CARE HOMES FOR OLDER PEOPLE
Dove Court Seaton Down Hill Seaton Devon EX12 2JD Lead Inspector
Teresa Anderson Announced Inspection 7th October 2005 10:00 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 DS0000021956.V252242.R01.S.doc Version 5.0 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 DS0000021956.V252242.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Dove Court Address Seaton Down Hill Seaton Devon EX12 2JD 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) 01297 22451 Doveleigh Care Limited Mrs Maureen Frances Goddard Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability over 65 years of age of places (19) Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th April 2005 Brief Description of the Service: Dove Court provides accommodation and personal care for up to 19 older people. The home is situated on a hill, overlooking the town and coast of Seaton. Accommodation is provided in 3 double rooms, 2 with ensuite facilities and in 13 single rooms, 7 with ensuite facilities. Bedrooms are on the ground and first floors. These floors are linked by a passenger lift. Communal spaces are made up of a large lounge, 2 smaller lounges, a dining room and a conservatory. Outside the home there are attractive gardens, paved and sitting areas and ample parking. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Each care service is inspected at least twice in the period between April and March of each year. This is the second inspection of Dove Court this year and this report should be read in conjunction with the report produced following the inspection in April 2005. This inspection was undertaken as part of the planned programme of inspection between 10.00am and 2.00pm. The inspector spoke with approximately eleven residents, with two members of staff, the manager, administrator and the owner. Six comment cards were received from residents and six from relatives/visitors. Records in relation to care planning, resident’s monies, fire safety and satisfaction surveys were looked at. The residents at Dove Court were not particularly interested in being a part of this inspection because, according to them, the home is so good it does not need inspecting. What the service does well: What has improved since the last inspection?
Since the last inspection the programme of covering radiators has continued. However, one resident feels this an infringement by CSCI upon her right to make her own decisions. She has agreed to keep the cover where it is for now but will keep this under review.
Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 6 Residents told the inspector that they had enjoyed numerous trips out since the last inspection on the local ‘charabang’ bus. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The systems for assessing residents prior to admission is thorough ensuring that staff will be able to meet their needs. EVIDENCE: Residents said that they had met with the manager prior to moving into the home. One said that a number of questions had been asked regarding health and abilities. All residents said that staff meet their needs. Care plans demonstrate that initial needs assessment were built upon as staff come to know the resident and that all residents receive a letter confirming that the home can meet their needs. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 9 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. Care plans give clear information enabling staff to meet resident’s health and social care needs. Residents are treated with respect and their right to privacy is respected. Medication records are not being attended to adequately to ensure the safety of residents. EVIDENCE: Many residents spoke of how their health and well being had improved since coming to live at Dove Court. They said that staff knew them and what they needed very well. Although many were not aware of their ‘care plans’ they felt that their care was very well planned and that staff communicated well. They said that staff always treated them with respect and valued their individualism and need for and right to privacy. Staff were observed treating each resident respectfully and as an individual for example, inviting them to lunch, asking them would they like to move from a wheelchair and asking them if they would like to be helped to the toilet. Staff demonstrated a sound knowledge of residents and their needs and idiosyncrasies and were seen to be particularly good at ensuring that less mobile residents had everything they might need or wanted within their reach.
Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 10 Care plans are easy to read and follow. They contain good information relating to the residents past medical and social history, likes and dislikes, social preferences and contain the plan of care to be provided. Appropriate referrals are made to, for example, GPs, district nurses, chiropodists and opticians. On the whole the management of medication is sound. However a number of entries (staff signatures or indications of reasons for not giving medication) in medication charts were missing. It appeared therefore that prescribed medication had not been given without reason. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 11 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 Residents’ benefit from activities and outings which they enjoy. The remainder of these standards were inspected during the April inspection. EVIDENCE: Since the last inspection the number of outings have increased. Residents said they had been out to Exmouth and Sidmouth, to a local thanksgiving service and to a local church hall for tea. Some residents did express a wish that the home had its own transport. Staff said they really enjoyed ‘doing things with’ and going out with residents and felt that residents would benefit from this. One resident said ‘I was given a lovely day for my birthday and for my anniversary’. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 12 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): These standards were inspected during the April inspection. EVIDENCE: No complaints have been made to the home or to CSCI since the last inspection. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 13 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): 25 After completion of agreed changes to one health and safety measure, residents safety will be safeguarded. EVIDENCE: The majority of health and safety measures are satisfactory. However, as agreed with CSCI, the rolling programme of covering radiators to prevent accidental scalding continues. This is based on risk assessment. Those residents identified by the home as being at risk of scalding will have their radiators covered first. All radiators must be covered, at the latest, by December 2007. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 14 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 numbers and skill mix of competent staff are sufficient to meet residents’ needs. Procedures for recruitment of staff are consistent and provide sound safeguards for the protection of people living in the home. EVIDENCE: Residents were very complimentary about the staff. They said they work hard but always have time to go that extra mile. Staff are described as ‘kind’, ‘caring’, ‘second to none’ and ‘genuine’. They say that bells are always answered quickly, day and night and that the staff know what the particular resident needs and likes. Staff rotas show that there are sufficient care staff on duty to meet the needs of residents. Housekeeping staff, maintenance, administration and care support workers provide further support to the residents. Training is ongoing and provides staff with the skills they need to care for the residents. 16 of care staff are currently trained to NVQ 2 or above. If those staff who are undertaking or about to undertake NVQ training complete this training successfully this will rise to over 50 which is the level recommended by CSCI. Staff feel they receive a good level of training and supervision and that working relationships are ‘good’ or ‘very good’. They demonstrated an excellent attitude toward and knowledge of care giving and talked of the satisfaction they get from a job well done or from the gratitude of residents.
Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 15 The home does not use agency staff and is currently holding a waiting list of people who wish to join the staff team. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 16 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, 38 There is clear leadership and guidance for staff ensuring residents receive consistently high standards of care in a safe environment. Residents would further benefit if the registered manager undertook the Registered Managers Award training. EVIDENCE: Residents were extremely positive about the manager and management of Dove Court. They believe a ‘tight ship is run’ for the benefit of residents. They say they are involved in decision making to the degree they want to be and that they feel this is their home, not a home. They complete satisfaction surveys on a regular basis and are invited to attend 4 monthly residents meetings. Any issues raised are dealt with swiftly and to their satisfaction. Records of satisfaction surveys and residents meetings show that changes requested are minor. For example a stool in a residents room to perch on when
Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 17 using the telephone, a request for an additional mirror and a table under a window. Accounting systems for residents monies are easily auditable and were checked and found in order. Fire records demonstrated that checks, drills and training are undertaken. Staff and residents confirmed this. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 18 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 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x 2 x 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 2 3 3 x 3 x x 3 Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 19 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 OP25 Regulation 13 (4) Requirement The registered person must ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. (This refers to the covering of hot surface temperature radiators). Timescale for action 31/12/07 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 Refer to Standard 9 31 Good Practice Recommendations The registered person should ensure that records are kept of all medications administered and of when they are not administered and the reason for this. The registered person should undertake the Registered Managers Award. Dove Court DS0000021956.V252242.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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