Inspection on 29/07/09 for Dove Court

This inspection was carried out on 29th July 2009.

CQC found this care home to be providing an Adequate service.

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.

Other inspections for this house

Dove Court 31/07/08

Dove Court 02/08/07

Dove Court 07/02/07

Dove Court 31/05/06

Dove Court 19/12/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Dove Court Kirkgate Street Wisbech Cambridgeshire PE13 3QU Lead Inspector Janie Buchanan Key Unannounced Inspection 29th July 2009 09:00 DS0000065318.V376872.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dove Court Address Kirkgate Street Wisbech Cambridgeshire PE13 3QU 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) 01945 474746 01945 474846 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Manager post vacant Care Home 76 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (74), Old age, not falling within any other of places category (2) Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Two named service users over 65 years of age (OP) for the duration of their residency only One named service user under the age of 65 years with dementia (DE) already resident in the home Maximum of 74 service users over the age of 65 years with dementia (DE(E)) for the duration of Condition 1 24th April 2009 Date of last inspection Brief Description of the Service: Dove Court is a purpose built residential care home, situated in a residential area on the outskirts of Wisbech. It is owned by Ashbourne Homes Ltd and provides care and support for up to 46 residents over the age of 65 with dementia. The home has 46 single rooms, all with en suite facilities. In addition to the en suite facilities there are 5 bathrooms and one shower, all with toilet facilities. Resident accommodation is on two floors, the upper floor being accessible by stairs or lift. There is a variety of communal areas available to service users. An enclosed garden is at the rear of the home and provides a safe environment for service users to enjoy the garden features. Fees for the home range between £415 and £525.25 per week. CQC inspection reports are available in the office for people to read if they wish or can be downloaded from: www.cqc.org.uk Dove Court DS0000065318.V376872.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 1 star. This means the people who use this service experience adequate quality outcomes. For this key inspection we (The Care Quality Commission) looked at all the information that we have received since the last key inspection. This included the annual quality assurance assessment (AQAA) that was sent to us by the home. 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. We received 24 completed questionnaires from residents, their advocates and people working in the home asking what they thought about it. We visited the home and talked with 6 people living there and six members of staff. We had lunch with the residents so we could watch how staff interacted with and helped them. We toured the premises and viewed a range of documents and policies. An expert by experience (ex by ex) was part of our inspection: an ex by ex is someone who has experience of social care services. During this inspection the ex by ex looked at activities, staff interaction with residents and mealtimes. Her feedback is included in this report. The home has been subject to additional inspections as a result of concerns raised by the local social services teams about poor care practices. Information from these inspections has been included in this report. Due to these concerns the local social service contracts department had suspended placements there, however because of the many recent improvements, they have now lifted the suspension following their monitoring visit. Four requirements and four recommendations have been made as a result of this inspection. What the service does well: We received many positive comments about the home including: ‘my mother has been in Dove Court since October 2008. I find the home to be very good and have no worry as to her care’; ‘the home does its best to make residents’ life happy’ and ‘staff are kind and caring’. Information about the home is readily available to help prospective residents and their advocates decide if it is where they want to live, and what the terms and conditions of there stay there are. Activities at the home are frequent and varied and offer real stimulation for residents. Montessori based activities in particular help residents enhance their remaining skills and abilities. Staff treat Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 6 residents respectfully and work hard at offering them genuine choice, no matter what their cognitive functioning is. The garden area is attractive, stimulating, safe and easily accessible to residents offering them fresh air and sunlight and interesting things to do. What has improved since the last inspection? What they could do better: A number of relatives told us that laundry management in the home was poor one stated in the home’s own survey; ‘mum seems to have wrong clothes in wardrobe, not her own. Another: ‘all white underwear comes back grey, trousers with iron marks on them’ and more must be done to maintain people’s clothes in good condition and to ensure they wear their own at all times. Although some medication practices have improved, staff must ensure they sign for all medication administrated to residents including creams and that blister packs containing medication match consistently with the medication records so that there is clear record of what has been given to residents. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 7 Residents’ pictures on their bedroom doors should be hung much lower so they can see them more easily and find which room is theirs. Mealtimes should be better co-ordinated so that residents eat in a calm and pleasant environment. The garden area is excellent with many items of memorabilia to interest residents, a safe circular walking route and attractive seating to use. However it could be made even better if a sheltered area were created so that residents could enjoy it, even in bad weather. Areas where dangerous chemicals are stored must be kept locked so that residents do not have access to them. Any complaints the home receives must be recorded clearly, investigated thoroughly and responded to in a timely manner so that people know their concerns will be taken seriously and fully looked into. Staff should not start working at the home until a full CRB (Criminal records Bureau) disclosure about them has been so received so that residents are protected and only the right people are employed. Staff are now getting regular supervision, however the quality of this needs to improve so they have the opportunity to raise any concerns, receive feedback about their working practices and have any training needs identified. This is vital if staff are to feel fully supported. Although the home scored an ‘adequate’ rating on this occasion, there has clearly been much improvement since the last inspection. The home now needs to show us that it can sustain these improvements. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 8 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 Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is good information available about the home to help people decide if it is where they want to live, and the home’s admission procedures ensure their needs can be met there. EVIDENCE: There is statement of purpose and service user guide which give good information about the facilities the home offers. These have been recently updated to include the new contact details of the Care Quality Commission. A brochure is also available to prospective residents and their families which lists the services available, staff training, how standards are maintained at the home, a sample menu and copy of the home’s most recent newsletter. People who completed our survey told us they received enough information about the care service to help them decide if it was right for their relative. Residents also Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 10 receive a contract which states the terms and conditions of their stay at the home and the fees payable. We checked the files of two recently admitted residents which showed us their needs had been fully assessed before they were admitted into the home. Further assessments were obtained from local health and social care teams and provided additional information about the person so the home could decide if it could fully meet their needs. One staff member told us that two new residents had been admitted the day previously and that their care plans had already been drawn up so that staff had good information about them. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health needs are monitored closely at the home and staff treat them respectfully. EVIDENCE: We checked the care plans for three residents which were generally well written with detailed information about people’s needs in relation to (amongst other things) their mental health, medication, eating and drinking, personal care, communication and pressure care. There was also good evidence that the plans had been reviewed regularly and meaningfully to ensure that any changes in residents’ needs were picked up quickly. Dependency level and nutritional assessments were completed monthly to monitor residents’ health, and they were also weighed. Records we viewed showed that residents saw a range of health care professionals including chiropodists, GPs and community psychiatric nurses and one member of staff told us: ‘we have nutrition and food charts for almost every resident’. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 12 Relatives who completed our survey told us they were kept up to date with important issues affecting their friend or relative in the home. One commented; ‘the home always ring me if dad is unwell or fell over/ out of bed’ During our inspection we noticed one resident with a large purple bruise on her face. We asked to see her notes: there was a clear record of what had happened, along with a completed incident report. Her relatives had also been informed that she had fallen during the night. We checked medication storage and a sample of medication administration records in Wisteria House. These were generally satisfactory with staff signing clearly to record that they had administered medications to residents. However we noted the following shortfalls: • • • Staff had not been signing when they had administered cream to one resident The date on which liquid medication bottles had been opened had not been recorded The MAR sheet for one resident did not tally with the blister pack causing some confusion as to whether or not they had received their medication as required. We watched a number of interactions between staff and residents which were mostly respectful, positive and enabling. In one particular instance, we watched a staff member accompany a resident whilst she walked to the dining room. This resident clearly found it hard work but the staff member gently encouraged her by saying- ‘well done’, ‘that’s it, you’re nearly there’, ‘keep going’ etc. She also explained to the resident how she was going to seat her at the table and answered the anxious resident’s repeated requests to know the time and day very patiently. This was a good piece of care which showed respect and consideration for the resident’s abilities. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have access to a range of activities to help keep them entertained and stimulated, however mealtimes need to be better organised so that residents eat in a calm and peaceful environment. EVIDENCE: Our expert by experience focussed on activities for residents in the home and reports: Residents benefit from having two activities coordinators and a range of things to do, including circle time and memory time. There are regular outings which, this summer, have taken in Wisbech Rose Fair, Hunstanton, the Norfolk Lavender Farm and the African Violet Centre, plus a planned visit to watch a play at a local school. Other routine activities include visits by the schoolchildren, who sing to the residents, frequent sessions by a visiting couple of professional singers, manicures and ministry by the Anglican and Catholic churches. The home has recently trained 9 staff to undertake specialist Montessori activities (a program based on developing and enhancing people’s remaining abilities) with residents and staff have started a structured 6 month Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 14 activity programme under the guidance of dementia consultant. Before lunch three residents and two staff participated in Montessori activities which, over a twenty-minute period produced measurable results and were clearly of benefit to the residents. A regular newsletter is produced for residents and visitors letting them know what activities are happening. Relatives who completed our survey told us that the home help them keep in touch with residents. One person told us: ‘we are made to feel very welcome and the staff are happy and approachable’ Lunch on the day we visited consisted of pork casserole or quiche, followed by chocolate pudding. Our ex by ex had lunch upstairs with the residents and reports: Each one was offered a choice of two fully plated meals to choose from, care being taken to establish exactly what individuals preferred. Similarly, when anyone’s glass was empty, jugs of orange and blackcurrant squash were offered for them to choose. The food was tasty, well presented and home prepared. There were no long delays and no hurry either. However lunch downstairs was a little more chaotic, with staff shouting loudly at each other over residents, no one being clear about who was doing what and which residents needed help with feeding. Although there were plenty staff available to help, one resident was left for a period of 25 minutes without help to eat her lunch. Her lunch would have undoubtedly been cold by the time she was assisted to eat it. Dove Court DS0000065318.V376872.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s concerns and complaints have not always been investigated and responded to properly by the home. EVIDENCE: The home has received a large number of complaints in the last year concerning, amongst other things, staff moving floors, a resident being left a long time in their room; poor personal care; missing clothes and toileteries, and staff shortages. Finding how the home responded to these was difficult as the complaints file was messy and confusing and there was no clear process in place for investigating the concerns raised, or whether or not they were upheld. One complaint we viewed was sent to the home on 1 August 2008 but the complainant was not responded to until 14 October: the home clearly failing to maintain its own response rate of 28 days. However a recent complaint concerning the lack if equipment, staff shortages, and staff covering for each other whilst they sleep was fully investigated by the new manager and responded to quickly and thoroughly. It was clear that many aspects of this complaint were not upheld. We have not received any complaints about the home in the last 6 months. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 16 Staff we spoke to had a satisfactory knowledge about the different types of abuse an older person could face and knew where to find details of the home’s policy on this matter. We viewed posters around the home giving residents, visitors and staff good information about who to contact if they wanted to raise any concerns and copy of the Department of Health’s ‘No Secrets’ guidance is available to staff to look at in their staff room. Dove Court DS0000065318.V376872.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a comfortable, interesting and stimulating environment. EVIDENCE: There are many excellent aspects to the design of the home’s dementia units. Our ex by ex reports: ‘Themed areas, such as a garden, a bus stop and the beach made excellent use of the former nurses’ stations and other appropriate areas. Here residents were transported back in time and could see and touch the items displayed, or simply sit there. These areas were creatively designed and presented. There was a doll therapy corner in the downstairs lounge, thoughtfully furnished with cot, high chair, changing mat and dolls, which staff reported, residents enjoyed greatly. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 18 The lounges were laid out in no particular fashion, armchairs casually placed mainly in small groups and with no regimentation. Likewise, this informality was evident in the activities room, where the table and chairs were set at an angle, rather than parallel with the wall’. The garden area too had been well thought out to meet the needs of people with dementia. It was full of memorabilia items, attractive seating for people to rest and a circular walking path so that residents could wander safely without getting lost. The garden area was easily accessible to residents via patio doors on the ground floor and easily visible from the main lounge so that staff could watch residents unobtrusively. There is also an allotment area where residents can grow vegetables. The only thing that might improve this area is for a sheltered area to be created so that residents could access it, even in bad weather. However we did notice the following: • In one toilet there was no toilet paper for people to use, and a soiled pad had been left on top of the cistern. In a bathroom there were no paper hand towels for people to dry their hands with. A weigh-chair, bed table and commode cluttered up the space in this bathroom, making access difficult for residents. The servery door in Magnolia House was left wide open, despite containing a dangerous cleaning material that could be harmful to residents. The surfaces were very worn and the floor in this kitchen area was very dirty. Although pictures of residents had been placed on their bedroom doors to help them find their rooms, they were placed far too high up for most residents to see them. The pictures were of the residents as they are now and it is unlikely that, given their dementia, they would recognise themselves. It would be much better to place pictures of when they were younger, or put the actual address of where they lived previously to help them identify their bedrooms. We saw a poster stating that cold drinks were available in both lounges. We looked in both lounges and no cold drinks were there. • • • Dove Court DS0000065318.V376872.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive their care from competent and qualified staff. EVIDENCE: There are currently 6 (and sometimes 7) care staff on duty throughout the day to meet the needs of 40 residents and four staff on duty at night. Staff we spoke to felt there were enough of them on duty to meet people’s needs and also reported that the use of agency staff had reduced considerably in the last few months. One relative reported: ‘perhaps the home has been a little understaffed at times, but this seems to have been addressed now’. People who completed our survey felt that staff were generally good, one commented: ‘the staff are kind and caring and use their sense of humour on difficult days’ Training for staff has improved and over 50 now have an NVQ level 2 in care. We looked at a sample of training files for night staff which showed they had received a good range of training to give them the skills and knowledge to look after people. We talked with one of the home’s house keepers who told us she had completed a NVQ level three in Housekeeping, and a 14 week course in infection control. Her knowledge of what extra precautions were required when dealing with a resident who is MRSA positive was excellent. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 20 We checked the personnel files for two recently recruited members of staff which showed us appropriate references and police checks had been obtained before they started working at the home. However, the home has been regularly starting staff with just their POVA first checks, whilst awaiting their full CRB disclosures. Although this is allowed in ‘exceptional circumstances only’ (Department of Health Guidance guidance), it is not best practice to do so and puts residents at some risk. Dove Court DS0000065318.V376872.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home that is improving due to better and more stable management. EVIDENCE: The home has been without a registered manager since 2007, and since then there have been 3 managers in post, none of whom have stayed for any length of time. This has resulted in considerable instability at the home and staff have felt unsettled as a result. However, a new manager was appointed in February 2009 and is clearly bringing much needed change and guidance to staff. Our expert by experienced talked to staff about their opinions of the new manager. She told us: I spoke to several members of care and domestic staff. Without Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 22 exception, they all said things had improved since the current manager had been in post [six months]. When asked to give examples, their comments included: • “Staff morale is very high now.” • “There’s lots more going on.” • “You can talk to Rachel [the manager] and it will stay in the office.” [A reference to the former lack of confidentiality.] It was said that there used to be gossip and back-biting, lack of team spirit, and an atmosphere of chaos beneath the surface. Now, ideas are pooled and shared; everyone knows what is expected of them; exact explanations are the norm; the nurses’ stations have been removed and especially beneficial ideas introduced, such as the doll therapy and imaginative wall boards. Staff noticed a definite emphasis on working together as a team now, with the full backing and participation of management. They was stated that Rachel offered fair, firm and consistent management skills and ability, being always available, approachable and ready to address any and all concerns of staff and residents. Relatives too have noticed changes, one told us: ‘now that the manager seems to be more permanent, services have improved’ There are regular meetings with staff and relatives where they can raise concerns and be kept up to date with changes in the home. We checked the supervision files for 4 members of staff which showed that they had begun to receive supervision regularly. Staff also confirmed they received time with their manager to discuss their working practices and described it as ‘useful’. However the record of one supervision record was very poor and contained little evidence that this staff member had received a meaningful session with her line manager as all that was written was ‘no concerns’. There was no evidence that the person’s working practices with residents had been assessed, that her training needs had been identified or that any of the home’s policies had been discussed etc. We checked a number of records in relation to health and safety including water temperatures, portable appliance testing, fire, electrical wiring and bed rails which showed us that the home regularly checks and maintains its equipment to ensure its safety. Dove Court DS0000065318.V376872.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 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 4 x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x x 2 2 3 Dove Court DS0000065318.V376872.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 OP9 Regulation 13(2) Requirement Staff must ensure they sign for all medication administrated to residents, including creams so that there is clear record of what has been given to residents Areas where dangerous chemicals are stored must be kept locked so that residents do not have access to them Any complaints the home receives must be recorded clearly, investigated thoroughly and responded to in a timely manner so that people know their concerns will be taken seriously and fully looked into. Staff must receive meaningful supervision so that they are properly supported to do their job. Timescale for action 01/09/09 2. OP19 13(4) 01/09/09 3. OP16 22(3) 01/09/09 4 OP36 18(2) 01/10/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 25 No. 1 2 3 Refer to Standard OP10 OP15 OP19 Good Practice Recommendations Laundry management in the home should improve so that residents have access to and only wear their own clothes Mealtimes should be better co-ordinated so that residents eat in a calm and pleasant environment Residents’ pictures on their bedroom doors should be hung much lower so they can see them more easily and find which room is theirs. Staff should not start working at the home until a full CRB (Criminal records Bureau) disclosure about them has been so received so that residents are protected and only the right people are employed 4 OP29 Dove Court DS0000065318.V376872.R01.S.doc Version 5.2 Page 26 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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 summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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