staff are undertaking a palliative care course. When we spoke to other staff they told us they were hoping to also do this course. In the AQAA we are told that all staff have three days paid training, and staff training needed are identified at their regular supervision and annual appraisal; each member of staff have a training plan. We also saw a training plan for the home which was on target. Staff were very positive about the training both in terms of the range of subjects covered and the quality of the training provided. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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 home is well managed and the manager is well able to discharge her responsibilities. She offers good leadership to the staff and ensures that people who live in the home are protected and cared for. People’s financial interests are safeguarded by the procedures in place. EVIDENCE: From discussion with staff, people and visitors it would appear that the home is well managed. The manager holds the manager’s award and NVQ level 4 in care. She has worked in residential care settings for many years. People, staff, and visitors Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 22 said that they receive support from the manager and can speak to her at any time. The manager holds regular meeting for all the different designations of staff where there is an agenda and minutes are taken. She also holds regular meetings with people and is always ready to listen to ideas put forward. Regular supervision sessions are in place for staff and records are kept of these. It was apparent that the officer team who are in charge of running of the home in the absence of the manager has had training and support to be confident to manage the home. Health and safety is promoted for staff and people through training and example. All staff have had moving and handling and fire warden training. All record keeping was up to date at the home and policies and procedures in place to make sure that people’s rights are safeguarded. Their interests are always put first by the manager and her staff. People commented that they were happy with the care and attention given; visiting relatives said they had no complaint about the care their relatives received at the home and if they had any concern they would talk to a staff member or the manager. People said “we are well looked after no complaint.” We were told that people relatives are able to comment on the service through the home’s quality audit, as a result an annual development plan is made to reflect the aims and objectives. We looked at records for moneys’ held for people and checked two people finances. We found that the home has a good recording system for handling people money with a good audit trail of all transaction. There is a system in place for regular auditing of people’s money. Along with the weekly check carried out by the manager. In the AQAA we are told that all necessary safety and service checks on equipment take place as required. There are monthly analysis of falls and accidents within the home, so any patterns or trends can be identified. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP27 Good Practice Recommendations The numbers of care staff on night duty should be reviewed taking in to account the dependency of the people living at the home and the layout of the home. This is to make sure that the safety and well being of staff and the people at the home is not compromised. Dolphin Manor DS0000033250.V376317.R01.S.doc Version 5.2 Page 25 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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