Care Home: Dormers

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What the care home does well Pre-admission and ongoing assessments are very detailed, and care plans, which reflect the needs of the client, are regularly updated with the client. The home employs two activities co-ordinators and a dementia project worker and a good variety of activities are arranged for the clients to take part in. Clients receive a wholesome, nutritious and balanced diet. Assessments. The home has a high percentage of staff who have been trained to NVQ 2 or above. An extract from a letter in the home`s compliments file includes: `I want to thank you and all your staff for the loving care of xxx. Dormers is such a friendly, comfortable place, a real home for the residents. The staff are all so friendly and caring`. What has improved since the last inspection? The requirements on the last report about the decorating of communal areas; maintaining full details of agency staff, and the locking away of cleaning materials have now been met. More choices have been made available to residents. The front doors have been fitted with electric openers, and drop kerbs have been put in to allow easier access for clients and visitors What the care home could do better: No requirements have been made on this report but there are a few recommendations. Clients contracts should be expanded to include details of the fee payable and by whom. All written entries on Medication Administration Records need to be double signed and dated as agreed at the time of the site visit. To meet the needs of the clients, and to enable more of them to enjoy the benefit of outings the home should purchase more wheelchairs for general use. Staff files need to be reviewed to make sure that they all meet the requirements. An analysis of quality assurance results should be produced and a copy should be made available to stakeholders. CARE HOMES FOR OLDER PEOPLE Dormers Foxon Lane Caterham Surrey CR3 5SG Lead Inspector Chris Woolf Unannounced Inspection 7th November 2007 09:25 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 Dormers DS0000033582.V352125.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. Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dormers Address Foxon Lane Caterham Surrey CR3 5SG 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) 01883 330927 christine.whiting@surreycc.gov.uk Surrey County Council - Adults & Community Care Christine Whiting Care Home 47 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (33), Physical disability over 65 years of age (5) Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Accommodation and Services may be provided to named persons aged 60 - 65 years with the prior written agreement of the CSCI. Intermediate Care may be provided to one Service User on Rose Unit the remaining beds on Rose Unit will only be used for Respite Care. Respite Care may be provided to a maximum of 5 persons at the same time. Bluebell Unit will be used exclusively for Dementia Care. A maximum of 6 Service Users with Dementia may be cared for in other parts of the Home. In addition to Service Users accommodated at the Home, Day Care may be provided on the Day Care Unit to a maximum of 7 persons. 4th January 2007 Date of last inspection Brief Description of the Service: Dormers is located in a quiet residential area close to local amenities. Care and accommodation is provided to older people some of who have dementia. At the present time the home is piloting an 8-bed rehabilitation unit for people suffering from Dementia, this is based in Heather wing. A day centre for up to 7 clients also operates within the home. The home is operated by Surrey County Council and was purpose built in 1982. Accommodation is arranged in 6 units at ground and first floor level. Each unit has its own bathroom and toilet facilities and a communal lounge/dining area. All bedrooms are of single occupancy. Offices are situated on the ground floor. All floors are accessed by means of a shaft lift. The main kitchen is located on the ground floor. In addition, part of each communal area is also equipped as a kitchenette. The home has ample off street parking and an enclosed garden. The current fees for the service at the time of the visit are £554.96 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is chris.whiting@surreycc.gov.uk People who live in this home are referred to as ‘Clients’ and this is the term used to describe them throughout this report. Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on the following information. An annual quality assurance assessment (AQAA) completed by the home. Questionnaires returned to the Commission by 6 clients, 4 relatives/visitors, 2 Health & Social Care professionals, 2 Care Managers, and 7 staff. A site visit to the home lasting just over 7 hours also took place. The site visit was unannounced; this means that neither the management, nor the staff and clients knew that it was going to take place. During the site visit a tour of the building took place. We witnessed activities taking place and a meal being served. We talked with clients in each of the units and in the day centre; we also talked with visitors, a variety of staff and the manager. A staff meeting took place on the afternoon of the site visit and we were able to sit in and listen to the discussions that took place. A variety of records were inspected including client assessments and care plans, staff recruitment files and various safety records. What the service does well: Pre-admission and ongoing assessments are very detailed, and care plans, which reflect the needs of the client, are regularly updated with the client. The home employs two activities co-ordinators and a dementia project worker and a good variety of activities are arranged for the clients to take part in. Clients receive a wholesome, nutritious and balanced diet. Assessments. The home has a high percentage of staff who have been trained to NVQ 2 or above. An extract from a letter in the home’s compliments file includes: ‘I want to thank you and all your staff for the loving care of xxx. Dormers is such a friendly, comfortable place, a real home for the residents. The staff are all so friendly and caring’. Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 6 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. Dormers DS0000033582.V352125.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 Dormers DS0000033582.V352125.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): 3, 4, & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients know that their needs will be assessed and that they will only be admitted if the home is confident of meeting these needs. EVIDENCE: A thorough assessment is completed by the home for all prospective clients before their admission to the home. Assessments include a full range of physical and mental health needs, equality and diversity needs, personal care needs, social care needs and likes and dislikes. Initially prospective clients and relatives are invited to visit Dormers informally. This is followed by a planned pre-admission introduction day when they spend the day in the unit in which they will be staying. This gives the home the opportunity to assess whether they can meet the individual’s needs and the client the opportunity to see whether they think the home is right for them. Where clients come under the Care Management scheme a copy of their assessment is also obtained prior to Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 9 the introduction day. Dormers operate an ongoing six-week assessment period for new clients and this is followed by a review and confirmation of the permanent residency. The home is currently piloting a rehabilitation wing (Intermediate Care) for up to 8 dementia clients in Heather Wing. The Rapid Response team assesses the clients for this wing and this team also provides Occupational Therapists, Dietician and other necessary health care professionals. Staff working on this wing are all trained in dementia care and promote the clients independence with the aim of them returning home at the end of their stay in Dormers. The maximum stay in this unit is 6 weeks. The Statement of Purpose for the home has been updated to reflect the current use of Heather Wing. Although all clients have a signed contract on their personal file these contracts do not include the fee payable and by whom and a recommendation is made regarding this. Dormers DS0000033582.V352125.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 good. This judgement has been made using available evidence including a visit to this service. Client needs are recorded in their plan of care and are met by the home supported by a multi-disciplinary health care team. Clients rights to privacy and dignity are supported EVIDENCE: A comprehensive plan of care is drawn up for each client. The care plans are based on the information gained during the pre-admission and 6 week assessments and they are updated regularly with the client. Care plans include information on a variety of health care, personal care, social care, and equality and diversity needs and there are risk assessments in place wherever needed. The care plans give sufficiently detailed information to enable staff to provide a good level of care to their clients. Clients’ health care needs are met by the staff at the home supported by a variety of health care professionals including doctors, district nurses, Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 11 chiropodist, the rapid response team, occupational therapists and dieticians. Clients comment cards confirmed that they always or usually receive the medical support they need. A client commented, “The nurse came to see me this morning”. Visitor comment cards included, ‘I feel Dormers take very good care of my mother’, and ‘They always keep me up to date. They care well for my mothers all round needs’. The home’s AQAA indicates that they are now working as part of a joint service with the health authority (Primary Care Trust). This has enabled the home to access further facilities i.e. Rapid Response, Night Service (D/Ns) and support from the Matron at Caterham Dene Hospital. All clients have their nutritional needs assessed on admission and their weights are recorded monthly. Any suspected incidence of pressure areas developing are reported to the district nurses who give treatment, support, advice and provide any necessary equipment. Professional advice is sought where needed for the promotion of continence. Medication policies and procedures are sound and protect the safety of the clients. The home procedures for recording the receipt, administration and disposal of drugs are sufficient to allow for an audit trail. Risk assessments are in place where clients wish to continue administering their own medication. At present the Medication Administration Charts are handwritten. All handwritten entries must be double signed and dated, this was discussed at the site visit and is being put in place. A recommendation is made regarding this. Signs are prominently displayed on the doors of all rooms where Oxygen is stored or used Clients’ privacy is respected and their dignity is upheld. A relative comment card included, ‘The carers at the home know their residents very well, and treat them as individuals’. Health care professional and Care Manager comment cards confirmed that the home always or usually respects individual’s privacy and dignity. One Care Manager comment card included, ‘Home staff are very respectful of individuals privacy and dignity’. A staff comment card indicated, ‘The home applies the basic care values, respect, individuality, rights, identity, choice, privacy, independence (‘as much as’) and dignity’. Observations during the site visit showed that the interaction between staff and clients is friendly but respectful. A visitor comment card included, ‘The staff interaction with clients is good’. One visitor comment card included the comment ‘Clothes are washed and tumble dried but not ironed or put away tidily in the wardrobe and chest of drawers’. This was discussed with the Manager who says that this problem has now been sorted. A new dedicated laundry person has been employed and each individual clients clothes are now washed separately, ironed, and put away. Dormers DS0000033582.V352125.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): 12, 13, 14, & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clients’ social needs are supported by the home. They are encouraged to maintain contact with family and friends. Meals are well balanced and varied. Clients are given choices in all aspects of their daily lives EVIDENCE: The home employs two full time activities co-ordinators and a part time dementia project worker. The activities co-ordinators have both done a 5month course on Activity in a Care Setting, which is equivalent to NVQ 2. The Dementia project worker has been working in the home for 10 years. She has had dementia training and also attends all of the in house statutory training. Group activities are held in the large lounge on the ground floor and include clients from the units together with day care clients. A mixture of intellectual and social activities is on offer ranging from Bingo to Quizzes, Reminiscence to crosswords, and Arts and Crafts to relaxation. A selection of pictures and collages done by the clients is displayed in the main lounge and on the units. A client commented, “I did those drawings, I have always liked Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 13 drawing”. Some activities also take place in the units, including promoting daily living skills. Client comments included, “I make a cup of tea sometimes”, and “They let me help with the washing up sometimes. 1:1’s take place, particularly with clients who do not have regular visitors of their own. The home organises a variety of outings and use ‘busses for you’ for the transport. The day before the site visit a group of clients had visited a garden centre. A Halloween party had been held in the home at the end of October. The activities coordinators maintain a record of activities that take place. Clients said, “I go to Brunton Day Centre once a week, I used to go there before I moved in here”, and “I like to do my crocheting, I make shawls and blankets”. The home has its own ‘Sweet Shop’ and the trolley visits each unit a couple of times a week. Day centre clients commented, “I love it here”, and “I can recommend anyone to come here, they are very kind and attentive”. Currently there are no clients with diverse religious faith or cultural needs. A Church of England vicar visits the home monthly, the Catholic priest visits members of his congregation, and the Salvation Army visit occasionally. The home will organise representatives of other faiths to visit at the request and preference of any client. The home encourages clients to retain contact with the friends and family. Visitors are made welcome and can visit at any time suitable to the client. A client commented, “I go home to my daughters sometimes”. A visitor comment card included, ‘They are very friendly and caring to residents and relatives’, and a visitor said, “Everybody is very friendly and helpful”. Staff commented, “We always make visitors a cup of tea”, and “When a client is at the stage of terminal care we give full support to the visitors and offer lunch, tea, and anything they need”. Clients are offered choices in all aspects of their lives and staff and clients confirmed this. The home’s AQAA states, ‘We have made more choices available to residents’. One visitor comment card included, ‘I don’t feel the manager has fought my mothers rights to smoke. I feel the shelter they have installed is inadequate and has safety issues over the winter months’. This was discussed with the manager on the day of the site visit and she confirmed that the shelter has been provided and the position is to meet the requirements of the County Council. There is a chair for the client to sit and enjoy her cigarette, and staff always accompany and assist the client when she wants to smoke and will continue to do so during the winter months. Clients in the home are provided with a good variety of balanced meals, which have been approved by a nutritionist. The home’s AQAA indicates that the chef and his assistant regularly speak with the residents to ascertain their likes and dislikes and then adjust the menus accordingly. Special meals, including cultural requirements, are catered for when required and currently include Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 14 diabetic, liquidised, and allergies. Clients said, “My meal was nice”, and “The food is alright”. A visitor said, “Mum says the food is very nice”, and a visitor comment card included, ‘The food always looks presentable and nutritious’. Staff commented, “He is an excellent chef and does marvellous on the budget allowed”, “He does the kind of food they like such as bacon pudding, spotted dick, jam rolly poly, butterfly cakes, and jam tarts”, and “Its really good, excellent”. Dormers DS0000033582.V352125.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients can be confident that their concerns and complaints will be listened to and acted upon, and that they will be protected from abuse. EVIDENCE: Surrey County Council, and subsequently the home, has a clear and accessible complaints procedure. No formal complaints have been received by the home or direct to CSCI in the last 12 months. The home’s AQAA states, ‘Managers have made themselves available to residents and relatives if there have been any areas of concern raised. This we believe has prevented any formal complaints as any concerns have been ironed out at the informal stage’. Client and relative comment cards confirmed that most knew how to make a complaint. Clients said “No complaints”, and “I love it here, I am happy and content”. A care manager comment card included, ‘The home has a clear complaints procedure. Managers are always open to discussing any concerns or issues’. As well as a complaints register the home keeps a compliments file. Extracts include, ‘I want to thank you and all your staff for the loving care of xxx’, and ‘The excellent provision, combined and underpinned by the staff, extended her life span’. Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 16 The home’s policies and procedures protect clients from abuse. All staff have either had training in Protection of Vulnerable Adults or this training is in the process of being arranged. All staff spoken with were aware of the importance of the protection of their clients and knew what to do if they suspected abuse. No new member of staff is employed until a satisfactory check of the Protection of Vulnerable Adults register has been received. Dormers DS0000033582.V352125.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients live in a home that is clean and comfortable with bedrooms that are personalised to meet their needs. EVIDENCE: Dormers is a purpose built home with accommodation arranged in 6 individual units over two floors and there is a passenger lift to access the upper floor. There was a requirement on the last report that the communal areas should be decorated and this has taken place. In areas of high wear and tear plastic protective sheeting has been put up to maintain the decoration. Electric openers have been put on the front doors to ensure easier access for the less mobile, and pathways have been re-laid with drop kerbs provided to enable better access for both clients and visitors. Clients commented, “This place is lovely”, and “It’s a nice place to be” Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 18 Each of the units has its own lounge, dining area and kitchenette. Each unit also has an assisted bathroom and toilet facilities but no bedrooms are fitted with en-suite facilities other than wash basins. There is a large lounge/dining area at ground floor level and this is used for the day centre and for group activities. Communal facilities are decorated and furnished in a homely and comfortable way. All bedrooms are for single occupancy. Rooms are personalised to meet the needs of the client. Clients who wish are able to bring in some pieces of their own furniture subject to space limitations and health and safety risk assessments. A client commented, “It’s a nice room”. When taking clients out for outings there is a lack of available wheelchairs meaning that some clients may be unable to go out when they wish. It is therefore recommended that the home purchase more wheelchairs for general use in order to meet the needs of the clients. The home is clean and odour free throughout. A client said, “Its very, very clean, 100 ”, and a visitor said, “‘its always kept clean”. Visitor comment cards included, ‘Its always clean but sometimes smells of old people’, and ‘The home is always clean’. There is a kitchen-cleaning rota in place and twice yearly the kitchen is closed for deep cleaning. The laundry is clean and well maintained and has the appropriate equipment for the prevention of infection. Personal protective equipment is readily available. There is a copy on each unit of the ‘Infection Control for Care Homes’ publication. A comment on a Health Professional comment card stated, ‘I would like to see hand wash, paper towels and rubbish bins in all the residents rooms to reduce infection risk’. This was also noted during the site visit and was discussed with the Manager who confirms that she has already arranged for a visit from a representative to get this organised. It was suggested that she liaise with the health professionals about the best way to achieve this without compromising the safety of the clients in the rooms of some of the dementia clients. Dormers DS0000033582.V352125.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sound recruitment processes protect clients, and they are cared for by a team of staff trained to meet their needs EVIDENCE: Evidence shows that there are sufficient staff on duty to meet the needs of the clients, although this may include a number of the home’s own bank staff and staff from a local agency. Where agency staff are used the manager tries to ensure that the agency provide the same people to give continuity of care to the clients. There was a recommendation on the last report that the home should keep details in the home of the agency staff employed, this has now been done and includes CRB number and confirmation of the introduction to Dormers. Staff morale has been low over the past few months, mainly due to uncertainty about the future of the home and the need to use so many agency staff. Surrey County Council set the levels for the number of permanent staff employed and the home is currently up to establishment although levels have been affected by leave for sickness etc. The home are currently interviewing for additional bank staff to supplement the staffing numbers. Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 20 Currently 74 of the permanent care staff are qualified to NVQ Level 2 or above. Staff commented, “I have got NVQ Level 2 and 3”, and “I have just got level 2”. Both of the activities coordinators have completed their NCFE Certificate in Provision of Activities in a Care Setting, which is equivalent to NVQ 2. Staff recruitment procedures are sound. No new member of staff is employed until a satisfactory check has been received from the Criminal Records Bureau and 2 satisfactory written references have been received. The home has an equal opportunities policy and staff from a variety of backgrounds are employed. Not all staff files contain the information required and a recommendation has been made that all staff files are reviewed to ensure they meet the requirements of Schedule 2 All new staff have induction training set by the County Council which reflects the specifications of Skills for Care. Mandatory health and safety related training is either up to date or is being arranged for all staff. This includes moving and handling, fire, first aid, basic food hygiene, and infection control. All staff have been trained in the Protection of Vulnerable Adults. All who work with dementia clients have had dementia training; the permanent staff who work with these clients have attended a 4 day course. Staff who administer medication have all had training and assessment of their competency. Staff receive training about equality and diversity during induction and there are also regular updates. Clients comments about the staff included, “The carers are very kind”, “The staff are very kind”, and “They make me laugh”. Staff comments included, “I love it”, and “It could be my mum and dad, I always treat the clients as I would want them to be treated”. Dormers DS0000033582.V352125.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the clients. The health, safety and welfare of clients and staff are protected. EVIDENCE: The Registered Manager and Assistant Team Manager both hold the Registered Managers Award NVQ Level 4 in Management and Care. The Manager regularly updates her training in line with new legislation. Staff commented, “I get support from the manager”, and “I definitely get support from the manager, I can go to her and her deputy anytime”. Staff comment cards varied in response. One indicated that the manager never meets with him/her to give support, however others included the comments, ‘I know that the Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 22 managers are available should I feel I need support, they are approachable’, and ‘Manager is always available to give advice/help when needed’. The home operates a quality assurance system using the Quality Standards tools. Questionnaires are circulated to service users, visitors, and visiting professionals. Currently an analysis of results is not produced and a recommendation is made that this is done and that a copy is made available to stakeholders. Regular audits are undertaken. Staff meetings are held regularly. Unit meetings for the clients are held 2 monthly followed by review of care plans and risk assessments. Day to day 1:1’s take place in the dementia unit. The home has robust systems for handling clients monies, individually named bank deposit accounts, with the interest going to the clients, are held where clients have any excess. Recording of clients monies is sound The health, safety and welfare of clients and staff are protected by the home’s policies and procedures. Staff training in health and safety related subjects are up to date and ongoing. Safety records observed were all in order. Dormers DS0000033582.V352125.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 X 2 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 3 X 2 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Dormers DS0000033582.V352125.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. 2. 3. 4. 5 Refer to Standard OP2 OP9 OP22 OP29 OP33 Good Practice Recommendations Clients contracts should be expanded to include the fee payable and by whom. All written entries on Medication Administration Records should be double signed and dated as agreed at the time of the site visit. The home should purchase more wheelchairs for general use in order to meet the needs of the clients. All staff files should be reviewed to ensure they meet the requirements of Schedule 2. An analysis of quality assurance results should be produced and a copy should be made available to stakeholders. Dormers DS0000033582.V352125.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Dormers DS0000033582.V352125.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. Re-publishing this information is in breach of the terms of use of that website. 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