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Inspection on 20/11/09 for Dovers

Also see our care home review for Dovers for more information

This is the latest available inspection report for this service, carried out on 20th November 2009.

it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Annual service review Name of Service: Dovers The quality rating for this care home is: The rating was made on: two star good service 1 3 1 1 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Deborah Sullivan Date of this annual service review: 2 1 1 0 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service Address of service: 9 Doversgreen Road Reigate Surrey RH2 8BU 01737244513 01737225737 dovers@fieldlane.org.uk Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Name of registered manager (if applicable) Field Lane Foundation (The) Conditions of registration: Category(ies) : dementia old age, not falling within any other category physical disability Conditions of registration: The maximum number of service users to be accommodated is 39 The registered person may provide the following category of service only: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Physical disability (PD) Old age, not falling within any other category (OP) Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: The home has become registered as a care home with nursing. The registered manager present at the last key inspection has left the home and there is an acting manager. 1 3 1 1 2 0 0 8 Number of places (if applicable): Under 65 Over 65 39 0 39 0 39 0 Date of last key inspection: Annual Service Review Page 2 of 7 Date of last annual service review (if applicable): Brief description of the service Dovers is a care home registered to provide accommodation and care to thirty nine service users over the age of sixty five years. The home is located in a residential area close to public amenities and other facilities. Accommodation is on two floors accessed by stairs or a lift and comprises of an office, lounges, kitchens, laundry, bathrooms, showers, toilets and single bedrooms, some with en-suite facilities. The home has mature gardens which are well maintained and accessible to service users. Private parking is available. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Surveys returned to us by people using the service and from other people with an interest in the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. What has this told us about the service? The AQAA (annual quality assurance assessment) completed by the acting home manager gives us clear and comprehensive information on the home,on how it has changed or developed since the last key inspection and about plans for improvement over the next year.The AQAA was returned within the timescale given in a reminder letter we sent. The AQAA tells us that the home provides a person centred service and changes have made it more person rather than task focused. There is an admissions process involving pre admission assessment,potential service users can stay overnight as part of the process if this is appropriate.The assessment form has been made more user friendly and falls and risk assessments take place.The home offers a respite service and the AQAA says some people use it repeatedly. The AQAA tells us that each resident has a combined care plan,life story and person centred plan,the information is kept up to date.A new Listen to me document is in place that enables staff to provide care and support to meet personal preferences and respect individuality.It says residents are treated with respect and dignity and staff are more aware of how to communicate with them. There is a medication policy that ensures safe medication practices,during the past year staff supervision in relation to medication administration has improved and each resident now has their medication dispensed from a locked medication cabinet in their room. The home works with health Annual Service Review Page 4 of 7 care professionals such as GPs and district nurses and states it hopes to improve links with them. The majority of survey forms sent to us by service users and relatives said they were satisfied with the care they received.Two relatives commented that there had been some issues regarding effective communication with the home regarding their relatives needs,one relative of a resident who was telephoned in response to their comments about this said that communication was improving and that meetings with relatives were being held and were helpful. The AQAA says that more choice of activity has been introduced and activities have been made more personalised.There is a dedicated day care team and music and art therapists are used.Recording of activities is now taking place.The need for more activities and especially outings was expressed on four surveys returned by residents,one from a relative and on two staff survey forms.Under the heading What could the home do better one resident who had been supported by a staff member to complete their form saidTake me into the community more and another said they wished to go more as they were bored. The AQAA tells us that residents choose their meals and the catering team discusses meal choices with them. The home has a complaints procedure and relatives and advocates are encouraged to raise any concerns with the home manager or senior staff.The AQAA says there have been three complaints made to the home in the last year,none were upheld. The home has safeguarding procedures and improvements over the past year have been more safeguarding training and staff awareness of their role in safeguarding vulnerable people.There have been four safeguarding alerts raised and the manager states in the AQAA they acknowledge that safeguarding issues have highlighted a need for more personalised and comprehensive risk assessments, this is being addressed.It also says that residents monies are recorded more effectively and more participation with personal finances is encouraged. Recruitment procedures are robust and all staff are CRB and POVA checked. The AQAA states that the space in the home is used in ways that respond to the needs of residents,signage is used to assist them to move around the building and residents rooms are personalised to their taste.Survey forms from residents and did not reflect any environmental concerns and a relative wrote that the home provided an open, friendly and clean environment. Improvements planned to the environment are a review of the siting of furniture to encourage socialisation and fire doors to residents rooms are to be upgraded this will exceed current safety requirements. The home promotes diversity amongst the staff group and is hoping to recruit more male carers.The AQAA says that residents are encouraged to be involved in the recruitment process,they can choose to be involved in interviews or meet staff applicants informally. New staff receive induction and the organisation has a training manager who provides all core training.Service specific training is provided such as on challenging behaviour and dementia. An improvement is that the manager attends weekday handover meetings with carers and more in depth discussion takes place regarding residents needs. Survey forms sent in by staff,relatives and residents were mixed as regards views on staffing levels,one staff member said that the home provided good quality care whilst more staff were needed.The majority of residents and relatives surveys expressed satisfaction with the availability of staff and their responsiveness and two relatives commented that the staff group seemed stable. A number of complimentary comments were received regarding staff including from a Annual Service Review Page 5 of 7 relative,The team at Dovers are always cheerful,helpful and professional as well as friendly and from a resident They listen to me,make me feel its my home,I feel they care. The home is currently without a registered manager.The acting manager has stated their intent to apply to become the registered manager.The acting manager is suitably experienced and is undertaking further relevant training. The service undertakes internal quality assurance and consults with residents and relatives.Regular residents meetings are held and visual tools used to help them express views. What are we going to do as a result of this annual service review? We are not going to change our inspection plan and will do a key inspection of this service by 13th November 2010. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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