CARE HOMES FOR OLDER PEOPLE
Dovehaven House 58 Moss Road Birkdale Southport Lancashire PR8 4JG Lead Inspector
Val Turley Unannounced Inspection 17th October 2007 09:30 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 Dovehaven House DS0000005973.V346955.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. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Dovehaven House Address 58 Moss Road Birkdale Southport Lancashire PR8 4JG 01704 564259 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) Mr Mark Jonathan Gilbert Mrs Wendy Josephine Gilbert Mr Peter Andrew Brookfield Care Home 40 Category(ies) of Dementia (40) registration, with number of places Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service is registered for a maximum of 40 service users in the category of DE (Dementia) 16/08/06 Date of last inspection Brief Description of the Service: Dovehaven house is situated in the village of Birkdale near Southport town centre with all its amenities being a short drive away. The home provides 24hour personal care for up to 40 older people who have a dementia related condition. The home has been designed to provide care on two separate units, each of which has its own lounge and dining areas. There is a passenger lift to the first floor. Single room accommodation is provided for all residents. Of the forty rooms, ten have en-suite facilities. Security is a prime concern at the home. There is a secure internal courtyard with a lawned area, flowerbeds and seating and a garden area to the rear of the home. Fees at the home range from £435 - £460 per week. There are additional costs for chiropody and hairdressing. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an inspection that took place over a fourteen-month period and culminated in a site visit to the home over one day in October 2007 by one regulatory inspector. We had discussion with people living at the home where this was possible, discussion with staff, observation of staff supporting the residents and an examination of records, policies and procedures. Every year the registered persons are asked to provide us with written information about the quality of the service they provide and to make an assessment of the quality of their service. We use this information, in part, to focus our inspection activity. We sent out a number of surveys to collect additional information about the service. We received back 2 from people living at the home, 4 from relatives, 3 from staff and 1 from a GP. The information from these surveys is also included in this report. As part of the inspection, we used ‘case tracking’ as a means of assessing some of the National Minimum Standards. This process enabled us to focus on three of the people living at the home. Records relating to those individuals were looked at and discussion took place with them where possible and with the staff team about their support needs. What the service does well:
Dovehaven provides a comfortable and clean environment for the residents living there and the staff who work there. The home is well furnished to suit the needs of the residents who are also encouraged to personalise their own rooms. The equipment and systems at the home are well maintained and there are good policies and procedures in place to keep the residents as safe as possible. The home is generally well managed with the manager being well established in post. We saw from the training records that he had undertaken additional training to update his skills. There were clear lines of accountability in the home and staff generally feel well supported by the manager. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 6 The home has a good and thorough approach when admitting new residents ensuring as far as possible that the choice of home is suitable and that the home can provide the support that the residents need. Care plans are in place for each of the residents and we found that these were detailed giving the staff good information about the support needs of the residents. Staff had a good knowledge of the residents needs and were keen to improve the quality of life for the residents. Risk assessments are undertaken for each resident every month and care plans are reviewed to help ensure that the care provided is appropriate. The home has good relationships with the relatives of the residents and involves them in the development of the residents care plans wherever possible. One relative wrote that they were very satisfied with the care provided and another wrote that they were happy with the care provided to their relative. The home has good relationships with a range of health professionals who provide additional support and guidance in the home. The health needs of the residents are attended to and a GP wrote that he had no concerns about the way the service meets the health needs of the residents and that staff always treat the residents with dignity and courtesy. We found that the medication in the home is generally well managed and that policies and procedures in respect of medication had been recently reviewed. Routines within the home were flexible with residents being able to decide what they would like to do. Staff responded to their needs and supported them to make decisions and choices. Activities are organised and these included trips out, entertainers and group activities. The residents were relaxed and settled in the company of the staff. Visitors are welcome to the home at any reasonable time and we noted that visitors could visit residents in the privacy of their own room. One visitor said that the food was excellent especially at Christmas when as a visitor he was made very welcome. The home had a four weekly menu but there were always alternative meals available and the staff had a good knowledge of the residents individual likes dislikes and dietary needs. There are a good range of training opportunities in place for the staff to take advantage of and staff receive at least three paid days of training each year. The home had a number of quality assurance measures in place to help ensure that the home is run safely and in the interests of the residents. Policies and procedures are updated regularly and as necessary and the homes owner visits the home regularly to make sure that the home is running well. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
There are a number of things that the home can do to improve the care that they are provide to the residents and to make the home a safer place to live. The home should ensure that any hand written entries on the Medication Administration Sheets (MAR sheets) are countersigned by a second member of staff to help ensure accuracy. The homes activity timetable should be presented in a format that all of the residents can understand. The home would also benefit from the appointment of an activities organiser who would be able to provide more one to one support for the residents.
Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 8 Not all of the relatives, who returned a completed survey, knew how to raise a concern if they were not happy with the service that the home provided. The home should write and inform relatives or representatives of the residents of the homes complaints procedure to help make sure that everyone knows what process they can follow and what support they should receive from the home. The home should look at the options open to them that would enable them to identify the owners of any valuable items found in the home and how best to deal with items that remain unclaimed. The home should develop a sexual and personal relationships policy to provide staff with information and guidance about consent issues and the protection of the resident from possible sexual and emotional abuse. Some of the staff thought that there could be an improvement in the way information about the care needs of the residents is passed on to them when they start work at the beginning of a shift. Each member of staff should also receive formal 1-1 supervision from a member of the management team six times a year, enabling any concerns or training needs to be discussed. Water temperatures in resident’s rooms should be checked more frequently to help ensure that the temperatures remain at a safe level. The home should also look at the Department of Healths publication Essential Steps to see if any improvements could be made to their health and safety procedures. The manager should recommence informing us of any notifiable incidents that may take place in the home, including the death of any resident. 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. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 9 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 Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 10 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 Standard. Standard 6 was not applicable. Quality in this outcome area is good. The home has a good and thorough approach when admitting new residents ensuring as far as possible that the choice of home is suitable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked the files of three residents in detail. These showed that the home had a thorough and detailed approach to admission. A pre-admission assessment process had been followed for all of these people. The assessment gave a good overview of the residents support needs and information about their preferences, likes, dislikes and links with family and friends. Assessments from care managers were also obtained where this was appropriate. The information obtained through the pre-admission process had been developed into a care plan for each of the residents.
Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 11 We received surveys that had been completed by relatives, or relatives on behalf of the residents. Of these, all but one felt that they had received enough information to enable them to make an informed choice of home. As well as providing a Statement of Purpose and Service User guide to prospective residents and their families, the home makes a copy of their inspection report available within the entrance area of the home. Information is also made available through a web site that enables interested parties to make an appointment to visit the home. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 12 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 residents individual health and personal care needs are met by the support staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans in place for each of the residents are detailed and provide staff with information regarding the personal support needs of the residents. Discussion with staff indicated that they had a good knowledge of the residents needs and are keen to improve their quality of life as far as possible. The home had undertaken a number of risk assessments for each resident every month, to monitor any changes in their support needs. Resident’s families are given the opportunity to become involved in the development of residents care plans. Care plans are reviewed monthly to help ensure that the residents changing needs are addressed.
Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 13 Information on the residents files, information provided in discussion with support staff and other records within the home indicated that the health needs of the residents are met appropriately. A number of health professionals are involved in the home including a District Nurse, a chiropodist, and an optician. There are also records to show that residents are supported to attend any health hospital appointments. Where there had been concerns about the weight of a resident, there was evidence that there had been liaison with the cook to address those concerns. The majority of the comment cards received from residents relatives stated that their relative always received the medical support that they needed, while the rest felt that medical support was usually provided. A survey completed and returned by a GP said they had no concerns about the way that the service met the health care needs of the residents and that the staff always treat the residents with dignity and courtesy. We found that the medication in the home is generally well managed. All of the staff members who administered medication have received appropriate training. Records in relation to the management of medication are all accurately maintained and the home conducted medication audits. It was recommended that the home ensure that any hand written entries on the Medication Administration Records (MAR sheets) are countersigned by a second member of staff to help ensure accuracy. Policies and procedures in respect of the management of medication are in place and these had been reviewed recently to ensure that any recent. We watched staff supporting residents and noted that they spoke to them in a respectful manner and included them in conversations, ensuring that they were given information and opportunities to make choices and decisions. Staff were seen to knock on residents doors before entering the room. Policies and procedures were in place in respect of resident’s rights to privacy and dignity. Induction training for staff included information regarding privacy and dignity and information was also included within the Statement of Purpose and Service Users Guide. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 14 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 are supported to make choices and decisions in their daily lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an activities programme in place and this is displayed in the entrance area along with photographs of the residents enjoying activities. The activities organised are varied and include group activities, entertainers and trips out. Those residents who were able to verbalise confirmed that they could join in activities if they wished. Although an activities programme is in place, staff stated that often activities had to be organised in accordance with the needs and wishes of the residents. It is recommended that the activities programme is presented in a different format to enable all residents to understand it. Unfortunately the post of activities organiser was vacant although the manager said that the residents would benefit from the additional one to one support that one could provide, with activities such as a trip to the local town.
Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 15 There is good information on the files of more recently admitted residents about their individual interests and information is included within care plans were people preferred or needed 1-1 support to follow their interests. The manager said that the aim was to have good information in place for all residents and that this was being addressed across the home. Information regarding resident’s religious needs is recorded within their file and arrangements were made for a visit from a minister where this was requested. People were seen to be offered choices, for example, a choice of drink or what they would like to do and staff engaged them in conversation as they moved about the home. People are able to receive visitors at any reasonable time and information regarding this is available within the Service Users Guide. Visitors are able to visit residents in the privacy of their own room. Care plans included specific information where there was a need for specific support for people to receive visitors. The staff spoken to were aware of the need to support residents to maintain personal relationships. Information regarding independent advocacy services is available within the reception area and an advocate provides support to one of the residents. The kitchen at the home is clean, tidy and well organised with food being stored appropriately. There is a four weekly menu in place and although this does not show any alternatives available the staff stated that alternatives are always available. A record is maintained of any alternatives served. The cook is well aware of the individual likes and dislikes and dietary needs of each of the residents. Independence is encouraged at meal times although assistance is provided discretely as required. All meals, including those which were liquidised are well presented to aid nutrition and appetite. One visitor said that the food was excellent especially at Christmas when as a visitor he was made very welcome. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 16 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 home has god policies and procedures in place to protect the resident as far as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes policies and procedures in relation to the protection of people living at the home contained the necessary information and guidance for staff, residents or relatives should they wish to raise any concerns about the home. The home has its complaints policy and procedure displayed around the home although two surveys completed and returned by relatives indicated that they were not aware of how to raise a concern. Information about making a complaint is also included in the Service Users Guide. It was recommended that the home inform all relatives of its complaints policy and procedure to help ensure that any barriers to raising any issues of concern are minimised. The homes training record showed that the home provides training for staff in the safeguarding of vulnerable adults. One allegation has been made since the last inspection and the home has responded appropriately to the concerns raised and worked closely with other agencies to help resolve the difficulties. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 17 The home does not have a policy in place dealing with personal and sexual relationships and it was recommended that the home develop one to provide staff with guidance about consent issues and the protection of the residents from possible sexual and emotional abuse. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 18 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 god. The home provides a clean, well-maintained environment for the residents who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Dovehaven is a clean, comfortable and well-maintained home that has been furnished taking the needs of the residents into consideration. Bedrooms are comfortable and residents are able to bring in some of their own possessions to personalise their rooms. Risk assessments are in place identifying those residents who are able to manage a lock on their bedroom door and they were seen to have been provided with a key to their rooms. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 19 Since the last inspection a great deal of work has been undertaken or is planned to improve the home still further. New windows have been installed around the home, redecoration is planned, arrangements have been made for handrails to be installed, a new hoist has been fitted in one of the bathrooms, furniture has been replaced and new garden furniture has been bought for the central garden area. A sensory room is to be provided and thought is being given as to how the homes reception area can be improved. The laundry appears to be well organised and the manager stated that it was sufficiently well equipped to meet the needs of the residents. The area is well ventilated and equipped with protective clothing, and hand washing facilities. Infection control policies are in place and staff have completed infection control training this year. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 20 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. The staff team are carefully selected and receive training that enables them to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the home’s staffing rota, this showed how many staff were on duty and in what capacity they were working. The staffing levels appeared to be adequate and staff said this was the case providing nobody was absent from work. There were also some staff vacancies that had put some additional pressure on staff although the manager was in the process of trying to recruit new staff. The home does use agency staff occasionally but the emphasis is on providing consistency of care by using regular staff to cover vacancies wherever possible. The training records show that the staff team have a range of skills and knowledge enabling the support needs of the residents to be met. They have been provided with a range of training opportunities over the last 12 months including first aid, infection control and abuse awareness. Dementia training is planned and training in the management of challenging behaviour has been provided. Over 50 of the staff have achieved a nationally recognised
Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 21 qualification in care and staff receive at least 3 paid days for training each year. The home also has some training materials that the staff were able to access, these include a DVD about sight and vision. The home has contacts with a number of health professionals who are able to provide additional training and advice. The files of three recently employed members of staff were examined. These showed that all of the necessary checks and references had been undertaken before they started work in the home. These members of staff have also received induction and mandatory training. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is good. The home is well managed in the interests of the residents who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager at the home has been in post for a number of years and has achieved an NVQ in care and management. We looked at his training record and this showed that he has undertaken additional training to update his skills. There were clear lines of accountability in the home and staff generally feel well supported by the manager. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 23 The home has a number of quality assurance and quality monitoring systems in place. It has also achieved a quality assurance award accredited by an outside body. A survey of relative’s views had been undertaken and the results made available to all visitors to the home. A survey of involved health and social care professionals’ views had also been undertaken. Staff meetings are held giving staff an opportunity to raise any concerns. Staff spoken to said that they generally felt well supported although the completed surveys returned by staff suggested that the information passed to staff at handover could be improved and made available to all staff. It was recommended that the manager look at how this could be improved. The manager has introduced additional measures to ensure that water temperatures in the home are safe for residents. In addition to this it was recommended that the water temperatures in bedrooms should be checked more frequently to ensure that temperatures here remain safe. Policies and procedures are reviewed and updated when required. The registered provider makes monthly monitoring visits to the home and a record of these visits is maintained at the home. The home keeps only a minimum amount of money on behalf of residents and this is used mainly to pay for chiropody and hairdressing. To protect the resident’s money receipts are kept for all transactions and individual records show the balance of money held for each resident. The home does not keep valuables on behalf of residents, although occasionally items, especially jewellery and watches, are found in the home. The home has experienced problems trying to return these items to their owners, as it is not always possible to identify who they belong to. It was recommended that the home look at the options open to them that would enable them to identify the owners of any valuable items found in the home and how best to deal with items that remain unclaimed. The staff at the home received informal supervision and support from the management team and staff are able to ask for advice and guidance at any time. It was recommended that 1-1 formal supervision be provided for all staff six times a year giving all staff opportunities to discuss any concerns or training needs. From observation on the day of the site visit and from information provided by the manager in the pre-inspection questionnaire, the environment was seen to be safe for residents. Policies and procedures in respect of health and safety are in place and staff have received appropriate training including first aid, food hygiene, health and safety and infection control training. Equipment and systems are serviced appropriately. It was recommended that the home look at the Department of Healths publication Essential Steps to see if any improvements can be made to their health and safety procedures.
Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 24 We looked at the homes accident records and saw that these were being stored correctly. The manager had analysed the accident records on a monthly basis and had been able to put additional measures in place to help prevent accidents from re-occurring. It was recommended that the manager recommence informing us of any notifiable incidents that may take place in the home, including the death of any resident. The homes fire procedures are displayed in the home and the manager stated that issues identified in the last fire officer’s report have been addressed. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 25 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 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 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 OP9 OP12 OP12 OP16 OP18 Good Practice Recommendations A second member of staff should countersign handwritten entries on the MAR sheets to help ensure accuracy. The homes activities timetable should be presented in a format that all of the residents can understand. An activities organiser should be appointed to help provide more one to one activities for residents. All relatives should be given details of the homes complaints policy to them raise any concerns they may have. The home should develop a sexual and personal relationships policy to provide staff with information and guidance about consent issues and the protection of the resident from possible sexual and emotional abuse. Consideration should be given to the way information is passed on to staff to help ensure they are fully aware of the residents support needs. 6 OP31 Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 27 7 OP35 8 9 10 11 OP36 OP38 OP38 OP38 The home should develop a protocol for identifying the owners of valuables belonging to residents that have been lost in the home and disposing of those which are not claimed. Formal supervision of staff should take place six times a year. The water temperatures in resident’s room should be checked more frequently to help ensure that the temperature remains at a safe level. The home should refer to the Department of Health’s publication ‘Essential Steps’ to see if improvements can be made to the their health and safety procedures. All notifiable incidents should be reported to the commission. Dovehaven House DS0000005973.V346955.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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
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