Care Home: Dunley Hall

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

What the care home does well Administration systems that have been developed by the manager provide clear evidence of how residents are cared for. Assessment and care planning processes are comprehensive. Living areas are very pleasant and clean environments well suited to the needs of the resident group. Residents and relatives stated that staff were very caring and patient. Respect and dignity seem integral to the day to day running of the home. What has improved since the last inspection? There have been significant improvements since the last inspection, evidenced by the fact that all outstanding requirements have been met. The manager has worked hard to develop the administration processes and service delivery and has put good staff support and quality assurance systems in place. What the care home could do better: The home needs to adhere stringently to health and safety requirements in key areas of the home to ensure that residents and staff are fully protected from preventable harm at all times. Whilst improvements are envisaged post extension work the health and safety needs of residents and staff cannot be put on hold until that work has been completed. The complaints process needs some minor improvements to provide clearer audit trails of when and how they have been resolved. The process used for Regulation 26 visits needs to be reviewed to eliminate any potential risk of collusion. CARE HOMES FOR OLDER PEOPLE Dunley Hall Dunley Hall Dunley Nr Stourport-on-Severn Worcestershire DY13 0TX Lead Inspector Martin George Key Unannounced Inspection 12th March 2008 09:35 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 Dunley Hall DS0000055364.V361160.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. Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunley Hall Address Dunley Hall Dunley Nr Stourport-on-Severn Worcestershire DY13 0TX 01299 822040 01299 828128 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Monica Arjan McGlynn Trading as Minster Grange Residential Home Ms Elizabeth Joy Flood Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (19) Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th and 22nd January 2007 Brief Description of the Service: Dunley Hall is a large, adapted residence occupying a secluded position near to the centre of the village of Dunley. The home stands in its own grounds at the end of a drive that provides shared access to other residents who live nearby. The home is accessible to people who use wheelchairs. There is ample car parking space for several vehicles at the front of the premises. The residents are accommodated on the ground and first floors in thirteen single bedrooms and three double bedrooms. Eight of the single bedrooms and all three double bedrooms have an en suite facility. The home provides two lounges and a separate dining room. The home also has a passenger lift. Dunley Hall is registered to provide a residential, personal care service for a maximum of 19 people over the age of 65 years, who may also have a physical disability and/or dementia. The main purpose of the home is to provide a high standard of care in a safe and happy environment for people who are unable, or who do not wish, to live independently. The homes stated aims are to provide all residents with a life that is as normal as possible, given their health and needs, in homely surroundings and with care which will enable them to live as independently as possible with privacy, dignity and with the opportunity to make their own choices. It has been the intention of the registered provider for some time to provide an extension to the premises that will increase the number of residents the home is able to accommodate. We were informed that good progress is being made with the planning application. At the time of the inspection the home’s fees ranged from £400 to £500 per week. Dunley Hall DS0000055364.V361160.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was carried out by a single inspector between 09:35 and 17:00. As part of the inspection all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’ were inspected. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection we were provided with written information and data about the home through their annual quality assurance assessment (AQAA). The views of a number of people living at the home, the proprietor, manager, deputy manager and, to a more limited extent, the staff working there were acquired through a number of discussions during the inspection. The views of two residents in particular were gained when we had had lunch with them. Information was analysed prior to inspection and helped to formulate a plan for the visit and helped in determining a judgement about the quality of care the home provides. On the day of the inspection we checked resident and staff records, looked round the building and observed practice. What the service does well: What has improved since the last inspection? There have been significant improvements since the last inspection, evidenced by the fact that all outstanding requirements have been met. The manager has worked hard to develop the administration processes and service delivery and has put good staff support and quality assurance systems in place. Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 6 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. Dunley Hall DS0000055364.V361160.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 Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. Residents and their families benefit from a comprehensive statement of purpose that details what can be expected. Pre-placement assessments cover a wide range of needs to ensure residents are well cared for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The information provided to prospective residents, their families and any other interested parties in the statement of purpose is written in plain language, is very well laid out and contains information that exceeds requirements. In some sections, where the manager has deemed it helpful, it makes reference to the regulations. Residents who we spoke to gave us the impression that they found the information useful and a true reflection of what the home offered. A copy Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 9 of the statement of purpose is situated by the visitors’ book in the main entrance hall and there is a copy in each of the residents’ bedrooms. The pre-placement assessments of need we examined had comprehensive and detailed information, and were written in a way that made it easy for staff to identify what the needs of a resident were and how to meet those needs. We noted that issues specific to dementia were included in the mental health section of the assessments. Whilst this is perfectly acceptable we discussed with the manager that it may be more beneficial for this information to be in a separate section, clearly signposted, so staff could more easily identify particular needs pertinent to dementia care. Dunley Hall DS0000055364.V361160.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 and 10 Quality in this outcome area is good. The health and personal needs of residents are well met by a team of staff informed by comprehensive care plans. Residents are safeguarded by good medication procedures and practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were well designed, easy to follow and used a person centred approach, providing staff with good quality information that helped them meet the needs of the residents. The care plans we examined were reviewed, dated and signed monthly showing an understanding that needs were constantly changing. There was a checklist that showed when the care plans and risk assessments were reviewed. The manager told us that the reviews were always planned to take place between the 15th and 20th of each month. We discussed with the manager how the home kept residents informed about the content of their care plans. The manager felt they did it quite well but during Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 11 our discussion she identified an interesting issue, in that she feels the staff are probably better at keeping those with dementia informed about their care plans than they are with the other residents. Following the discussion she stated she would be reviewing how they keep all residents informed of their care plans and would probably do some training with her staff to improve that aspect of their work. Records indicated good monitoring of, and response to, the health needs of residents. Details of appointments with a range of health care professionals were clearly recorded. Names and signatures of all those who can administer medication was kept up to date. We saw a dated and signed list of all those currently able to carry out this task. During our inspection there was a medication audit being undertaken by a representative of Lloyds pharmacy. Her findings were that the medication storage, recording, administration and disposal practices were of a good standard and safeguarded residents from the risk of harm, which could result from poor medication practice. During discussion with us after her audit she confirmed that medication is stored securely in a locked cupboard, the medication fridge is kept at the correct temperature and all staff required to administer medication had undertaken an accredited training course. We also confirmed that medication errors were recorded appropriately and noted that the medication policy had been updated and was consistent with best practice guidance. We saw an example of very good practice in the Medication Administration Records (MAR), where an explanation of how medication should be taken was also written by a relative as the resident recognised the handwriting, which made her feel safer about taking her medicine. A note of allergies was kept and there was an “as required” (PRN) sheet for each resident which identified particular issues that the individual may have with one or more of their medicines. We discussed issues of privacy with three residents and were satisfied that the home respects this aspect of their care. Dunley Hall DS0000055364.V361160.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 and 15 Quality in this outcome area is good. Residents have a wide range of leisure and activity options to access should they so wish. Giving residents choice is seen as a high priority. Food is varied and wholesome. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager explained to us about her views regarding group outings, which she felt could very easily become a pattern in homes as it occupied all the residents for a period of time but this risked it becoming institutional. As a general rule she tried to avoid group outings, preferring to respond to individual or small group choices. Although the lack of suitable transport available for use at the home had been raised at the last key inspection she felt that what was available was sufficient for the range of activities the home organised in the community. Having examined the activity options we would concur with that view. The activities file gave comprehensive information about what was available, who has taken part or declined and what was planned for Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 13 the future. There was also good information about external people who came to the home to provide certain activities. One activity which had been very popular was based around small animals. We saw evidence that this activity was being planned again for the future. The AQAA identified that spiritual development is provided by a local Methodist minister who visits the home on a monthly basis. The AQAA also stated that the home actively encourages residents and family to access their personal file as and when they want to. Family are actively encouraged to visit and during our inspection we had the opportunity to meet the daughter of one of the residents. She was very complimentary about the current manager and felt the staff were excellent, stating that she was amazed by their levels of patience. The only concern she could identify related to a situation that occurred under the previous manager, when she had noticed that her mother’s possessions seemed to be going missing from her room and she felt the response she had received was not as she would have expected. She did emphasise though that since the current manager had been in post any issues were resolved very satisfactorily. We had lunch with two of the residents, both of whom had mild dementia. Both were very positive about the standard of care they received. One resident said the home was “above average” but when we asked her to say what could be improved she could not think of anything. Lunch was standard English fare, well cooked and tasty. Both residents said the food varied in quality but was generally good. One made the comment, “well you have to eat it don’t you”. However our observation was that they both ate the food provided and seemed to enjoy it. Menus we examined were varied and included the preferences of residents. Dunley Hall DS0000055364.V361160.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): 16 and 18 Quality in this outcome area is good. The complaints process was not as robust as it needed to be but evidence suggests that residents were kept safe. There was evidence of adherence to the Protection of Vulnerable Adults policy but some minor amendments would further strengthen this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We examined the complaints book and found it to be well structured and completed satisfactorily. We discussed with the manager that we felt it would benefit from having an additional section explaining whether the complaint was resolved, partly resolved or still remained unresolved. For partly resolved and unresolved complaints there should also be an explanation of follow up action being taken. This would provide a clear audit trail, especially useful for complaints that take some time to fully resolve. We were satisfied that the current complaints process is transparent and safeguards residents from unsatisfactory practice. We were also satisfied that the manager seemed determined to resolve any past failings in this area. We pointed out to the manager that there had been an anonymous complaint received by the Commission for Social Care Inspection (CSCI) on 16/4/07, which had been passed to the provider on 24/4/07. However this had not been recorded in the Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 15 complaints log. The manager talked us through how it had been resolved and we were satisfied with the explanation. Protection Of Vulnerable Adults (POVA) training was being provided to staff and this was confirmed in the training records, which were completed in a manner that made it easy to track individual staff training attendance. The POVA policy was up to date but we would prefer the word “restraint” to be replaced by the term “physical intervention” as restraint is now fairly widely accepted as a term restricted to what the police use. We also felt the policy would benefit from having a clear statement about physical intervention being used only as a last resort option, to prevent a resident harming themselves or others and only when no other strategy has proved effective. We noted that the policy had a section on indicators of different types of abuse but there was no information regarding sexual abuse. The manager stated she would address this shortfall without undue delay. Dunley Hall DS0000055364.V361160.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): 19 and 26 Quality in this outcome area is adequate. Residents benefited from pleasant living areas and bedrooms but there were some shortfalls in specific areas of the home that could potentially lead to a risk of cross contamination or injury to staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: First impressions upon arrival at the home were very positive. We were met by one of the residents at the door who showed us in and introduced us to a member of staff. Whilst we were waiting for the manager the resident informed us that the home was a very friendly place. The home was odour free and the main living areas were clean and tidy at the time of our visit. Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 17 During the tour of the building we noted several pleasing features, which enhanced the living experience for residents, but we also noted a portable electric heater on one of the upstairs landings, which was a potential hazard and should not be used. The bedrooms we went into we found to be pleasant environments, were spacious and all had a pleasing outlook over some part of the surrounding grounds and surrounding countryside. There was evidence that residents had personalised their room. Unfortunately we were disappointed by two areas of the home, which contrasted significantly with the well maintained, general state of the home. These two areas were the patio and the kitchen. The patio area just outside the dining room was littered with odds and ends from ongoing maintenance work and a rolled up carpet. We were informed by the proprietor that this area was not used by residents but the manager expressed concern because staff do use that area to take rubbish to the bins and there was a significant trip hazard. Our disappointment was also that the home had provided a large glass patio door from the dining room onto the patio area, through which residents had a very clear view during mealtimes, only for them to look out onto the aforementioned littered area. The kitchen was also a very disappointing area. The deep fat fryer was dirty and looked as if it needed replacing. The floor cupboards were not flush to the wall, leaving a narrow gap, which was very hard to keep clean. The diligent hygiene standards required in the kitchen were not evident and although we were satisfied that the kitchen staff did everything possible to ensure residents were safeguarded from cross infection, the environment was not to the standard we would expect. The proprietor explained that there were plans to extend the home, which will include a new kitchen, but the requirements to safeguard residents from the risks of cross infection need to be adhered to at all times, not just following refurbishment or extension work. The proprietor put his case quite strongly that the home was committed to high quality care and it was only because of the planned building work that these areas were as they were. Nonetheless we held the view that the needs of residents had not been given the necessary consideration with regard to these two areas. We were asked by the proprietor to contact the Environmental Health Officer (EHO), who we were informed had not raised the same degree of concern and had actually been quite happy with the state of the kitchen. We tried several times between the inspection and writing the report but had no success. We therefore have to accept what we were told and acknowledge the difference between our view and that of the EHO, as it was explained to us. Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 18 One week after the inspection we were informed by the manager that the proprietor had replaced the deep fat fryer, painted the walls and ceiling in the kitchen, addressed the issue of the gap between the kitchen unit and the wall and made the patio area a more pleasant aspect for residents to look out on. We acknowledge this positive response to our comments. Dunley Hall DS0000055364.V361160.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 and 30 Quality in this outcome area is good. Residents are looked after by a caring staff team and a manager committed to continuous development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We examined the rotas and found evidence of the necessary level of cover to safeguard residents from predictable harm throughout the 24 hour period. We found evidence in the records of a commitment to qualifying staff to the appropriate NVQ level. The training schedule detailed which staff had attended training courses and also provided evidence that the range of training being offered matched skill and knowledge requirements needed to care for the resident group. At the time of inspection we found the percentages of those that had completed safe handling of food and infection control to be lower than we would expect. The manager confirmed that further training in these areas was planned and we would expect the necessary degree of urgency to be given so that residents continue to be fully safeguarded. Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 20 Waking night staff were expected to attend staff meetings and the manager informed us that they were provided with the same training and qualifying opportunities as their daytime colleagues. This showed a good appreciation of the need to have similarly skilled staff at night to provide a consistent level of care to residents. The home had only recently started using the Skills for Care common induction standards and the manager acknowledged that their current induction package needed reviewing and amending to make it Skills for Care compliant. Based on the staff records we examined we were satisfied that the recruitment process was robust. We noted that one of the recently appointed cleaners, whose file we examined, had a conviction for possession of a class A drug (conviction 19/10/07), but the manager confirmed that after addressing the issue with the person she was satisfied enough to employ her. The manager confirmed that all staff were only allowed to start employment once their POVA and Criminal Records Bureau (CRB) checks and references had been received. Dunley Hall DS0000055364.V361160.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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager provided evidence throughout the day of her ability to perform her role to a good standard, giving us confidence that residents and staff were in good hands. There was evidence of quality assurance systems that showed how certain aspects of the home and service provision had improved. Supervisions were up to date and we also examined some annual appraisals, which provided good evidence of how the member of staff was progressing in Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 22 their job role. We also noted that the highest rating in the appraisal was “above average” rather than “excellent”, indicating that there was an appreciation that there was always room for improvement and/or development to further enhance the quality of care provided to residents. Regulation 26’s were happening monthly as required but the process being used by the home would benefit from being changed slightly. Currently the manager and Regulation 26 visitor have a discussion about issues and develop action plans together (if needed). We discussed with the manager that we would prefer the Regulation 26 person to carry out their visit alone so there is no potential for the manager to influence or manipulate the person doing the Regulation 26 visit. We were not concerned that the current manager would do that but if the manager left the current system could be misused. Work identified in the action plan following the fire officer report had all been completed. Electrical circuits had been serviced and residual work was underway, which was going to require the circuit boards being moved. The heating system had been serviced but was due to be upgraded as part of the planned extension work. We found that not all the accident forms contained the accident report number; neither did they all indicate whether there was a need to inform the Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) authority. The manager explained how money and valuables of the residents was managed and we were satisfied that it was a safe system. Effective systems to monitor health and safety issues were in place and training in health and safety related matters had either been completed or was planned, although as mentioned in the staffing section we would like outstanding health and safety related training to be given the necessary priority. The manager and deputy were able to provide evidence of how they had tried to resolve the kitchen and patio area issues raised in the environment outcome section with the proprietor, without the response they would have wanted. Dunley Hall DS0000055364.V361160.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 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 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 3 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 4 x 3 Dunley Hall DS0000055364.V361160.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. 1 Standard OP26 Regulation 16 (2)(g)(j) Requirement The kitchen area must be kept clean and hygiene standards rigorously maintained to ensure any identifiable risks due to cross contamination are eliminated. Timescale for action 31/05/08 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 OP16 Good Practice Recommendations The record of all complaints made by residents or their relatives/representatives would benefit from having an additional section explaining whether the complaint was resolved, partly resolved or still remained unresolved. For partly resolved and unresolved complaints there should also be an explanation of follow up action being taken. The patio area outside the dining room should be kept free of clutter and should provide a pleasing aspect for residents to look out on during their mealtimes. As this area is used by staff to take out rubbish etc there is also a potential trip hazard. 2 OP19 Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 25 3 4 OP30 OP37 Any outstanding training shortfalls, especially health and safety related issues such as safe handling of food and infection control, must be rectified as soon as possible. The process used for Regulation 26 visits to the home by the registered provider should be reviewed to ensure there is no potential risk of collusion. Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Dunley Hall DS0000055364.V361160.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!