Care Home: Dunster Lodge

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What the care home does well The home is well managed. The premises are well presented, very clean and well maintained. Home cooked food is served, this is nicely presented and people living at the home had praise for the food. Lunch was taken and was delicious. The care given is of a very good standard and people are treated with respect and dignity. The owners are very involved in the day to day running of the home and have set a high standard of care. People living at the home are supported to attend out patient clinics and other health care appointments to monitor and meet their health care needs. What has improved since the last inspection? The home has updated it`s web site information that is available for people looking to see what the service offers. A conservatory dining room has been installed. This room has new furniture and has enhanced the home`s communal space. The dining room was nicely presented tables had flowers and menu cards. CARE HOMES FOR OLDER PEOPLE Dunster Lodge Manor Road Alcombe Minehead Somerset TA24 6EW Lead Inspector Barbara Ludlow Unannounced Inspection 17th June 2008 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunster Lodge Address Manor Road Alcombe Minehead Somerset TA24 6EW 01643 703007 01643 703007 dunster_lodge@compuserve.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Margaret Joan Hayes MRS ANNE CLARKE Mrs Margaret Joan Hayes MRS ANNE CLARKE Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 19 26th June 2007 Date of last inspection Brief Description of the Service: Dunster Lodge is an established care home situated in a quiet part of Alcombe approximately one mile from the town of Minehead in Somerset. The care home is at the top of the hill accessed along a steep narrow drive leading off Manor Road in Alcombe. The home is set in approximately 3.5 acres of landscaped grounds with panoramic views of Minehead and the Bristol channel across to Wales. The home is registered to provide personal care for up to 19 people over the age of 65. The registered providers and managers are Mrs Margaret Hayes and Mrs Anne Clarke; both live within the grounds of the home and are hands on in the home. The accommodation is over three floors with access by stairs and a passenger lift. Accommodation is mainly single rooms with one room being a shared room at the present time. The providers intend to make this into a single room in the future. The communal rooms include two sitting rooms, a dining room and conservatory all on the ground floor and accessible for ambulant and people who use wheelchairs. Toilets are close to the communal areas. The communal rooms are spacious with comfortable seating for all people in the home. The conservatory is mainly used for group activities and provides a suitable environment for people to sit and socialise. The current fees range from £390 to £ 540 per week. Extra charges are made for personal items, hairdressing and newspapers. The providers have established a stable staff group, many of whom live locally to the home. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried by one inspector and an ‘Expert by Experience’ from Help the Aged. The inspection was well received. Both owners were present at the inspection visit and both received feedback from the expert by experience and the inspector at different stages of the inspection day. The expert met and chatted with people living at the home. The inspector made a tour of the premises with the provider, met with people living at the home. Both were invited to stay to lunch. Staff were seen and spoken with and daily life was observed. This was a very positive inspection visit. Records were sampled and care records were seen as part of the case-tracking sample of care plans examined for people living at the home. Prior to the inspection the owners had completed the Annual Quality Assurance Assessment (AQAA.) This was completed and gave a good level of information about the service. Five people living at the home, three relatives/carers and four staff completed questionnaires prior to the inspection and some of their comments have been incorporated into this report. The Expert by Experience gave feedback to the inspector and the owners before leaving the inspection and filed a short report on the experience. Some of this reporting has been included in the body of the report. The inspector would like to thank the people living at the home; the management and the staff team for their time and contributions to the inspection process. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dunster Lodge DS0000016016.V365366.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, NMS 6 does not apply. Quality in this outcome area is good. There is information available for prospective people and their representatives to make an informed choice. Pre admission assessment is undertaken to ensure that care needs can be met at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a brochure with photographs. There is also a small map, which will be helpful when first locating this care home. Information is also available in CD format. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 9 The management have updated the statement of purpose and have included a link to the home’s website. The web site has photographs and further information about the home and the service offered. This also has a web link to the map and directions to the home. The home offers a trial period of four weeks to enable people to be sure they have made the right choice of home. Two people were spoken with about their admission experience. One person was assessed in hospital with little family involvement and could not remember seeing a brochure. But the experience of living at the home was very positive and they said the staff were “very, very good to them”. The other person said their family had visited for them and had received information and a brochure. They commented that “they have been very good to me here”. Written feedback from five people and three relatives confirmed that information is available about the home. Four people confirmed having received a contract. One relative said the home was recommended and the care is working out well. All relatives responding said their relatives needs are met. Five care plans were examined. Pre admission assessments were seen in the sample of care plans. Community Single Assessment Process forms and hospital discharge information was seen on the files and is used to inform the care planning at the home. Property lists are completed on admission. Contracts were sampled. The inspector was informed that a draft contract is included in the service user guide, the individual’s contract being issued after the trial period. The information includes that extra costs may be incurred for hairdressing and items such as newspapers and toiletries, at cost price. At the last inspection it was noted that: Incontinence pads where an assessment has not been made will be charged for. Dunster Lodge DS0000016016.V365366.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. People are cared for in a dignified and person centred way. Personal care is well managed and access to appropriate health care is supported. Care is enabling and independence is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People were seen and spoken with during the inspection. All looked well kempt. Everyone had a care plan, a sample of five were chosen for inspection. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 11 The care plans were informed by the pre admission assessment and information gathered from health care professionals in the community assessment and any hospital discharge letters. Personal information and family contacts was well recorded. Medical and social history was recorded. This included any special dietary needs. Religious needs were identified. Daily records are made of well-being and important events for the individual. One of the care plans did not have photographic identification of the person. The care plans included risk assessments to alert staff to the risk of falls. One person identified a high risk but had no falls recorded since admission. Falls, treatments and any professional health care input by the G.P or district nurse is recorded in the individuals care plan record. Weights were not recorded in the care plans on a regular basis. The owners indicated that weights are taken on a monthly basis and two staff are allocated to this task. There is a need for attention to weight record keeping practice. Professionals allied to health care such as the chiropodist and optician visit the home and the care plans identified their input. Attention to out patient appointments for example for routine and regular blood tests was recorded. One person commented that the home are “very efficient” at arranging and taking people to appointments. One person had been taken to an out patient appointment on the day of the inspection and was observed to be well supported on returning to the home after lunch. Skin care was examined for one person and there was evidence of planned care to prevent their skin becoming sore. Community nursing input is sought for advice when needed. People living at the home all said they receive the care and the medical support they need. Written feedback from three relatives confirmed that care needs are met. The relatives said they visit regularly and they were confident that the home would be in touch if something happened. Staff interactions with service users were observed to be polite and friendly. Carers were described as ‘very helpful’. Medications management was examined, the records were complete and the main storage appropriate. The controlled medication was safely recorded. Self medication is encouraged especially where someone is being prepared for discharge home after recuperation at Dunster Lodge . One person was self medicating but did not have lockable storage in their room. The medication was held in a drawer and the bedroom could be locked when unattended. This was discussed with the managers and lockable storage was to be arranged. Dunster Lodge DS0000016016.V365366.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 good. The home is comfortable and there is a friendly and welcoming atmosphere. There could be more meaningful organised activities. The catering is well presented, nutritious, fresh foods are used and special dietary needs are catered for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Morning tea / coffee with biscuits was being served as the inspection visit commenced. People were sitting together in the main lounge. The expert by experience attending with the inspector from the Commission met with people living at the home. Time was spent time observing the daily Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 13 routines and chatting with people in the communal areas of the home and in private Some people said they did not have enough to do. It was noted that there has been a change in activities, with one full time staff having left since the last key inspection. There are activities at the home provided by one person who works two days each week. The owners are planning to employ two part time staff to provide more variety and opportunities for people living at the home. People had their nails attended to during the morning. Visitors were spoken with and they confirmed always being made to feel welcome and that they are offered refreshments. People living at the home also said their visitors are welcomed. The homes notice board is used to advertise events such as the summer ball and events in Blenheim Gardens, Minehead for which trips can be arranged for those who wish to attend. The details for contacting an Age Concern advocate were also displayed. There is regular entertainment at the home which includes a weekly dancing session which is popular amongst the people living at the home however there was no session this week due to holiday. A Summer Ball which was successful last year, is planned as an garden event again this September. The expert by experience reported that it was pleasing “to find that one lady had been able to bring her much-loved cat with her while another had brought a small dog.” The AQAA stated that it allows small pets to be brought into the home with only vet bills and food being charged for. People said they spend their time as they choose. One person said they get up when they want to and go back to their room in the evening, after a supper drink and biscuit at about 8.30pm retiring to bed about 10pm. Day staff work until 9pm then one staff is in the building with a senior person (manager) ‘on call’ on site. Hourly checks are made on people overnight unless they request otherwise. Night routines are documented in care plans. Breakfasts are served from 7am by the night staff, special instructions are passed to staff, a notice in the office alerted staff to one person who prefers to come down to breakfast before 8am. The expert by experience spent time with the chef and heard that fresh ingredients are used and home cooking and baking is prepared. Cake was made for teatime. The menu was displayed. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 14 The meal at lunchtime was seen served in the dining room. The food looked hot and the service was nicely done from a trolley with all the staff on hand to assist . A choice of main meal was available, fruit juice was followed by a vegetarian or meat option with vegetables. Alternatives to this can be made on request. Dessert was lemon meringue pie. Special diets are catered for these included diabetic preferences, gluten free diets and softer diets. All people asked about the food at the home commented positively saying it was “tasty”, “delicious” and “always enjoyable”. The inspector and the expert were invited to have lunch and a choice from the lunchtime menu was made. The expert reported that, “I have to say the food was absolutely delicious, and I could understand why I had found universal appreciation amongst residents”. The inspector fully concurred with this view. The comment cards indicated that relatives had noticed that “there is always a good menu on the notice board”. Staff also reflected that the food is always fresh and tasty. The care plans and AQAA demonstrated the recognition of religious needs and access to worship. Dunster Lodge DS0000016016.V365366.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): 16,17,18 Quality in this outcome area is good. The home has a complaints policy and procedure. There have been no complaints made to the home or CSCI. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints reported to the home or to CSCI since the last inspection. The home has a complaints policy and procedure, details of which is on the service users information available about the home. People were asked if they felt they could raise a concern or complaint at the home. All said they were confident that they could complain and one said they take their concerns “directly to Anne or Margaret” (the Owner/ managers). In the comment cards four people said they knew how to make a complaint, one said ‘no’. Two relatives said ‘yes’, they knew how to make a complaint about the care provided. One said ‘no’, but they would “quickly sort something out by ringing various places”. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 16 One person asked said they were on the register of electors and were taken out to vote if they wanted to. The AQAA stated that the owners would respond to complaints by “even the slightest complaint from residents, relatives or staff are dealt with immediately and resolved”. The owners stated they would suggest an advocate if they felt someone may be vulnerable. Staff asked demonstrated an awareness of safeguarding people in their care and comment cards confirmed that training as part of National Vocational Training helped with the understanding of the individual needs and relating to disability, age, gender, race and ethnicity, faith and sexual orientation. The AQAA stated that there has been improvement over the past twelve months with the engagement of a “company to oversee all our company law and recruitment practices” Dunster Lodge DS0000016016.V365366.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): 19,26 Quality in this outcome area is good. The premises are homely, comfortable and are generally well maintained. The home is clean and there are good standards of hygiene with hand washing facilities for staff and hand cleansing gel for staff and visitors to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector made a tour of the premises and the home was found to be clean and comfortable. There are hand washing facilities for staff with liquid soap and paper towels and flip top waste bins, one was found to be broken and in need of replacement. One first floor window was identified for risk assessment for being unrestricted in opening. The owner agreed to attend to Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 18 this. One fire door was identified that did not fully close, this must be repaired for fire safety. One carpet was due to be deep cleaned to reduce the malodour; this was discussed with the owners at the inspection. The expert by experience reported that: ‘looking round the home, everything seemed clean and fresh. The bathrooms in particular were immaculate with huge basins and baths with safety rails. There were no showers’. ‘I noticed that rooms were labelled not just with numbers but with the names of the occupants – a nice personal touch.’ ‘The standard of decoration was generally good’. The expert by experience also noted that ‘Hand gel was freely available throughout, including at the entrance to the Home’. There has been investment in the home with a new conservatory and dining furniture. This was confirmed in the AQAA which also stated that there have been some improvements made in the kitchen and the home has employed a regular gardener. There are plans to provide a staff rest room and funding permitting replacement lounge chairs will be purchased. Comment cards indicated that the people living at the home found it to be kept very clean, one said it is “always spotless”. Relatives also commented on the cleanliness of the premises when they visit. Dunster Lodge DS0000016016.V365366.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. The home has a skill mixed staff team. Staff training is given and staff supervision is in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there was 17 people in residence being cared for by two care staff and the home owner / managers. The cook and a cleaner were on duty. There are two carers on duty throughout the day and one at night with a manager on call. There are no kitchen staff on duty at teatime. The staff compliment seems to be sufficient to deliver the care needs of the people in residence. No complaints were raised about the staffing levels by people, relatives or staff. One staff commented that the owners are always there to help if needed. The owners stated that they will be employing two part time activities staff to assist the present person who provides activities on two days each week. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 20 Staff recruitment files for four staff were examined. All demonstrated good recruitment practice with satisfactory references and Criminal Record Bureau checks/ Protection of Vulnerable Adult list checks being in place before their employment commenced. Staff are encouraged to undertake National Vocational Qualification (NVQ) training to NVQ level 2 in care. One person commented in their feedback that they had received good training and support including an opportunity to undertake an NVQ in care and they appreciated the owners’ commitment to the investment in them. The AQAA indicated that there are 13 care staff and 1 bank care staff. 8 or 57 have achieved NVQ level 2 or above and 4 or 28 are working towards the qualification. This demonstrates a good commitment to having a qualified care team. Supervision is informally carried out on a day to day basis as the owners are frequently on duty at the home. The supervision records are computerised and access was given to view them. They were found to be regularly updated, detailed and provided evidence of an excellent level of support for staff. The last staff meeting was held on 31/3/08. Dunster Lodge DS0000016016.V365366.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): 31,32,35,36,38 Quality in this outcome area is good. The owners proactively manage and lead the good practice at the home on a day-to-day basis. The health and safety at the home is well managed, one requirement and one recommendation are made for environmental safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered owners have engaged a company to oversee the health and safety of the premises and service matters such as safe recruitment and compliance with employment law. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 22 The maintenance records for the home were examined. The fire alarm records demonstrated regular weekly checking of the system and was up to date. Fire extinguishers were serviced in July 07. A fire lecture by an external trainer was given to staff last month. The owners said that day staff have 6 monthly in house training and night staff now have 3 monthly training. Staff spoken with confirmed having received mandatory training including fire training. The AQAA indicated that equipment used for lifting people such as portable and bath hoists and the passenger lift had been serviced in May and February 2008 respectively. The emergency call equipment had been serviced in 12/2007. Staff supervision is recorded as a computerised running record; this was sampled and demonstrated regular supervision entries. The home was working towards the reassessment of Somerset ‘s Quality Rating scheme at the last inspection in 2007. The AQAA indicated that this was achieved. Dunster Lodge DS0000016016.V365366.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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 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 3 18 3 2 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 4 X X 3 X 3 3 Dunster Lodge DS0000016016.V365366.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 OP19 Regulation 23(4) Requirement One fire door was identified that did not fully close, this must be repaired for fire safety. Timescale for action 15/09/08 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. 2. 3. 4. Refer to Standard OP24 OP8 OP26 OP19 Good Practice Recommendations One carpet that requires regular deep cleaning should be replaced if the cleaning fails to remove the malodour. Weight monitoring or frequency of agreed monitoring should be clearly recorded in the care plans. Flip top waste bins for hand wash waste should be kept in working order. Windows above ground floor should be risk assessed or restricted in opening to a safe limit, in line with HSE guidance of 100mm. Dunster Lodge DS0000016016.V365366.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Dunster Lodge DS0000016016.V365366.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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