Inspection on 19/08/05 for Dove Court Nursing Home

This inspection was carried out on 19th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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 Nursing Home 26/05/09

Dove Court Nursing Home 10/11/08

Dove Court Nursing Home 27/05/08

Dove Court Nursing Home 04/06/07

Dove Court Nursing Home 28/09/06

Dove Court Nursing Home 21/04/05

Dove Court Nursing Home 09/07/04

Dove Court Nursing Home 04/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dove Court Nursing Home Albert Street Kettering Northants NN16 0EB Lead Inspector Sarah Smart Unannounced 19 August 2005 10.00 th 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 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 C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dove Court Nursing Home Address Albert Street Kettering Northants NN16 0EB 01536 484411 01536 484410 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Four Seasons Healthcare Ltd Vacant Care Home with Nursing 58 Category(ies) of DE(E) Dementia - Over 65 Years (9) registration, with number OP Old Age (58) of places PD Physical Disability (10) TI Terminal Illness (9) Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age range for Physical disability and Terminally ill is from 35 years of age. 2. Of a total of 58 persons requiring personal care 10 of which may have physical disability over 65 years of age. 3. Of a total of 58 persons requiring personal care 9 of which may have dementia over 65 years of age. 4. Of a total of 58 persons requiring personal care 9 may be terminally ill. 5. One named service user falling in the category of learning disability (LD). Date of last inspection 21st April 2005 Brief Description of the Service: Dove Court is a large, purpose built nursing and residential home situated in the back streets close to Kettering town centre. The home offers single rooms with ensuite facilities, over two floors. The home has several lounges and dining areas, and assisted bathrooms. The home has outdoor space which is accessible to the service users. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An additional visit was made to the home following receipt of four complaints by the Commission for Social Care Inspection. The area manager for the home had been asked to investigate three of the complaints, however, a response to this had not been received within the required timescale. A response has since been received, however this was dated four days after the timescale date, and was received 10 days after this date. The areas of the complaints are as follows: • There has been a deterioration in standards of care • Teeth, clothing and hair are generally dirty • Catheters are emptied, but not cleaned • Significant weight loss of service users • High number of overseas staff in the home • Bedroom carpets are dirty, soiled with food • Service users requiring nursing care are on the opposite floor to where the nurses are based • Carers bring their children to work with them who run about in the home • The children ride bicycles in the corridors • The children serve the service users with drinks and food from the trolley • The children climb on the borders and garden • The manager is not available, and is never there • The manager is aware of the issues relating to the children, and said it has been agreed with the her • Poor standard of personal care • The service users bedroom and ensuite were filthy • A service user with evidence of a urine infection had not had her urine tested • Service users are not assisted to wash and dress • Prescribed creams were not administered • Tablets were not given as they should be • A service user was discharged home with sores without District Nursing back up being arranged. The inspection covered the following areas: case tracking, medication, staff and service user interview, the staff rota, observations of care practices, tour of the premises. Case tracking involves selecting a number of service users and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 6 The standards observed varied between the ground floor which offers accommodation and care to service users receiving residential care, and the second floor which accommodates service users receiving nursing care. What the service does well: What has improved since the last inspection? What they could do better: Care plans were not written for all service users, and some did not appear to be current, although they were being reviewed monthly. Reviews for the month of July had not been recorded on any of the documentation viewed. The care plans did not demonstrate that service users or their representatives were involved fully in the care plan contents. The care plans, assessments, and actual care being given did not correspond in one instance. In one instance a service user was not being assisted with her personal hygiene as stated in her care plan, and at least one service user stated that he is not assisted sufficiently. Service users were not safe nutritionally, weights were not always recorded timely, and nutritional scores were not reviewed. There was no evidence that service users were referred to the multidisciplinary team appropriately. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 7 Pressure area care was not routinely maintained. Two service users had turn charts in their rooms which had not been completed for over 6 hours, and two air mattresses did not appear to be working properly, however this had not been addressed by the staff on duty. The management of medication was poor. Both medication storerooms were above the required safe storage temperature. Creams belonging to one service user were found in use in the rooms of other service users. They were not always signed for when administered. Medication was left with service users rather than the staff observing the service user take the tablets, and the medication keys were not stored safely on the ground floor. Eye drops were not stored in the fridge , and did not have date of opening recorded. Medication administration record sheets dating back to January were in a cardboard box awaiting filing. The nurse stated that no service users were poorly, or had pressure sores, however numerous service users on the first floor remained in bed for the duration of the inspection. One service user on the first floor stated that he was bored, and there were no activities on this floor. Staff stated that they were too busy to take service users down to the carpet bowls on the ground floor. Service users on the first floor were wearing soiled clothes, one service user had an apron on for the duration of the entire inspection, and two male service users did not have shoes or slippers on their feet. Several service users appeared to be unshaven, and the inspectors were advised that staff have to be reminded to clean service users teeth. A senior carer was observed to wake a service user to ask her to get up. Although a choice was available at mealtimes it was evident that service users are not always offered that choice, and staff select for them. Service users who were eating in bed were observed to be reaching over bed rails in order to reach their food. The décor throughout the home was in a poor state of repair. Walls, floor and skirting boards were soiled, and in some places had food splashed over them. The serveries and kitchen areas in the dining rooms were very dirty and unhygienic. Wheelchairs and window cills were also dirty. An immediate requirement was made in relation to the cleanliness. First floor windows were not restricted in several instances, and one window handle was broken. An immediate requirement was made in relation to this. Some areas of the home had an odour of urine, in particular most of the first floor. Catheter bags on the first floor were not stored appropriately when not in use, subjecting the service user to a cross infection risk. The staff rota on the first floor indicated that staff are working excessive hours, their surnames were not stated, and some shifts did not appear to have adequate cover. A immediate requirement was made in relation to staff working excessive hours. Staff had not been training in relation to the Protection of Vulnerable Adults, and a carer who had been promoted to a senior position had not received any training for her new post. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 8 Service users were observed to be transported in the home in wheelchairs without footrests in place. This had been the subject of a previous requirement, and was restated as an immediate requirement on this occasion. Risk assessments were not recorded accurately, with numerous entries stating N/A – not applicable. Numerous service users had bed rails on their beds. These did not all have protective bumpers on them , and consent to their usage was not available. The laundry chute on the first floor was unlocked, offering the risk of a person entering the chute. 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 C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 9 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 Standards Statutory Requirements Identified During the Inspection Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 3 Service users are suitably assessed. EVIDENCE: All the service users files viewed contained assessments which were either carried out prior to admission, or on the date of admission. These contained an adequate amount of information. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 Service users health and personal care needs are not met. EVIDENCE: On the ground floor care plans were generally written to an acceptable standard. One service users file contained three care plans in one section, and a further two in a second section. It appeared that the two care plans were no longer valid, as they were written in 2003, however staff were continuing to evaluate these plans on a monthly basis. The care plans were signed as agreed by the service user and next of kin, however this was dated 2003, and it appeared that they had not been consulted in the changes made to the plans. In most instances documentation on the ground floor had not been reviewed for the month of July. One service users care plan stated that she required assistance from staff to wash and dress, however the daily summaries indicated that the service user was maintaining her own personal hygiene. On the first floor the information in the care plan and the assessment, and the practice observed did not correspond. Healthcare assessments were recorded accurately, however they had not been reviewed since June. One service user whose records demonstrated gradual Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 12 weight loss had not had her nutritional score, or weight, reviewed since May. There was no evidence that any action had been taken in relation to her weight loss. A service user on the first floor had not had his weight recorded, despite the assessment stating his reason for admission was weight loss. The daily summaries did not indicate that his needs were being met with the same entries being made on a daily basis, which did not refer to food intake. Several service users on the first floor had turn charts recorded in their bedrooms relating to pressure area care. These were not routinely or adequately completed. Records for the day of inspection at 11.30am were last entered at 5am, and charts for previous days were dated 28.6.05, and 17.6.05. A service user on the first floor was sitting in the lounge in a recliner chair. The position in which he was sitting, and the use of cushions, was putting him at risk of deep vein thrombosis and/or pressure sores. The ground floor medication store room was very warm, and the thermometer indicated that it was 25.5 degrees. The temperature of this room was recorded daily at 9am, however staff stated this gave an unrealistic temperature as the room is in high usage at this time allowing cool air to enter the room. The inspector recommended that temperatures are recorded randomly during the day. The records indicated that the temperature has exceeded the required 25 degrees once at 9am during the last week. The manager must keep this under close review. A sample of service users medication administration record sheets indicated that creams are signed for when administered. The senior carer was unable to locate the medication administration record sheets for an identified service user, but confirmed that her creams were not documented upon it, and therefore not recorded as administered. The carer added that the service user sometimes refused to have the creams applied, although this was not recorded either. The fridge for medication had broken on the ground floor, and a bottle of eye drops were found on the drug trolley which must be stored in the fridge. They did not have a date of opening on them, despite being opened. The senior carer advised the inspector at 9.30am that she had finished the medication round, however, when the carer was asked about this medication at 11am she advised the inspector that she had just finished using them. Some box lids had been removed from medication such as analgesia in the trolley, removing the expiry date. This was brought to the attention of the senior carer, who disposed of the tablets immediately. The first floor medication store room was also hot, and recorded as 27 degrees. Daily temperature records were not being kept, despite a requirement at the previous inspection stating that the temperature must be maintained below 25 degrees, and no other action being taken. The senior carer was noted to store the keys to the medication in the office drawer. She was also observed to leave medication with a service user, rather than observing the tablets being taken. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 13 In the ground floor medication room there was a cardboard box containing past medication administration record sheets, some dating back to January, which were waiting to be filed. In numerous areas of the home prescribed creams were found belonging to a service user who no longer resided at the home. In two instances cream belonging to one service user was found in another service users ensuite bathroom. Four service users on the ground floor were spoken to, three of whom were happy with the care and assistance they received. A further service user felt she should be assisted in a more appropriate manner. A service user on the first floor stated that staff treat him “like an idiot”, and if he asks for anything he is told to wait. He added that he is given a cold flannel to wash his face, and is not helped to keep clean. Several service users on the first floor remained in bed for the duration of the inspection. The nurse in charge advised the inspector that none of the service users were poorly, or had a particularly high level of need. None had pressure sores. The inspector felt that there was no reason for these service users to remain in bed, if they wished to get up. One service user on the ground floor was waiting to see a GP as she felt unwell. This was arranged timely. The senior carer gave a clear description of how service users are referred to the district nurses for their input. The documentation pertaining to a service user who had been at the home for respite care was extremely limited. An assessment had been carried out, however no care plans had been written in relation to how this service users needs were to be met. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 12,14,15 Activities are not adequate, and service users are not afforded choices in their daily life. EVIDENCE: At the time of the inspection a group of service users were playing carpet bowls in the ground floor lounge. An activity diary was available on the ground floor notice board. Staff on the first floor stated that the service users on the first floor are unable to join in the activities on the ground floor due to time constraints of moving service users downstairs. The inspectors were advised that there is no provision of activities on the first floor. One service user on the first floor was asked if she wished to join the activities downstairs. A second service user on the first floor stated that he feels bored, and there are no suitable activities. A number of service users were wearing clothes which were soiled with food or drink stains. Staff were not seen to respond to this. One service user on the first floor was noted to wear an apron style cover over his clothes for the entire duration of the inspection, a total of 5 hours. Numerous male service users on the first floor did not appear to have been shaved, and a staff member expressed concerns that service users teeth are not always cleaned. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 15 Two male service users on the first floor did not have slippers or shoes on their feet. A member of staff on the ground floor was observed to wake a service user, who once awake agreed to get up. Other than this incident, staff on the ground floor were noted to communicate pleasantly with the service users. A choice of meal was available on both floors, however staff indicated that sometimes service users are not offered the choice, and the menu is completed by staff without consulting the service users. Lunch was observed on the day, which appeared to be a balanced meal of fish and chips with vegetables. The lunch was served on tea plates rather than dinner plates, however the quantities appeared to be satisfactory. Desert was a portion of gateau, which was presented on a brown tray, rather than a plate, before being served to the service users. Service users on the first floor were noted to be taken to the dining room for lunch as early as 11.30, at which time there were five service users waiting for their lunch at the table. Several service users on the first floor remained in bed for the duration of the inspection. At lunchtime their meals were placed on bed tables to the side of the bed, and service users were left to reach over to gain access to their food. This sometimes meant reaching over bedrails. Service users on the ground floor stated that they are satisfied with the food. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 18 Staff knowledge of the abuse procedure was satisfactory, however they had not received training. EVIDENCE: Staff knowledge of the procedure in the event of receiving an allegation of abuse was assessed, and although none of the staff had received training on this subject, they demonstrated adequate knowledge of the procedure to be undertaken. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,25,26 The environment of the home is not maintained to an acceptable standard of repair or cleanliness. EVIDENCE: The fabric of the home was in poor state of repair. Numerous rooms, both communal areas and service users individual bedrooms had dirty and scuffed wall coverings. One service user on the first floor was residing in a bedroom which had cigarette burns in the carpet, however this service user was not a smoker. On the ground floor ensuites and bathrooms were cleaned to an acceptable standard, although one service user stated that her family sometimes dust her room. On the first floor the ensuites viewed were dirty, and in at least one instance contained filthy equipment. The serveries and kitchen areas in dining rooms were also very dirty, with food debris on the cupboard doors and splashed up the walls, skirting board and floor. In one servery a flip top bin was filthy. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 18 A cutlery tray, a microwave and toaster were soiled with food debris, and one microwave had a plate of dried up food in it. Two fridges were dirty and damaged. One servery cupboard contained a bowl with brown marks in it. Food was also stored in this area. An immediate requirement was made in relation to the cleanliness of the home. Numerous first floor rooms did not have the window restrictors in operation, and one service user boasted that she knew how to remove it. One windows handle was broken leaving a sharp piece of metal protruding. An immediate requirement was made in relation to this. One service user was being nursed on an air mattress which was not inflated, and a second mattress was found to be alarming. Staff did not appear to have responded to either of these issues. Several areas of the home had an odour of urine, in particular most of the first floor. Several wheelchairs were soiled with food debris. One service users bed table was badly damaged, the surface being rough giving a risk of cross infection. Catheters bags on the ground floor stored in the bathroom for nightime use had caps placed on them, however this was not the case on the first floor, where a tube was wrapped in a piece of tissue. This would not prevent infection risk. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 Staffing rotas are incomplete, staff are working excessive hours, and in some instances are not trained in line with their responsibilities, putting service users at risk. EVIDENCE: The staffing rota indicated that staffing levels are maintained. On the ground floor no staff were found to be working excessive hours, however this was not the case on the first floor. On the first floor the staff rota did not accurately detail the staff working on duty, as surnames were not featured, and there was no nurse rotered to work that afternoon or the following day. The nurse in charge stated that he would be covering these shifts. It was also noted that on many occasions nurse were working double shifts, i.e. a late shift starting at 2pm followed by a night shift finishing at 7.30am. This is not safe, and an immediate requirement was made in relation to this. Staff training records were not viewed, however staff spoken to advised the inspectors of the training which they had undergone. The senior carer stated that she had not received any training in relation to the role of a senior carer when she was offered the promotion. She had received medication training, but had not had any training in relation to the writing of care plans, which was now part of her responsibilities. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,38 The home is not being managed satisfactorily, and service users safety is compromised in several instances. EVIDENCE: The manager is currently in an acting capacity, and has been for some time. She has attended interview with the Commission for Social Care Inspection, however a reference from her previous employer remains outstanding, meaning that her registration cannot be completed. Several service users were observed in wheelchairs without footrests in place. A nurse was noted to be demonstrating this bad practice, despite the inspector advising him that this was unacceptable at the last inspection. An immediate requirement was made in relation to this. Risk assessments carried out contained entries of N/A – not applicable. In a home with stairs, the risk assessment for a service user falling on the stairs cannot be N/A, and should be assessed in order that all areas of risk are identified. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 21 Many of the service users beds had bed rails in situ. In one service users file two risk assessments were recorded, however in no instance were consents recorded. In two cases on the first floor, the bed rails did not have padded protectors on them. The laundry chute on the first floor was unlocked, leading to a risk of a person entering the chute. A lock was available, but was not being used. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 1 15 2 COMPLAINTS AND PROTECTION 1 x x 2 x x 2 1 STAFFING Standard No Score 27 1 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 1 x x x x x x 1 Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? previous requirements were not checked 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 25 Regulation 23(2) Requirement IMMEDIATE REQUIREMENT. A risk assessment must be undertaken in relation to the unrestricted opening of the first floor windows, and identified action taken. IMMEDIATE REQUIREMENT. Dangerous moving and handling must not be practised by staff. IMMEDIATE REQUIREMENT. Serveries and kitchen areas in dining rooms must be cleaned, including fridges, cutlery trays, and cupboards. By 5pm 20.8.05 St 26, Reg 23(1) IMMEDIATE REQUIREMENT. Staff must not work excessive hours. Care plans must be written for all service users needs, including thoise receiving respite care. Care plans must be valid, and reviewed timely. Service users personal hygiene needs must be met, in line with the needs identified in the care plans. Healthcare assessments must be reviewed timely, and demonstrate that referals are Timescale for action 5pm 19.8.05 2. 3. 38 26 13(5) 23(1) 5pm 19.8.05 5pm 20.8.05 4. 5. 6. 7. 27 7 7 7 18(1) 15(1) 15(1) 15(1) 5pm 19.8.05 20.9.05 20.9.05 12.9.05 8. 8 12 30.9.05 Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 24 9. 10. 8 8 12 12 11. 9 13(2) 12. 9 13(2) 13. 14. 15. 9 9 12 13(2) 13(2) 16(2) 16. 17. 18. 19. 20. 14 14 15 19 19 12 12 16(2)(i) 23 23 made to the multidisciplinary team when required. Service users weight must be recorded timely. Pressure area care must be maintained, and records kept to reinforce this. Ref: incomplete turn charts. Action must be taken to reduce the temperature of both medication store rooms. The Commission for Social Care Inspection must be advised of the action taken. Prescribed medication must be recorded when given. Staff must observe service users taking the tablets given to them. Medication prescribed for one service user must not be used for other service users. The medication cupboard keys must be held by a member of staff at all times. Appropriate activities must be offered and available to all service users. Details of how this will be achieved must be forwarded to the Comission for Social Care Inspection. Service users must be offered choices relating to daily life. Ref: meals, getting up. Service users must be dressed appropriately, in clean clothes. Meals must be positioned so that service users eating in bed can eat easily. The carpet with cigarrette burns must be replaced. A detailed maintenance programme must be written and adhered to demonstrating how the decoration of the home will be improved. This must include timescales. A copy must be forwarded to the Comission for 12.9.05 12.9.05 30.9.05 12.9.05 12.9.05 12.9.05 10.10.05 12.9.05 12.9.05 12.9.05 30.9.05 30.9.05 Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 25 Social Care Inspection. 21. 22 23 Staff must respond to pressure relieving equipment from which an alarm is sounding, and the necessary repairs, or action, arranged. Action must be taken to remove the odour in several area of the home. Night catheter bags must have caps over the open end when not in use. These bags must be changed regularly. A training matrix and plan must be forwarded to the Comission for Social Care Inspection. This must include statutory training, NVQs, and training for senior carers, and state timescales. Service users, or a representative must give consent for the use of bed rails, which must have padding on them. General risk assessments must have meaningful entries in all instances. N/A - not applicable, must not be used. Service users and visitors to the home must not have access to an unlocked laundry chute. Care plans and assessments must not contain conflicting information, and must reflect the actual care being given. The staff rota must accurately reflect the shifts worked by each staff member. Staffs full names must feature on the rota. 12.9.05 22. 23. 26 26 16(2)(k) 13(3) 20.9.05 12.9.05 24. 30 18(1) 30.9.05 25. 38 12(1), 13 20.9.05 26. 38 12(1) 30.9.05 27. 28. 38 3,7 12(1) 15(1) 12.9.05 20.9.05 29. 27 18(1) 12.9.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 26 Dove Court Nursing Home 1. 2. Standard 7 9 Service users, or their representative should sign agreement following reviews to the service users plan. this should be at least annually, or as needs change. Past medication administration record sheets should be filed. Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 1st Floor, Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Dove Court Nursing Home C51 S12611 Dove Court V246387 190805 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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