Inspection on 14/07/05 for Dove House

This inspection was carried out on 14th July 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 39 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dove House 17/05/06

Dove House 20/10/05

Dove House 01/12/04

Dove House 06/07/04

Dove House 22/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Dove House Monyhull Hall Road Kings Norton Birmingham B30 3QF Lead Inspector Alison Ridge Unannounced 14th July 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dove House Address Monyhull Hall Road Kings Norton Birmingham B30 3QF 0121 443 5470 0121 443 2043 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) Family Housing Association Vacant Care Home 6 Category(ies) of Learning Disability (6) registration, with number Physical Disability (6) of places Sensory Impairment (6) Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home accommodates six people with a learning disability under 65 years. 2. The home can accommodate three named service users over 65 years. 3. That an application for a registered manager is received by the CSCI by 30 September 2005. 4. All staff must receive training in dementia by 31 July 2005. Date of last inspection 1/12/04 Brief Description of the Service: Dove House is a purpose bulit care home, on the site of the former Monyhull Hospital, in a new development of houses. The home accomodates six people who have a Learning Disability, and additional needs relating to impaired mobility or poor physical health. The accomodation is on the ground floor and comprises of six single bedrooms, an adapted bathroom, shower room, wc, lounge, dining room, kitchen,laundry and quiet room/office. The home is on a bus route to Kings Heath, Kings Norton and Birmingham City Centre. The home has transport, to which service users financially contribute. The home is covered by a minimum of four staff during the day, and by two waking night staff. The post of home manager is currently vacant, and temporary management arrangements are in place. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection over one day. The home was previously registered as part of a group of six homes. This was the first inspection of the home in its own right. During the inspection, the inspector spent time talking with and observing the care and support provided to the people who live in the home. Records of care, and activities were assessed together with relating to staffing and health and safety. The inspector undertook a full tour of the premises. The inspector met with the home acting manager. What the service does well: What has improved since the last inspection? What they could do better: The majority of areas assessed during the inspection were found to need improvement. The inspection raised concern about the way in which service users healthcare had been planned and delivered. This area must get better. The inspection raised concern about the activities and opportunities available for people that live in the home. This area must get better. It was not apparent that people are getting food presented in the way required to assist with their swallowing needs. Food was not safely stored or prepared. The menu did not show enough fruit or vegetables were being offered. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 6 The home has no manager. The provider must employ a manager, and ensure the temporary arrangements are good enough. The environment of the home was poorly decorated and presented. It was dirty, and a lot of the home needed a deep clean, redecoration, or replacement. The way in which people that live in the home are kept safe was not good. Two adult protection matters have been investigated in the past three months. The home hasn’t undertaken all the actions required to stop this happening again. Checks on staff before they start work are not good enough to ensure service users safety. 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 House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) x None of these standards were assessed. EVIDENCE: The home has a stable service user group. There have been no new admissions and there are no residential vacancies. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,910 Care documents and risk assessments do not show service users needs are well planned or delivered. This could place service users at risk of harm, or leave needs unmet. How decisions are reached, and that these are in service users best interest was not apparent, which does not ensure service users are being supported to live the life of their choice. Confidentiality is well maintained. EVIDENCE: The plans of two service users were assessed. Information stored in the file was not in good order or easy to locate. Much of the information presented was not relevant to service users current situation, or was repeated on a number of documents within the file. Plans available were generally brief, and did not give clear guidance on how the care and support was to be delivered. Statements such as “Support the person…” or “Encourage the person…” were common. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 10 The plans did not evidence that service users had been consulted or that the plans represented their wishes regarding the way in which they prefer care to be delivered. The home has not undertaken any lifestyle planning, and the plans sampled purely reflected clinical and care needs. Service users accommodated at Dove House have limited verbal communication. The plans did not contain details regarding how to communicate with the person. Events such as holidays and purchases were tracked, and evidence to establish how decisions had been made was requested. The staff and acting manager reported that they do try and involve service users by looking in brochures, and magazines. The need to underpin these efforts, in a way that evidences the decision was made in the service users best, and with reference to the service user, or there significant others has been required. Risk assessments were generally a repeat of information in the care plan. The inspector has required this be reviewed. The production of duplicate documents is not helpful to the reader or the service user. It was recommended that staff receive re-training in the purpose of both care plans and risk assessments, that documents are reviewed, and if appropriate documents combined. Risk assessments had been reviewed regularly. It was not evident in all instances that the person completing the review had fully reviewed the situation, and made the necessary amendments /developments to the plan. An example was given of a waterlow risk assessment. This had been reviewed monthly, but the score not adjusted to take into account the change from the person having healthy skin, to having a pressure sore. Risk assessment that were no longer pertinent to the person had not been archived. New risks identified had not all been assessed. Manual handling risk assessments had been completed in January 2002. No indication that the assessment had been reviewed was available. The inspector did not observe any breaches of confidential information, and records within the home were securely stored. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,17 Service users have few opportunities to take part in a range of interesting activities on a regular or frequent basis. Meals served are varied, but do not contain adequate portions of fruit or vegetables. EVIDENCE: The activities offered to two service users in the month of July to date were assessed. The inspector did not evidence that service users had been offered an interesting or varied range of activities in which to engage. During the inspection service users relaxed in the home, or the garden. One service user went with staff to book a holiday. This was not a holiday for that service user. The interactions between service users and staff were observed to be positive. Staff were friendly, and helpful to the people accommodated. Neither of the two service users tracked had been out of the home in thirteen days. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 12 One service user was recorded as listening to music every day. The other service user was recorded as watching TV, or undertaking bed rest. A party had been held in the home on one of the days tracked. Holidays for all the service users accommodated have been explored and planned. The way in which the decision about the destination had been reached was not evident. Care plans were not written in such a way as to prompt staff to work in a developmental way with service users. Staff reported that they do encourage service users to help with household tasks and cooking. No record of this was noted during the inspection. Service users do undertake a college course based at the home. This was not tracked on this occasion. Food recorded as eaten by service users identified that a varied diet is offered, however there was no evidence available to indicate that the diet was nutritionally adequate in respect of daily servings of fruit or vegetables. Service users have some eating and drinking needs. Reference was made in one of the assessments of speech and language guidelines regards dysphasia. The specific eating and drinking guidelines or a care plan regards this need could not be located at the time of inspection. Evidence that review appointments regards this had been undertaken were not available. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 There was not evidence to support that service users receive the healthcare they require. Health and personal care is not well planned. Medication is generally well managed, ensuring service users receive their medication at the dose and time required. EVIDENCE: The service users all appeared well dressed at the time of inspection, and clothes were well laundered, and individual to the person. Daily records identified that service users are offered personal care each day, but the record does not state if this is a shower, bath, or wash. It is recommended this be developed. Care plans do cover how to deliver personal care, or any indication of the persons preference. Toiletries were observed in all the bathrooms. They were not labelled and it was not possible to track who these belonged to. Healthcare outcomes for service users were not positive and specific healthcare support needs were not detailed. In the records available it was not evident Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 14 that service users had been supported to attend routine health checks or specialist appointments. One of the plans tracked made reference to the service user having specific needs regards eating and drinking. Copies of the eating and drinking guidelines developed by the speech and language therapist could not be located. Care plans were not specific, and contained vague statements such as, ”If the condition fails to rectify itself…” without giving clear guidance on how long to leave the situation, or when to call for urgent medical help were not available. Waterlow risk assessments had been inaccurately completed which had been compounded by regular, inadequate reviews even when a service user had developed a pressure sore. The supporting care plan for pressure management made no reference to the Waterlow assessment did not make provision for the service users regular use of a chair. The weight of service users had not been taken regularly. (Twice in 2005) This was of concern for service users prescribed nutritional supplements, and at nutritional risks. The acting manager reported that one service user was being supported to challenge a medical decision, and that support from the family and multidisciplinary team had been sought. The inspector recommended exploring a referral to the pain clinic for this service user. Medication was assessed and found to be generally well managed on a day-today basis. The need to ensure protocols are available for all as required medicines was noted. Once completed protocols must be kept under review. Two medicines not blister packed were assessed. The number of tablets did not tally with the records of receipt, administration and disposal in either instance. Effective audits to track this must be developed. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Processes within the home are not robust enough to ensure that service users safety and welfare is safeguarded and promoted. EVIDENCE: The CSCI and provider jointly investigated an Adult Protection matter in May 2005. The investigation concluded that one service user had been inappropriately supported with personal care. The investigation did not identify the staff members responsible, but did identify a number of shortfalls in the management and delivery of care that contributed to the situation arising. Requirements regarding this were made at the time of the investigation. Theft of £145 was reported from the home in June 2005. The provider’s investigation identified that proper procedures to check finances held by the home had not been utilised by staff. The inspection identified that procedures in this are have been reviewed, and additional checks commenced. The CSCI has requested confirmation that the money stolen has been reimbursed to the individual. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,30 The décor and furnishing in the premises does not promote service users comfort or welfare, in that they are not homely, comfortable or suitable to meet their needs and lifestyles. Standards of cleanliness and food hygiene place service users at risk. EVIDENCE: Dove House was purpose built as a care home. It has not been well maintained or subject to cyclical renewal or redecoration since it was commissioned, and the décor was in some places tired, and in some places worn, where wallpaper has lifted or peeled, and plaster has been damaged. Furnishings and flooring in all communal areas appear in need of a deep clean, or replacement. The décor and carpets in service users bedrooms were also found to require attention. The home has small snoozelen room/office. The purpose of the room is presently undefined, and it is recommended that this be established. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 17 Service users financial records identified personal money had been utilised to purchase a specialist chair, and linen for a bedroom. These items are the responsibility of the provider, and monies paid must be reimbursed. The home was not clean. Numerous examples of spills that had not been wiped up, and general dust and debris on furnishings and the floor were evident through out the home. The general order of the home was untidy with empty boxes not discarded , a full bag of clinical waste left in the bathroom, posters and fliers well past the relevant date still on display, and records spread across the dining room, small office/snoozelen, and office evident. Food hygiene was very poor at the time of inspection. Vegetables, cooked meats, and food items prepared and left in the fridge undated or unwrapped were evident. The evening meal (oven chips and pies) were placed in the oven, far in advance of being required, which considering the extreme hot weather was unadvisable. Fridge/freezer temperatures had been recorded on an irregular basis with gaps of up to three days between tests. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,36 Adequate numbers of staff are available to promote consistency within the care home. Recruitment checks made, do not evidence that robust practices are employed to protect service users from harm Staff receive balanced and detailed supervisions that help them undertake their job role. This is not with adequate frequency. EVIDENCE: Rota for the weeks commencing July 4th and 11th 2005 were assessed. The rota confirmed that the number of staff available met the agreed minimum. The rota identified significant levels of absence due to annual leave and sickness. These had been covered by bank and agency staff. Over the two weeks, eight different staff, in addition to some of the homes own staff who worked extra hours were employed to meet this deficit. The home must recruit adequate numbers of staff to ensure continuity of care is provided. Recruitment records of all the staff employed were assessed. Staff recruitment records did not confirm that robust and thorough checks are made of staff prior to them commencing work in the home. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 19 No file contained all the required documentation as identified at schedules 2 and 4 of the Care Homes Regulations. Evidence that matters such as gaps in employment history had satisfactorily been accounted for were not available Supervision records for three staff identified variety in the frequency of supervision. These need to be undertaken with greater frequency to meet the target of six times each year. The content of supervision was balanced, reflecting training, performance and care matters. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 Management arrangements are not adequate to ensure service users needs are well or consistently met, or to ensure the smooth, effective and safe running of the home. EVIDENCE: The home has been without a permanent manager for some time. The temporary management arrangements have not been satisfactory to ensure the smooth running of the home or that outcomes for service users have been well or consistently met. The temporary management arrangements are about to change again, with anew acting manager and senior due to commence at the home in the next week. The management arrangements of the home have been raised as a matter of serious concern with the provider. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 21 Health and safety records identified that the testing of the fire alarm was up to due, and that testing of the emergency lights had not been carried out in June, or February 2005. Records of fridge and freezer temperatures, and food hygiene practices were unacceptably poor, and must be improved as previously stated. The security arrangements at the home must be reviewed regarding the development of the site, on which the home is located. Issues regarding security and privacy have become evident as new properties are built around the home. Furniture and equipment no longer required must be discarded from outside the home. At present this is unsightly, and could pose a hazard to health and safety. Risk assessments pertinent to the premises, fire, staff and the running of the home were all found to require review and updating. The home has a commode pan and bedpan. At present these are hand sluiced, and the arrangements for ensuring good standards of hygiene are maintained are not clear. It has been required this be reviewed, and a protocol for this practice established, and the use of disposable commode pans explored. Dove House E54 S24871 Dove House V238475 140705 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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 1 x 1 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 2 2 2 x 1 Standard No 11 12 13 14 15 16 17 1 1 1 1 x x 1 Standard No 31 32 33 34 35 36 Score x x 2 1 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dove House Score 2 1 2 x Standard No 37 38 39 40 41 42 43 Score 1 x x x x 2 x E54 S24871 Dove House V238475 140705 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 YA6 Regulation 15(1)(2) Requirement Timescale for action Unmet from the previous inspection. 1/10/05 1/10/05 2. YA6 3. 4. YA6 YA6 5. 6. YA6 7. YA9YA42 Service users care plans must include details of service users goals and aspirations and how their social and leisure needs are to be met. 15(2)(b) Service users plans must be up and to date. 17(3)(a) Information no longer pertinent to the individual should be archived. 12(1)(a) Clear guidance on how the care and and support is to be delivered 13(1)(b) must be included in the plans. 12(2) Evidence that service users or their representatives have been consulted in the drafting and reviewing of the plan must be available. 12(2) Guidelines on how service users communicate must be available, and followed. 12(2) and Evidence of the process by which 16(2)(m0 decisions are made with or for n) and service users must be 13(6) available.This must evidence consultation with the service user, relevant others, and that the decision is in the persons best interest. 13(4)(a-c) All risk assessments must be and regularly reviewed and updated E54 S24871 Dove House V238475 140705 Stage 4.doc 1/10/05 1/10/05 1/9/05 1/9/05 Unmet from the Page 24 Dove House Version 1.40 8. YA9YA6 15(2)(b) and 17(3)(a) 18(1)(a) to reflect any changing needs. Staff awareness training on the purpose and development of care plan and risk assessments must be undertaken. previous inspection. 12/8/05 1/10/05 9. YA9 10. YA11 The content of such documents must be reviewed to ensure they are serving the required purpose. 13(4)(a-c) Manual Handling risk and 13(5) assessments must be reviewed at least six monthly, sooner if needs change. 16(2)(mOpportunities for service users to n) undertake developmental activities within the home and community must be provided. 16(2)(mn) Service users records must evidence that service users are participating in activities of their choice in the community on a regular basis. 12(1)(a) The menu and food offered must and be nutritionally balanced, and 16(2)(i) include at adequate portions of fruit and vegetables each day. 12(4)(a) Service users must have a and 13(3) personal supply of toilettries 12(4)(a) Service users must be offered and healthcare appointments as 13(1)(arequired. A record of these must b) be maintained. 13(4)(b-c) Eating and drinking guidelines and must be available in the home 12(1)(a) and followed. 12(1)(a) Careplans must contain specific, and clear and measurable goals. 13(1)(b) and 15 12(1)(a) Relevant health care monitoring and must be undertaken and records 13(1)(amaintained. b) E54 S24871 Dove House V238475 140705 Stage 4.doc 1/9/05 11. YA13 Unmet from the previous inspection. 12/8/05 12/8/05 12. YA17 12/8/05 13. 14. YA18 YA19 12/8/05 1/9/05 15. 16. YA19 YA19 12/8/05 1/10/05 17. YA19 12/8/05 Dove House Version 1.40 Page 25 18. YA20 13(2) 19. 20. YA20 YA23 13(2) 13(6) 21. YA23 13(6) 22. YA23 23(2)(b)( d) 23. YA24 23(2)(b)( d) 24. YA24 13(6) and 23(2)(n) 16(2)(k) and 23(2)(d) 13(3) and 23(5) 25. YA30 26. YA30 27. YA26,27,30 23(2)(b)( d) Protocols must be available for all as required medicines. These must be reviewed at least six monthly or as required. Systems to audit non blister packed medicines must be implimented and utilised. Evidence that all actions as identified in the adult protection investigation report must be undertaken. Money stolen from one service user must be repaid, and confirmation of this sent to the CSCI. The lounge,dining room and hallway requires redecoration. Lounge furniture must be cleaned, and covered, or replaced. Carpets throughout the home must be cleaned. Provision to replace carpets must be made if cleaning is ineffective. Personal monies used by service users to purchase items of linen and furniture must be repaid to them. A thorough clean of all areas of the home must be undertaken, and cleanlines maintained to a satisfactory standard. Food hygiene practice must be reviewed and improved to include regular testing and recording of fridge and freezer temperatures, wrappring and labelling foods, and using or discrading products by the use by date. The laundry room must be redecorated The identified service users bedrooms must be redecorated 1/9/05 1/9/05 12/8/05 12/8/05 1/10/05 1/10/05 1/9/05 5/8/05 5/8/05 Unmet from the previous inspection 1/10/05 Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 26 28. YA34 19 Schedule 2 and 4 13(6) and 18(1)(c )(i) 13(6) and 18(1)(c )(i) 18(2) All staff recruitment records must include; proof of identity,a recent photograph, and two written references All staff must receive training in the area of adult protection. All staff must receive training in the needs of older people with a learning disability. A record of this training must be maintained in the home. All staff must recieve regular, recorded supervision sessions at least six times a year. A suitably qualified and experienced manager must be recruited for the home, and application made for registration with the CSCI. Adequate temporary management arrangements must be put in place in the home. Emergency Lighting must be tested monthly and a record of tests maintained in the home. Security arranagements to include the height and placing of the perimeter fence must be reviewed and improved. Hygienic arrangements for the cleansing of commode pans must be explored and implimneted in the home. Furniture no longer required, awaiting collection outside the home must be safely discarded. Adequate numbers of staff must be emplyed to ensure service users needs can be consistently met. 29. 30. YA35 YA35 Unmet from the previous inspection 12/8/05 1/10/05 1/10/05 31. YA36 32. YA37 8,9 Unmet from the previous inspection. 1/9/05 30/9/05 33. YA37 8,9 12/8/05 34. 35. YA42 YA42 23(4)(iv and v) 13(6) and 23(1)(a) 13(3) and 23(2)(k) 16(2)(k) 18(1)(a) 5/8/05 1/10/05 36. YA42 12/8/05 37. 38. YA42 YA33 5/8/05 1/10/05 Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 27 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 YA19 YA24 Good Practice Recommendations It is recommended that the refferal of one service user to the pain clinic be explored with the GP. It is recommneded that the space in the small office/snoozelen room be defined. Dove House E54 S24871 Dove House V238475 140705 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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. 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