CARE HOMES FOR OLDER PEOPLE
Dove Court Nursing Home Shuttleworth Street Burnley Lancs BB10 1EN Lead Inspector
Marie Matthews Announced 30 August 2005 10.00 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 F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Dove Court Nursing Home Address Shuttleworth Street Burnley Lancs BB10 1EN 01282 830088 01282 839898 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) BUPA Care Homes Ltd Ms Stephanie Maginn Care Home 120 Category(ies) of OP Old age 90 registration, with number PD Physical Disability 15 of places DE Dementia 10 MD(E) Mental Disorder excluding learning disability or dementia over 65 years of age DE(E) Dementia 60 20 Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Staffing for service users requiring nursing care will be in accordance with Notice issued 25 May 1999 2. 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 services 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 Date of last inspection 23/02/05 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 a 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 surrround 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 F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The announced inspection was conducted at Dove Court on 30th August 2005. The inspection involved looking at records, talking to management, thirteen staff, fifteen residents and six visitors, a tour of the home and generally looking at what was happening in the home. Information was also taken from comment cards filled in by four visitors. This inspection looked at things that should have been done since the last visit and a number of areas that affect resident’s lives. At the time of the visit the manager was not registered with the Commission for Social Care Inspection. An application was being processed. There were one hundred and twelve 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 were satisfied with the overall care provided. Residents commented that staff were ‘super’ and ‘very nice’. What the service does well:
The home provided appropriate training for staff to ensure they were able to meet the needs of the people who lived in the home. Staff awareness regarding privacy, choice and dignity had a positive impact on the lives of residents. Residents said they were treated with respect. One resident said staff treated her ‘kindly’ another said she ‘felt safe’. The home was good at making relatives feel comfortable and welcomed into the home. Visitors said they were kept informed about important matters and consulted about the care of their relatives. Generally the standard of care planning was good and showed how residents needs would be met by staff. Residents were only admitted once the home could confirm that they would be able to meet the resident’s needs. Care plans had been reviewed regularly. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 6 The home provided a varied activity programme to meet resident’s choices, expectations and needs. Residents said they were able to join in or spend time in their rooms. The home offered a varied and nutritious diet that residents enjoyed. A choice of meal was always available and there was also an ‘alternative menu’ for those who did not like any of the choices offered. One resident said the ‘food is good’ another said ‘there is always something nice to choose from the menu’. Residents and relatives were aware of whom to raise any concerns or complaints with and were confident they would be listened to and staff would try to resolve the problem. The standard of environment, both internally and externally, was good providing residents with a bright, clean, comfortable and safe place to live. Relatives commented positively about the cleanliness of the home. One resident said ‘I have my own room and I enjoy it’. Residents said they could bring in their own items to ‘try to make it more like home’. The gardens were safe and accessible for residents and their visitors. One resident said the ‘gardens were beautiful’. The way in which the home recruited new staff was safe; procedures were followed and this protected the people living in the home. Staff were enthusiastic and positive; this improved the quality of life for the residents. One visitor said her relative was ‘very contented, looks well and is very peaceful’. Others said their relative ‘was really looked after’. What has improved since the last inspection?
The home had almost completed work to ensure all bedroom doors had locks; some residents had keys. Further work to improve the garden areas had been done. There was a ‘sensory’ garden and also a secure themed ‘seaside’ garden. Seating and patio areas were available. Residents and their relatives were seen enjoying the gardens. A number of specialised adjustable beds had been provided. Swallow unit had been redecorated. A smoking area and ‘snoozalum’ therapy room had been provided. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 7 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 F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 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 standard(s) 3 and 4. Standard 6 not applicable. Residents were generally admitted only when detailed assessments had been completed and when the home was clear their needs could be met. EVIDENCE: Eight care plans were looked at. All residents, except one, had evidence of a care needs assessment being completed prior to admission. One assessment was incomplete and care needs had not been transferred to a plan of care. Residents and visitors confirmed that an assessment visit had take place prior to admission to the home. From discussion with staff, residents and their visitors and review of training records it was clear staff were able to deliver the care that the home offered to provide. The home provided written confirmation they were able to meet resident’s needs.
Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 10 Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 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 and 10. The care plans were reviewed regularly but did not consistently reflect that resident’s needs were identified and 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. Staff awareness regarding privacy, choice and dignity had a positive impact on the lives of residents. EVIDENCE: Prior to the inspection a concern had been raised regarding the standard of care documentation. The manager and senior staff were addressing the issues and an audit of care plans was due to take place. Eight care plans were looked at in detail. All residents had a plan of care. Generally the care plans detailed the actions to be taken by staff to ensure all aspects of care needs were met. However two care plans were incomplete and did not fully reflect the resident’s care needs.
Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 12 Various risk assessments had been completed but two care plans did not contain falls risk assessments. There was evidence that residents had access to healthcare and specialist services and specialised equipment had been provided to meet their needs. There was evidence of monthly review. However only one plan evidenced involvement of residents or their representative in the development or review. Four visitors said they were consulted and made aware of any matters affecting care. Generally records in respect of medication were clear. However staff had not adhered to the homes medication policies and procedures on all units. Staff were observed talking to residents and visitors in a friendly but respectful manner. Residents confirmed they were treated with respect and one resident said staff treated her ‘kindly’ and that she ‘felt safe’. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. The home provided varied activities to meet resident’s social and recreational choices, expectations and needs. The home offered a varied menu and people were able to exercise choice and control over their diet and what they eat. The home was good at making relatives feel comfortable and welcomed into the home. EVIDENCE: Residents and staff said the routines of the home were flexible to suit people’s needs and they were offered choices about many aspects. One resident said ‘I can do what I like’. Another said ‘I like it here’ and ‘I can help out now and again’. There was information on the notice boards about a range of activities and entertainments available both inside and outside the home. Three residents said they could either join in or spend time in their rooms ‘reading or watching television’. One resident told the inspector about the activities available. A ‘snoozalum’ therapy room was provided on one unit; staff said some residents found this to be relaxing and calming. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 14 Visitors said staff and management made them feel welcome and they were able to visit in private. A resident said his visitors could visit at any time. Residents were encouraged to maintain links with their families, friends and community groups. One resident was being visited by his advocate. Residents confirmed they received a varied and nutritious diet which they enjoyed. A choice of meal was available and there was also an ‘alternative menu’ for those who did not like any of the choices offered. The cook visited each unit and had worked very hard to meet the choices and preferences of residents. The food was served hot and was nicely presented. One resident said the ‘food is good’ another said ‘there is always something nice to choose from the menu’. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The complaints process in this home was good and residents and their relatives were confident any concerns would be dealt with. EVIDENCE: Residents and relatives were aware of whom to raise any concerns or complaints with. They felt that staff would try to resolve the problem. Clear complaints information was seen on all units. Clear records were maintained of any complaints raised and of any action taken to resolve them. Policies and procedures relating to adult protection were clear. Staff were aware of the procedure. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 16 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, 20, 22, 24 and 26. 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. Relatives commented positively about the cleanliness of the home. There was a programme of routine maintenance and renewal. Grounds were accessible and safe. There was a ‘sensory’ garden and also a secure themed ‘seaside’ garden. Seating and patio areas were available. Some resident’s enjoyed access to the gardens and patio areas directly from their rooms. Bird tables and attractive planters had been placed near to windows. One resident said the ‘gardens were beautiful’. Bedrooms were generally clean and odour free. A number of carpets were being cleaned or replaced. Residents said they could bring in their own items
Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 17 to ‘try to make it more like home’. Alarm facilities were available in all rooms although not all had wander leads. A number of lampshades were missing from the recently refurbished unit; the senior sister said these were being replaced. Locks were still being applied to all bedroom doors; some residents had keys to their rooms and had chosen to lock the doors. Lockable storage was supplied in all rooms. One resident said ‘I have my own room and I enjoy it’. Adjustable beds were being provided to ensure residents and staff safety. The laundry was well organised. Residents and relatives commented on how efficient the laundry was. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 18 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, 29 and 30. The procedures for recruitment of staff were robust and protected the people living in the home. Good progress was being made to address staffing shortages. Staff were enthusiastic and positive and this had improved the quality of life for the residents. The induction and training for staff was good. Staff were aware of their responsibilities and the needs of the residents. EVIDENCE: Rotas showed staffing levels on occasion had been reduced by staff sickness. There was evidence that some of the gaps had been filled with other staff. A visitor commented that staffing levels were ‘inadequate’. Residents confirmed that the home was employing agency staff at times. Residents said ‘ staff do their very best but are busy’. Other comments included staff are very ‘kind’ and ‘nice’. One visitor said her relative was ‘very contented, looks well and is very peaceful’. Others said their relative ‘was really looked after’. The manager was currently interviewing new staff for all units and using existing staff and agency staff to maintain staffing levels. Staff recruitment files were checked and appropriate documents were in place prior to employment.
Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 19 Training records were available for all staff. New staff had completed required training. Other training had been provided that enabled staff to meet the needs of the residents in their care. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 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, 32, 34, 36 and 37. The manager was supported by senior staff to provide clear leadership throughout the home with staff demonstrating an awareness of their roles. The systems for formal supervision of staff were inconsistent. EVIDENCE: Mr Alasdair Swan had recently been employed to manage the home. An application to register him with the Commission for Social Care Inspection was being processed. Staff were aware of the lines of accountability and made positive comments regarding the support they received from the manager and senior staff. Regular meetings had taken place. Staff said they were confident to raise any issues. Heads of department meetings had also taken place. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 21 Clear accounting and financial records were maintained; the company audited these records. Appropriate insurance cover was in place. Concerns relating to other record keeping have been referred to under the appropriate standard (see standard 3 and 7). The standard of formal staff supervision records varied. Not all staff had received appropriate and regular supervision. Staff said they felt they were supervised during their day-to-day work. Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 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 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4
COMPLAINTS AND PROTECTION 3 3 x 2 x 2 x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x 3 x 2 3 x Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? 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 3 Regulation 15 Requirement The registered person must ensure full assessments are undertaken prior to admission and a plan of care is developed from this assessment. 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 the administration of all medications be recorded on the Medication Administration Record charts and appropriate codings be used for any omissions. Timescale of 31/05/04 not met. The registered person must ensure that all residents are provided with a nurse call bell unless their risk assessment
F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Timescale for action By 31/10/05 2. 7 15 By 31/10/05 3. 7 15 By 31/10/05 4. 9 13 By 31/10/05 5. 22 13 By 31/10/05 Dove Court Nursing Home Version 1.40 Page 24 6. 24 12 7. 27 18 8. 31 9 suggests otherwise. (Previously a reccomendation.) The registered person must ensure that bedrooms are fitted with locks and that residents are given keys unless their risk assessment suggests otherwise. Timescale of 30/07/04 not met. The registered person must ensure the staffing numbers are appropriate to the assessed needs of the residents, the size, layout and purpose of the home, at all times. The registered person must ensure an application to register the manager with the Commission is completed. By 31/10/05 By 31/10/05 By 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 9 9 24 24 Good Practice Recommendations The registered person should ensure criteria for the administration of when required and variable dose medication be clearly defined and recorded on all units. The registered person should ensure that transcribing is witnessed The registered person should ensure all rooms have appropriate light fittings in place. The registered person should ensure that adjustable beds are made available to facilitate care, promote independence and reduce the risk of injury to both residents and staff. The registered person should ensure that 50 of care staff are qualified to NVQ level 2 or equivalent by 2005. The registered person should ensure that formal supervision for care staff is documented and that they receive this at least six times per year. 5. 6. 28 36 Dove Court Nursing Home F57 F07 S22501 Dove Court V236025 20.8.05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit 4 Petre Road Clayton-le-Moors Accrington Lancs BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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