CARE HOMES FOR OLDER PEOPLE
Dove Court Nursing Home Shuttleworth Street Burnley Lancashire BB10 1EN Lead Inspector
Mrs Marie Matthews Unannounced Inspection 14th February 2006 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 Nursing Home DS0000022501.V283199.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 Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Dove Court Nursing Home Address Shuttleworth Street Burnley Lancashire BB10 1EN 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) 01282 830088 01282 839898 www.bupa.com BUPA Care Homes (CFHCare) Limited Care Home 120 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (60), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (20), Old age, not falling within any other category (90), Physical disability (15) Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Staffing for service users requiring nursing care will be accordance with Notice issued 25 May 1999 The home is registered for a maximum of 120 service users to include:A maximum of 90 service users who require nursing care. A maximum of 90 service users who fall into the category of OP. A maximum of 15 service users who fall into the category of PD. A maximum of 20 service users who fall into the category of MD(E) A maximum of 60 service users who fall into the category of DE(E). A maximum of 10 service users who fall into the category of DE. 30th August 2005 Date of last inspection Brief Description of the Service: Dove Court Nursing and Residential Home is a 120 bedded home situated on the outskirts of Burnley. The home comprises of four units. Robin is an elderly frail nursing unit; Kingfisher and Swallow are dementia units and Nightingale a residential unit. Each unit has 30 beds, all are single rooms and on the ground floor. The communal areas on each unit comprise a lounge, dining area, conservatory and smoke room. Swallow also has a snoozalum therapy room. There is a central administrative block that contains the main office, kitchen and laundry areas and a hairdressing salon. Ample parking areas are provided for visitors and staff. Garden and patio areas surround each unit. There is also a sensory garden and a secure themed garden that provide pleasant, stimulating areas for residents and their visitors. The home is located on a main bus route and is close to local amenities, including a Post Office, a Church, Public House, bowling green and local shops. A health centre and public library are also within the locality. Dove Court provides care for 120 people, male or female, generally over the age of 65 years. Care can be provided for young adults, who are under pensionable age, who have physical disabilities. The registered provider is Care First Health Care Ltd. A company owned by BUPA. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted at Dove Court on 14th February 2006. The inspection involved looking at records, talking to management, ten staff, seven residents and five visitors, a tour of the home and generally looking at what was happening in the home. This inspection looked at things that should have been done since the last visit. At the time of the visit the manager was not registered with the Commission for Social Care Inspection. An application was almost completed. There were one hundred and eight people living in the home on the day of the visit. The home was inspected as a whole and any concerns regarding individual units were discussed with the manager at the time of the inspection. Visitors and residents were happy with the staff team. One residents said staff were ‘very, very nice’, another said ‘they work very hard’. To obtain an overall view of the home the report of 30 August 2005 should also be read. What the service does well: What has improved since the last inspection?
Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 6 The home always completed detailed assessments before residents were admitted to be certain the home could meet their needs. All bedrooms had been fitted with locks and residents could have a key if they wished. This provided privacy for people. New staff had started and all the units were fully staffed. This meant the home did not have to cover as many shifts with agency staff and could provide residents with care given by staff that were aware of their needs. 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 Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 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 Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 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. Residents were admitted only when the home was clear their needs could be met. EVIDENCE: All residents had evidence of a care needs assessment being completed before they were admitted to the home. Care needs had been transferred to a plan of care to ensure that staff knew how to look after them. One visitor confirmed that an assessment had been done prior to admission. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 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 and 9. The care plans did not consistently detail resident’s needs or what action staff would need to take to ensure their needs were met. The home was not good at involving residents or their representative in the development or review of care plans. The medication system was not consistently well managed and potentially placed residents at risk. EVIDENCE: A further concern had been raised prior to this visit regarding the standard of care documentation. This was discussed with the manager and senior staff in detail and it was recommended that a regular audit of care plans be completed. Four care plans were looked at in detail. All residents had a plan of care that had been developed from the initial assessment information. On three units the care plans were lacking in detail, had not been updated and did not clearly show what resident’s needs were or what action staff needed to
Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 10 take to make sure their needs would be met. Various risk assessments had been completed but action to be taken by staff to reduce the risks had not always been included. The use of bed rails had not been risk assessed or discussed with the resident or representative. There was evidence that residents had access to healthcare and specialist services. Specialised equipment had been provided to meet their needs but this was not always included in the plan. Reviews of care plans were not consistent on all units. Only one care plan evidenced involvement of residents or their representative in the development or review. The manager was aware of this problem and a letter regarding involvement was due to be sent to all relatives. Clear records in respect of medication had not been maintained and staff had not adhered to medication policies and procedures on all units. Concerns from the last inspection were brought forward. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 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): None assessed. EVIDENCE: Standards assessed and met at the last inspection. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 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): None assessed. EVIDENCE: Standards assessed and met at the last inspection. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 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): 22, 24 and 25. The standard of environment, both internally and externally, was good providing residents with a bright, clean, comfortable and safe place to live. EVIDENCE: The home was bright, clean, safe and well maintained both internally and externally. Kingfisher unit was due to be refurbished, as part of the maintenance and renewals programme, to improve the environment for the residents. The bedrooms were clean and fully furnished. Some residents had brought in personal items to make their rooms more homely. Residents were happy with their rooms. Alarm facilities were available in all rooms although not all had wander leads or risk assessments in place to explain this. Locks had been applied to all bedroom doors to ensure residents privacy.
Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 14 On one unit the radiator thermostat had been broken for some time. This had not been reported to the handyman in accordance with the procedure. It was recommended that regular audits were re-commenced to ensure all required repairs were identified. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 15 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 and 28. The home had provided regular staff and this had improved the care for the residents. EVIDENCE: New staff had been recruited and all units were fully staffed. The home did not rely on as many agency hours and this provided a continuation of care for the residents. Visitors and residents were happy with the staff team. One residents said staff were ‘very, very nice’, another said ‘they work very hard’. A number of staff were working hard to achieve a suitable care qualification. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 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, 35, 36 and 38. Staff did not receive regular formal supervision to ensure they had the skills and knowledge to meet resident’s needs. Health and safety records had been properly maintained and systems protected residents, staff and visitors to the home. EVIDENCE: An application to register the manager with the Commission for Social Care Inspection was due to be finalised. Clear accounting and financial records were maintained; the company audited these records to ensure residents best interests were protected. Supervision records showed that staff had not received one to one supervision to update their skills and knowledge to look after residents. The manager had discussed this issue with staff and one to one sessions were due to take place.
Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 17 Health and safety records had been properly maintained and systems protected residents, staff and visitors to the home. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 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 2 X 3 2 X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 2 X 3 Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 15 Requirement The registered person must ensure that the residents plan sets out in detail the action needed to be taken to ensure that all aspects of health, personal and social needs are met. (Timescale of 30/07/04 not met) The registered person must ensure residents or their representative are involved in the review and development of the plan of care. (Timescale of 30/07/04 not met) The registered person must ensure that risks to residents are fully assessed and interventions are discussed with the resident or representative, documented in the care plan and kept under review. The registered person must ensure administration of all medications is recorded on the Medication Administration Record charts and appropriate coding is used for any omissions. (Timescale of 31/05/04 not met) The registered person must
DS0000022501.V283199.R01.S.doc Timescale for action 03/04/06 2. OP7 15 03/04/06 3. OP8 13 03/04/06 4. OP9 13 03/04/06 5. OP22 13 03/04/06
Page 20 Dove Court Nursing Home Version 5.1 6. OP36 18 ensure that all residents are provided with a nurse call bell unless their risk assessment suggests otherwise. (Timescale of 30/08/05 not met) The registered person should ensure that formal supervision for care staff is documented and that they receive this at least six times per year. (Previously a recommendation.) 03/04/06 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. 7. Refer to Standard OP3 OP7 OP9 OP9 OP9 OP25 OP28 Good Practice Recommendations The pre admission assessment should be dated. The registered person should ensure that care plans on all units are subject to a regular audit. The registered person should ensure criteria for the administration of when required and variable dose medication is clearly defined and recorded on all units. The registered person should ensure that transcribing is witnessed The medication administration chart should have identical instructions to the labels. A regular audit of the home should be completed to identify areas in need of repair. The registered person should ensure that 50 of care staff are qualified to NVQ level 2 or equivalent. Dove Court Nursing Home DS0000022501.V283199.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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