CARE HOMES FOR OLDER PEOPLE
Dove Court Kirkgate Street Wisbech Cambridgeshire PE13 3QU Lead Inspector
Lesley Richardson Key Unannounced Inspection 10:00 31st May 2006 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 Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 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. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 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 Ashbourne (Eton) Limited Ms Julie Curtis Care Home 46 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (46), Old age, not falling within any other of places category (6) Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th December 2005 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 now owned by Ashbourne Care Homes and provides care and support for up to 46 residents over the age of 65 with dementia. Fees for the home range between £415 and £525.25 per week. 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. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 7 hours and was carried out as an unannounced inspection on 31st May 2006. It was the first key inspection for this home for the 2006-2007 year and was completed by the lead inspector and a second inspector. 4 hours were spent with staff members, service users and undertaking a tour of the home. Not all conversations with service users can be included in this report, due to the level of dementia suffered by some people who live there. The inspection was conducted with the manager present. The home was asked to complete and return a pre-inspection questionnaire to the Commission before the inspection took place, although the Commission has not yet received this. The Commission has not received a completed pre-inspection questionnaire from the home since 2003. One comment cards from relatives and visitors, and no comment cards from service users were returned. Twelve requirements and six recommendations have been made as a result of this inspection. Seven of these requirements have been carried over from the last inspection as they have not been met. Failure to comply with requirements may lead to legal action being taken against the home. What the service does well: What has improved since the last inspection?
There have been only a few improvements since the last inspection. Recruitment and vetting checks have improved and all but one piece of information that has to be obtained is obtained. This means the home is much more able to employ people who are safe to work with vulnerable people. Improvement is still required in this area, but it is good to see action has been taken. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 6 Most staff are now receiving supervision from senior staff members. This gives them the support and guidance needed to care for people living at the home. However, the home must still make sure all staff members receive supervision and there is the opportunity to discuss issues in private. Fire equipment has now also been checked, which makes sure people who live at the home are safe but also that the staff have equipment they can use with confidence. What they could do better:
There are quite a number of issues the home has to address to make sure they meet the Care Homes Regulations 2001 and the National Minimum Standards for Older People. Seven of these issues were also issues raised at the last inspection. The home must improve the way it finds out what the people who live there think of the home and how they are cared for. This has an impact on many other issues that arise and if it is done well it can have an extremely positive effect on the care provided. Not every person who lives at the home is able to say how he or she would like to be cared for. There is some concern about the choice some people have in the way they are cared for and the way staff interact with them. For example, the same question can sometimes be asked repeatedly, but this can be ignored after the first answer even though the person asking the question may not have understood the answer. Not all staff members ask people who live at the home how they would like something done; occasionally the person isn’t even told something is going to happen. This must improve to make sure feelings of ill-being do not become the primary focus of that person and lead to withdrawal from life or displays of ‘challenging behaviour’. Staff training plays an important part in preventing some of these issues, and information from the inspection shows that not enough of the staff members have had up to date training. This potentially affects the health and safety of everyone who lives and works at the home, and includes the manager and senior care staff as there are very few people who have had all required training and regular updates. Staffing levels remain below those that are acceptable for a home of this size that cares for people that are highly dependent, some with unpredictable behaviour. This was shown during the lunchtime meal in one part of the home, when three staff members were unable to move everyone living in that unit into the dining room. Some people refused to move to the dining room and were left in the unit, without care staff always present. The home should look at the way meals are taken in this unit and consider alternatives that take everybody’s likes and dislikes into consideration. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 7 Care plans and care records must show how the home plans to meet changes in a person’s needs and they must also be reviewed regularly. Assessments of prospective residents must be completed before that person enters the home; otherwise the home cannot show it can properly meet their needs. If referrals are made to healthcare professionals or visits are made to the home by them, this should be recorded and be easily accessible to all staff reading the records. Although activities are conducted at the home and aim to maintain skills, such as using cutlery, this programme is not appropriate for all the people living at the home. Information about what each person likes to do must be obtained; specific details about these interests must also be recorded. It is not enough to find out that a person likes to watch TV, if the programme is one they are not interested in. There are ongoing issues with medication recording, which has to be more accurate to prevent mistakes with controlled drugs. There is no information to show which staff members have undertaken medication training. There is a distinctly offensive smell in the ground floor unit, which must be removed if people are to live in pleasant surroundings. Relatives on people in the home should be advised if there are restrictions to visiting the home, before these restrictions are put into place. 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. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 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.V288395.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The outcome for these standards is poor. The home does not fully assess potential service users needs prior to admission, so cannot give assurances that care needs can be met. EVIDENCE: Pre-admission assessments are completed to ensure new service users needs are properly assessed and planned for. Assessments of need are also obtained from healthcare professionals and social service departments. This gathers as much information as possible about each person before they enter the home and ensures their needs can be met. However, of the four service user files looked at only one contained a pre-admission assessment, and this had been obtained from the placing authority for that service user. Another service user’s file contained an assessment completed by the home on the day of admission and hospital transfer information, also dated the day of admission. The home does not provide accommodation for intermediate care. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The outcome for these standards is poor. There has been little improvement in the care recording and this is such that it cannot ensure personal and health care needs are met. EVIDENCE: Individual care plans are available and little progress has been made on the previous requirement to ensure that all aspects of the personal and social care needs are identified and planned for. Plans give general guidance to staff members about how to meet needs but do not give guidance that is specific enough to each person’s individual need. Review of plans should take place on a monthly basis, and when this is done the whole document is reviewed together, rather than individual needs being reviewed. However, it was evident from observing service users that plans are not updated as service users needs change. For example, one plan stated the service user requires transfer to the dining room in a wheelchair, although the service user was walking to the dining room with the help of a frame during the inspection. The associated falls risk assessment had been completed, but this was not dated and appeared to be the original assessment that may have been completed when the whole document was written in August 2005. Descriptions of service
Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 11 users behaviour continues to be written in vague terminology without identifying the exact behaviour, possible triggers or antecedent behaviour. Records of referrals to and visits from healthcare professionals are difficult to find in care records. Plans and admission assessments identifying needs not recorded in hospital transfer records do not show whether referrals were made to relevant healthcare professionals once these needs were identified. Medication is administered by senior staff members to service users who are unable to or do not wish to administer their own medication. Medication held in the home is stored correctly. Medication administration records are maintained with recording for medications given and not given, although some missed entries in recording were noted. Recording of controlled drugs is completed in a page numbered register, although there are discrepancies within these records. Balances of one medication in this register had been reduced after new medication had been received and before the next administration record, but there was no entry or signature to show who had administered or who had received the medication. Another controlled drug was received into the home and written in the register, but without a balance of the amount available or signatures of staff receiving the drug into the home. There is no information on the training matrix to show which staff members have received medication training, which may indicate no staff have had training. One staff member, however, confirmed she does not administer medication as she has not received the appropriate training. Although observation of staff members showed many were polite, talked with service users and asked rather than told service users what they would like. There are a number of examples of poor practice throughout this report that indicates not all staff members understand or uphold the principles of choice or privacy and dignity. Staff members ignored two service users after they had been given an answer to a question, but repeatedly asked the questions again. Both service users left the area, although one person returned a number of times asking the same question. The staff member didn’t rephrase her answer and continued to ignore the service user. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The outcome for these standards is poor. There has been little improvement to ensure service users are able to exercise choice in their lives. EVIDENCE: Activities within the home centre around maintaining service users skills by using a Montessori approach, although this doesn’t suit all service users and more conventional activities are also available. The home employs one therapist for each floor, who arranges activities and works with service users in enabling them to keep key skills. However, this is not documented well, with extremely brief information in care records about therapy and little or not information about service users life histories or social interests. There is little correlation in care records between the activities given to maintain skills and the care given. Social interests are often recorded with very basic information, such as, “likes to watch TV”, which gives new staff no guidance about the type of programmes a person likes to watch or information about assessing for wellbeing. The home has an open visiting policy and service users said they were able to have relatives and friends to visit, and go out with them. However, the person who responded to a survey sent out prior to the inspection said although he was may welcome at the home he was not able to visit his relative in private.
Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 13 The Commission for Social Care Inspection received information from a visitor to the home, advising access to service users had been restricted due to infection control reasons. However, advise from a public health officer was that infection control measures should be taking place rather than closing the home to all visitors. Service users have access to church ministers as they wish and a service is conducted on the first floor. Observation of staff suggests service users are not always given a choice about how their care is performed, asked whether they would like assistance or even, occasionally, told what is about to happen to them. One service user sitting in a wheelchair was wheeled back to her room without anything being said to her by the carer, or any alternative form of communication being offered. This may be an example of ill-being through passive acceptance of a situation. Another service user said she liked very weak tea to drink, but was brought a stronger cup of tea following lunch. Although the staff member brought her another cup of tea, the service user said she was never usually asked how she liked or wanted her tea. Given the staff numbers on duty on the day of inspection it is difficult to understand how staff members can enable choice if they are to give appropriate care. This is of most concern in the high dependency unit where there is a greater degree of challenging behaviour and physical dependency. The need for staff to take service users feelings and wishes into consideration was made a requirement at the last inspection; failure to meet requirements may lead to legal action being taken against the home. A main meal was served during the inspection. This appeared appetising, contained a variety of food groups and was served in a comfortable, wellpresented environment on both floors. However, on the ground floor the meal is served in a dining room that is separate from the rest of the unit. Service users are encouraged to leave the unit and walk a short distance through two locked doors to eat their meal. While this poses few issues for most of the service users the change at meal times does distress a few people and means staff numbers are split at a time when most would be occupied with people who require assistance. Consideration should be given to resolving this issue as mealtimes continue to be a stressful time for staff and service users and was identified as such at the last inspection. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The outcome for these standards is adequate. Although the home has systems in place for the protection of vulnerable adults, this does not ensure all staff have adequate training to protect service users from abuse. EVIDENCE: The home has records to show they have received one written complaint and one verbal concern. Both were dealt with and responded to within the appropriate timeframe. Although relatives and visitors spoken to at the inspection said they had not felt the need to make a complaint and would know who to talk to if they had concerns, the person responding to a survey sent out prior to the inspection said he was not aware of the home’s complaints procedure. There has been no protection from abuse issues raised since the last inspection. Protection from abuse training is incorporated into the home’s own resident welfare training, although this doesn’t include local guidelines. It is recommended therefore that the home either incorporates these into the training or has staff members attend local protection from abuse training. 27 out of the 59 care staff on the training matrix, which includes the manager and deputy manager, have not had this training. Of the 32 remaining staff, dates indicate 7 staff members have had protection from abuse training but this has not been updated on an annual basis. This is not acceptable, as staff members do not have the knowledge to adequately protect service users. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 The outcome for these standards is adequate. The standard of the environment within this home is good, providing service users with an attractive and homely place to live. However, there is one area that must be addressed if service users are to live comfortably. EVIDENCE: The home is well decorated and maintained, and all areas that are easily accessible are safe for people who live there. The home has open communal spaces along each corridor where service users can sit, lounges with televisions are also available. Service users rooms are individual and personal possessions and furniture were visible in all rooms seen. There are themed boards are attached to the corridor walls in the ground floor corridor to engage service users interest as they walk along. Access to the garden area is through the ground floor lounge or an alarmed door at the end of the corridor. The garden has been developed to look like a park with a tea room and general store, a beach area has also been developed, although this
Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 16 was not available to service users at the time of inspection. However, there was a smell of urine along the main corridor and in a number of individual rooms. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The outcome for these standards is poor. There has been some improvement in systems to ensure service users are safe, but further improvement is required. EVIDENCE: Staffing rotas show staff scheduled to work at Dove Court and an adjacent home as they are being run as one home. There is no indication on the rota of which staff members work in which area in Dove Court, or on the night duty rota which home they work in. Daytime staffing rotas show there are not enough members of staff to cover the home, and on the day on inspection there were only 5 staff members on duty with no senior carer. Night staffing rotas show there are seven staff members to cover both homes. Staffing rotas show a significant improvement in the amount of sick leave taken by care staff. However, 2 weeks in the 7 week period between the end of March and mid May had nearly 150 hours of sick leave, and as the average of these 7 weeks is 90 hours per week, this equates to more than 2 fulltime care staff members. Care staff are supported by managers on each unit, although these staff members are not available everyday and there are concerns as discussions with staff members show they are not aware of this new management structure. The Commission for Social Care Inspection received one response to a survey sent out prior to the inspection. This person felt there are not always sufficient numbers of staff on duty. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 18 The manager said 47 of staff members have gained NVQ qualifications in care at level 2 or above. However, the training matrix supplied at the inspection shows only 8 of staff members have this qualification. This means that not enough staff members may have a qualification matched to their job role. A training matrix was made available during the inspection. This shows that of the 56 care staff on the list, 21 have not had moving and handling training and 24 have not had health and safety training. Four of the remaining staff have had moving and handling training but this was out of date and there was nothing to show updated training had been given. This is not acceptable and does not ensure the health and safety of service users. The files of three recently employed staff members’ shows the home does not always undertake the necessary recruitment checks to ensure the protection of service users. There was one area of concern that the home must improve to ensure new staff are safe to work with vulnerable adults. No evidence was seen in any of the files that gaps in employment had been explored by the home. This was a requirement at the last inspection. Failure to comply with requirements may lead to legal action being taken against the home. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The outcome for these standards is poor. The systems for service user consultation are limited with little evidence that service user views are sought and acted upon within the home. EVIDENCE: The manager was registered with the National Care Standards Commission in May 2003, and has managed the home since then. She has a NVQ qualification level 4 in management. However, all staff, including the manager, must undertaken regular mandatory health and safety training and other training to update her knowledge, skills and competence, whilst managing the home. A training matrix was supplied at the inspection that indicates the manager has had no specific infection control training and previous moving and handling, and health and safety training was undertaken in 2001.
Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 20 There has been no formal quality assurance survey conducted since the last inspection, although the manager said a questionnaire has been provided by the provider organisation. Staff, and resident and relative meetings are conducted to enable discussion of common issues, although the minutes of several of these had not been typed to enable action or consultation by nonattendees. Discussion with therapy staff shows the home’s commitment to service users lifelong learning, using Montessori techniques. However, none of this therapy is documented or related to service user needs in individual care plans. A manager from another home in the same group completes an audit report each month; this doesn’t appear to feed into any development and improvement plan for the home. Records are kept for all money held on service users behalf, credits and debits, together with receipts are documented and the person performing the transaction signs to show who is responsible. Records were seen for three service users, which were in order. A recommendation made at the last inspection for good practice that two staff members sign each debit has been met, although the second person signing does not always do so at the time the transaction is recorded. Staff supervision takes place on a regular basis; a selection of supervision records were seen, which showed this occurred approximately every 2 months. However, not all staff members said they received individual supervision, although clinical supervision, e.g. that which involved assessing skills and ability, was given. Checks are completed to ensure the health and safety of service users and the results of these are recorded. Fire equipment is tested and maintained on an annual basis. Unfortunately, the Commission for Social Care Inspection has not received information requested prior to the inspection to show other health and safety checks the home completes. The Commission has not received this information since 2003 and the manager has not kept copies of the information she has sent. This information has been requested since the inspection, but has still not been received. Mandatory health and safety training is given during induction but many staff members do not receive regular updates. This has been discussed in the previous section. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 21 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X 3 X 1 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 2 X 2 Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14(1) Requirement The registered person must not provide accommodation to a service user at the care home unless the needs of the service user have been assessed by a suitably qualified or suitably trained person, and the registered person has obtained a copy of the assessment. The registered person must prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. The plan must be kept under review. (Previous timescale of 31/01/06 has not been met.) Arrangements must be made for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (Previous timescales of 31/07/05 and 31/01/06 has not been met.) The registered person must make suitable arrangements to ensure that the care home is conducted in a manner which
DS0000065318.V288395.R01.S.doc Timescale for action 15/08/06 2 OP7 15(1), (2)(b) 15/08/06 3 OP9 13(2) 31/07/06 4 OP10 12(4)(a) 31/05/06 Dove Court Version 5.1 Page 23 5 6 OP12 OP14 16(2)(m) 12(3) 7 OP18 13(6) 8 OP26 16(2)(k) 9 OP27 18(1)(a) 10 OP29 19(1)(b) 11 OP30 18(1)(c) respects the privacy and dignity of service users. The registered person must consult service users about their social interests. The registered person must ascertain and taken into account service users wishes and feelings. (Previous timescale of 20/01/06 has not been met.) The registered person must make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. A programme of scheduled training must be provided by the timescale for action date. The registered person must keep the care home free from offensive odours. (Previous timescale of 31/01/06 has not been met.) The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. (Previous timescale of 31/07/05 and 20/01/06 have not been met.) The registered person must not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in Schedule 2. (Previous timescale of 20/01/06 has not been met.) The registered person must ensure that persons employed to work at the care home receive training appropriate to the work
DS0000065318.V288395.R01.S.doc 15/08/06 31/05/06 31/07/06 31/07/06 31/07/06 31/05/06 31/07/06 Dove Court Version 5.1 Page 24 12 OP33 24(1)(a), (b), (3) they are to perform. A programme of scheduled training must be provided by the timescale for action date. The registered person must establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. The system must provide for consultation with service users and their representatives. (Previous timescale of 28/02/06 has not been met.) 15/08/06 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 6 Refer to Standard OP8 OP13 OP15 OP18 OP28 OP36 Good Practice Recommendations Referrals and visits made to and by healthcare professionals should be recorded and easily accessible in care records. Service users relatives should be advised of restrictions to visiting the home before restrictions are enforced. Consideration should be given to how best to provide meals to all service users. Protection from abuse training should also include local PoVA guidelines. 50 of care staff should have a NVQ qualification at level 2 or above. Staff supervision should include private one to one discussions that identify career development needs. Dove Court DS0000065318.V288395.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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