Inspection on 17/05/06 for Dove House

This inspection was carried out on 17th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dove House 20/10/05

Dove House 14/07/05

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 West Midlands B30 3QF Lead Inspector Sarah Bennett Unannounced Inspection 17th May 2006 10:00 Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 House DS0000024871.V289730.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dove House Address Monyhull Hall Road Kings Norton Birmingham West Midlands B30 3QF 0121 443 3460 0121 443 2034 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Family Housing Association South Birmingham Primary Care Trust Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home accommodates six people with a learning disability under 65 years. The home can accommodate three named service users over 65 years. That an application for a registered manager is received by the CSCI by 30 September 2005. All staff must receive training in dementia by 31 July 2005. Date of last inspection 20th October 2005 Brief Description of the Service: Dove House is a purpose built care home, on the site of the former Monyhull Hospital, in a new development of houses. The home accommodates six people who have a Learning Disability, and additional needs relating to impaired mobility or poor physical health. The accommodation 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 DS0000024871.V289730.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. The unannounced fieldwork visit was carried out over seven hours. This was the homes key inspection for the inspection year 2006 to 2007. The Social Care Manager and the staff on duty were spoken to. Due to the communication difficulties of the service users they were not able to give their views of the home. Therefore observation of care practice was used to find out what their experiences of living at the home are. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: What has improved since the last inspection? A lot of things have improved since the last inspection. Care plans are more detailed and show staff how to meet the needs of the individual. These show that people’s wishes and preferences have been considered. Some pictures are used so that they are easier to understand. Plans have been reviewed when the person’s needs have changed. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 6 Risk assessments are regularly reviewed so that all risks to the person can be as little as possible without restricting their life. There is more variety of food offered to people at mealtimes. Healthcare has improved and people are supported to attend the appointments they need. The records of people’s monies that are kept in the home are accurate and clear. Receipts are kept when people spend their money. The lounge and dining room have been redecorated so the home is a nicer place to live in. The people that live in the home go out more often, as there is now four staff on duty during the day to support them when going out into the community. Staff know the people that live in the home well. Full recruitment checks have been done including Criminal Records Bureau (CRB) before staff start working at the home. Health and safety checks are regularly completed to make sure that the home is a safe place to live in. What they could do better: The Service User Guide must include up to date information so that anyone looking to move into the home can know what is provided. Care plans must be available for all the needs of service users. Risk assessments must be in place for all risks that service users face in their dayto-day lives. Each person that lives in the home must have a Health Action Plan in line with ‘Valuing People.’ This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. Furniture and carpets must be replaced and the bedrooms and kitchen redecorated to make the home a better place to live in. The snoozelen room must be available for the people that live in the home to relax in. Old records must be moved from there and stored securely in another place. Staff must have the training they need to make sure that they know how to meet the needs of each person that lives in the home and protect them from harm. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 7 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 DS0000024871.V289730.R01.S.doc Version 5.1 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 1, 2, 5 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have the updated information they need to make an informed choice about living at the home. Prospective service users individual aspirations and needs are assessed. Each service user has a contract that states the terms and conditions of their stay. EVIDENCE: Each service user has a service user guide in their bedroom. These included all the required information however some of it was out of date. Staff said that they are going to be reviewed and updated. The Statement of Purpose was on the computer and a hard copy could not be found. Staff said that the Acting Manager was updating some of the information. There are five service users living at the home. The Social Care Manager said that a number of referrals have been received for the service user vacancy. However through the assessment process they have identified that they are not suitable as it is important that they are compatible with the other people that live there. Service users records sampled included a licence agreement stating the terms and conditions of their stay. These had been signed and dated by a representative from Family Housing and the previous Registered Manager. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 10 The updated version of the Statement of Purpose was forwarded to the CSCI after the inspection. This includes all the relevant and required information. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 6, 7, 8, 9 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Generally staff have the information they need so that they can support service users to meet their needs and goals. Service users are supported to make decisions and are encouraged to participate in all aspects of life in the home. Service users are generally supported to take risks within a risk assessment framework. EVIDENCE: Two service users records were sampled. Records included an individual care plan. These stated how staff are to support the individual with their health needs, communication, mobility, activities, daily routines, personal care, diet, behaviours, making decisions and their finances. Generally care plans detailed how the support was to be given. One care plan for communication stated that the person needed a lot of support and encouragement in order to be understood. However, it did not state how staff were to support or encourage the individual. Some pictures were used in the care plan to make it easier to understand. One care plan stated the individual’s hopes and dreams but did not state how staff are to support them to achieve them. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 12 The care plan stated how staff are going to meet the cultural needs of service users. For one service user it was stated, ‘staff need to explore your culture and what sort of person you are’. Staff said that they would do this by talking to the person’s relatives so that they can understand more about their background and cultural identity. Care plans lacked detail on service users health needs. Service users meeting minutes showed that these are held regularly. Minutes sampled included discussions about the snoozelen room, holidays, decoration of bedrooms and activities. Some minutes indicated that the personal health needs of service users were discussed and this is not appropriate when all the people that live in the home are present. The minutes indicated how individuals were involved in the meeting. Individual’s non-verbal communication, facial expressions and gestures were recorded. Each service user had individual risk assessments. These included how staff are to support individuals to minimise the risks involved when they access the community, using the minibus, eating and drinking, using their bedroom, the shower or bath, going on holiday or outings, managing their finances and making decisions. Where appropriate risk assessments were in place that state how the individuals behaviour is to be managed to minimise risks to them and to others. Risk assessments had been reviewed and updated where things had changed. There is not a lock on the laundry room door and staff said this was not necessary. However, one of the service users has behaviour of eating inappropriate objects. Washing powder, fabric conditioner and gloves were seen unlocked in the laundry room. A risk assessment is not in place and this is required. If it is assessed that a lock is necessary this must be provided. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 12, 13, 14, 15, 16, 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are adequate to ensure that people living in the home experience a meaningful lifestyle. Some improvement is needed to evidence that service users are offered a healthy diet. EVIDENCE: Two service users went out shopping supported by staff. One of the service users was at a painting class at college. Two service users went out for lunch with staff. Daily records sampled showed that service users go shopping, to church, out for lunch, to the Nature Centre, out for drives and walks and on day trips to Weston Super Mare and Chester Zoo. Staff said that all service users are going to Rhyl for one day the next week with staff. In house activities include watching TV, DVD’s, videos and looking at magazines. One service users record showed that they have been referred to the occupational therapist for advice on activities that they would enjoy. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 14 Staff said that since the staffing levels have been reviewed and there is now four staff on duty during the waking hours there are more opportunities for service users to go out. Staff said that some garden games have been bought however they have not been able to use them yet as the weather has not been good. An activity planner for each service user was displayed in the office. For one service user this said that they should have gone to hydrotherapy. Staff said that the person has been to the hydro pool to find out if they wanted to go but they are now waiting for the organiser from the pool to allocate a regular day they can go. Staff said that they were planning holidays with the people that they are key worker to. One service user is going to Fuerteventura and they chose this by looking at several holiday brochures. Last year this service user went to Cyprus on holiday. Staff said two service users might go to Disneyland, Paris as they thought the individuals would enjoy this. Staff said that one of the service users relative visits every week. Daily records stated that relatives keep in contact by telephone and by visits to the home. Daily records showed that service users take part in cleaning their bedrooms and helping with the laundry. Staff sat with service users to eat their lunch and supported them appropriately. A choice of tea, coffee or a cold drink was offered. Food cupboards were well stocked. Information on healthy eating was displayed in the kitchen. Food records sampled showed that a variety of food is offered. They did not indicate that the recommended five portions of fruit and vegetables are offered each day. Some records stated that they had a casserole or curry but did not state if vegetables were included in these. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 18, 19, 20 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. Arrangements are not sufficient to ensure that the health needs of service users are met. Generally, the management of the medication ensures that service users are protected. EVIDENCE: Care plans detailed how staff are to support individuals with their personal care and hygiene. There were step- by- step guidelines on how the person liked to be supported when having a shower. Service users were dressed appropriately to their age, the weather and the activities they were doing. Service users records sampled showed that where appropriate individuals are referred to health professionals. These include the Speech and Language Therapist, the Consultant Psychiatrist, Dietician, District Nurse and the Physiotherapist. The chiropodist visits regularly. The optician visited in the afternoon. Records did not include check-ups with the dentist. Staff said that a dentist visited but this may not have been recorded. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 16 Care plans lacked detail on service users health needs. Records are kept of when service users have bowel movements, as due to their verbal communication skills they are unable to tell staff this. One service users record was blank for five days and no record of any action taken to alleviate their constipation was available. Their care plan did not state how staff are to support them to do this. Staff said that they can usually tell the person is constipated by their behaviour but this is not documented as to what behaviour indicates this or what staff should do. Records of health appointments attended showed that where advice was given or follow-up appointments made, generally appropriate action was taken to ensure that this was carried through. At a multi-disciplinary team meeting on 10th May 2006 it was agreed that one of the service users should be weighed fortnightly. However, no record of their weight was available since 20th April 2006. Health Action Plans in line with ‘Valuing People’ have not yet been developed. This is a personal plan about what an individual needs to stay healthy and what health services they need to access. Staff said information on these is to be shared at the senior staff meeting the following week and then this work is to be allocated to key workers. Boots supply the medication to the home using the monitored dosage system. Each medication administration record (MAR) had a photograph of the person and details of how they like to take their medication. Some medication is supplied in boxes of tablets, as they cannot be stored in blister packs. Staff had dated the box of tablets when they started using them so it was clear to see that medication was given as prescribed. The MAR had been signed for appropriately. Some Controlled Drugs (CD’s) are prescribed for service users. These are kept in a separate locked cabinet and are checked by two staff at the handover of shifts. Staff checking them record in the CD register how much of each medication is in the cabinet. The amount in the cabinet cross-referenced with the amount in the CD register. Eight members of staff have been assessed as competent to administer medication. Staff said that it would be helpful if a couple more night staff were assessed as competent to do this. If none of the night staff can give medication one of the day staff works until 10pm to give it. This has only happened occasionally. A locked fridge for any medication that needs storing at a cool temperature is provided. Staff test the temperature daily and recent records of this showed that it was within the recommended temperature of 0-5 degrees centigrade. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 22, 23 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate arrangements are in place to ensure that service users views are listened to and acted on. Arrangements are not sufficient to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: There have been no complaints made to the home or the CSCI since the last inspection. Each service user has a copy of the complaints procedure in their bedroom. The complaints log does not include a section where compliments can be recorded. It is recommended that these be recorded. Service users records included an inventory of their belongings. One of these had not been updated since December 2005. Staff said that the person had purchased some personal items since then but they had not been recorded. There was no record on the training matrix that staff had received training in adult protection and the prevention of abuse. Staff confirmed that they had not received this. Each service user has their own bank account and their benefits are paid directly into these. A relative is the appointee for one of the service users. Receipts are kept of all purchases. The receipts and the amount in individual’s wallet/purse cross-referenced to their financial record. Staff check service users money held in the home at the handover of each shift and keep a record of this. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 18 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 the following standard(s): 24, 26, 27, 28, 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The redecoration of some rooms has improved the environment. However, arrangements are not sufficient to ensure that service users live in a homely, comfortable and safe environment. EVIDENCE: The lounge, hall and dining room have been redecorated to a high standard. The lounge furniture and carpets in the lounge and hall have not been replaced but staff said that these have been ordered. The table and chairs in the dining room looked worn. Staff said these are to be sanded down and re-varnished to improve their appearance. Staff said that the net curtains are to be replaced and these have been ordered. The office is now in the room off the lounge. The office used to be near to service users bedrooms and this room is now empty. Staff said that they plan to use this as a snoozelen room for service users to relax in. A bubble tube has been provided and a frieze has been put on the wall. The safe is in this room so this needs to be relocated. Some old records that need archiving need to be removed. Staff said that extra power points are needed for the sensory equipment. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 19 Service users bedrooms are personalised according to individual tastes and interests. The bedrooms are in need of redecoration. A bathroom with an assisted bath is provided. A separate shower room is provided; staff said that the flooring is to be replaced in this room. A separate WC is provided. The kitchen cupboards are in good condition. The decoration of the kitchen is showing signs of wear and tear. The home was clean and free from offensive odours. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 20 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are generally adequate to ensure that an effective staff team who are supported and supervised support service users. EVIDENCE: Five members of staff have NVQ level 2 or above and one member of staff is undertaking NVQ level 3. This meets the standard of at least 50 of staff achieving NVQ level 2 or above. There are no vacancies for staff. Rotas showed that minimum staffing levels are met. Bank staff are used to cover sickness absence when necessary. The staffing levels have been reviewed and there is now four staff on duty during the waking day. One service users record on 12th April 2006 stated, ‘due to staff levels not able to follow activity plan.’ Staff said this was before the increase in staffing and now things are much better and they are able to do more activities with service users. Staff meeting minutes showed that there have been five meetings in the past twelve months. To meet this standard at least six staff meetings should take place. Four of the five meetings have been held since January this year indicating that there is improvement in the frequency of these. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 21 Staff discuss service users needs, care planning, activities, record keeping and the snoozelen room in meetings. Three staff records were sampled. These included all the required recruitment records including evidence that a Criminal Records Bureau (CRB) check has been undertaken. A training matrix is available. This showed that staff have received training in manual handling, food hygiene and first aid. Three staff need to do an update in first aid. Some members of staff have had training in medicine awareness, menu planning and health and safety. One staff has had training in dysphagia and one in epilepsy. Given the needs of the service users this must be provided for all staff. None of the staff have received training in adult protection and the prevention of abuse. Staff have an induction when they start working at the home and a record of this is kept. Staff records sampled showed that since January 2006 the frequency at which staff receive supervision has improved. Staff have had supervision at least every two months. Records showed that during supervision they discuss the service user they are key worker and agree targets to ensure their needs are met. They also identify the training and development needs of the member of staff. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 22 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Adequate arrangements are in place to ensure that service users benefit from a well run home. Service users are confident that their views will underpin all self-monitoring, review and development by the home. Arrangements are adequate to ensure that the health, safety and welfare of service users are promoted and protected. EVIDENCE: The Manager has several years of experience of working with people who have a learning disability in a supervisory role. He previously made an application to be registered with the CSCI but was then transferred to work at another home. In April 2006 he decided that he wishes to be the Registered Manager of this home so his application is currently being processed by the CSCI. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 23 A draft quality assurance system was seen that has been developed by the South Birmingham PCT. This included looking at medication, record keeping, fire safety and complaints. Audits will be carried out at weekends, nights and days. They will include looking at inspection reports and monthly monitoring visits by the Social Care Manager. A number of people who have a learning disability have been recruited and trained to assist in carrying out the audits and lay visitors will also be used. The Manager has developed an improvement plan for the home. This includes reference to replacing the carpets, lounge furniture and the flooring in the shower room. It also states that care plans are to be continuously improved, more activities are to be identified for service users and their holidays are to be arranged. Staff said that when these objectives have been met other objectives would be added to ensure that improvements are made. Fire records showed that staff test the fire alarm and emergency lighting regularly to make sure they are working. Regular fire drills are held to ensure that staff and service users know what to do in case of fire. An engineer regularly services the fire equipment. Five staff require training in fire safety, however this is booked for June 2006. An electrician completed the five yearly electrical wiring installation test in 2003 and stated that it was in a satisfactory condition. The portable electrical appliances were tested in December 2005 to make sure they are safe to use. A Corgi registered engineer tested the gas equipment in March 2006 and stated that it was in a satisfactory condition. Staff test the fridge and freezer temperatures daily and records showed that these are within the recommended temperatures for safe food storage. An Environmental Health Officer visited in February this year and they were generally satisfied with the standard of food hygiene. They said that the food probe needed calibrating so that it worked properly and that a record should be kept of hot food temperatures. Staff said that these are now being done. The hoists and lifting equipment are serviced regularly to make sure they are safe to use. Staff test the water temperatures weekly to make sure they are not too hot or cold. The last testing record showed that the bath was 44 degrees centigrade and one of the service users bedrooms was 36 degrees centigrade. The recommended safe temperature is 43 degrees centigrade. The Social Care Manager and Senior Care staff were informed of this and said that they will ensure action is taken. A valid certificate of employers liability insurance was displayed. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 24 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 Standard No Score 1 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X 2 3 X Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA1 YA6 Regulation 4 (1), 5 (1) 12(1)(a) 13(1)(b) Requirement The Service User Guide must be reviewed and updated. Unmet from previous inspections. Clear guidance on how the care and support is to be delivered must be included in all the plans. Care plans must state how the health needs of the individual are to be met and what support staff should give. A risk assessment must be in place for the laundry room door that is not locked. Unmet from previous inspection. Service users must be supported to obtain a Health Action Plan as identified in Valuing People. Unmet from previous inspection. Service users must be weighed monthly, or as required by the dietician. Unmet from previous inspection. A record of all healthcare appointments must be maintained. Sufficient night staff must be assessed as competent to administer medication. All staff must receive training in DS0000024871.V289730.R01.S.doc Timescale for action 30/09/06 30/06/06 3. YA6YA19 12(1) (a) 15(1) 13 (4)(a-c) 12(1)(a) 30/06/06 4. 5. YA9 YA19 18/06/06 01/06/06 6. YA19 12(1)(a) 16/06/06 7. YA19 12 (4)(a) 13 (3) 13 (2) 13 (6) 11/06/06 8. 9. YA20 YA23 31/07/06 30/09/06 Page 26 Dove House Version 5.1 10. YA24 11. YA24 12. 13. YA24 YA24 14. 15. 16. 17. 18. YA24 YA24 YA35 YA35 YA41 adult protection and the prevention of abuse. 23(2)(b-d) Unmet from previous inspections. Lounge furniture must be cleaned, and covered, or replaced. 23(2)(b-d) Unmet from previous inspection. Carpets throughout the home must be cleaned. Provision to replace carpets must be made if cleaning is ineffective. 23(2)(b-d) The dining room table and chairs must be sanded down and revarnished. 23(2)(b,c,h) The safe must be relocated, extra power points provided and the snoozelen room be safe to use. 23(2)(b–d) The service users bedrooms must be redecorated. 23(2)(b–d) The kitchen must be redecorated. 18 (1)(a,c) Where necessary staff must receive updated training in first aid. 18 (1)(a,c) All staff must receive training in dysphagia and epilepsy. 17(4) Unmet from previous inspection Records no longer required must be securely archived. 18/06/06 18/06/06 30/09/06 31/08/06 31/10/06 31/12/06 31/08/06 31/08/06 31/07/06 Dove House DS0000024871.V289730.R01.S.doc Version 5.1 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. 3. 4. 5. Refer to Standard YA8 YA17 YA22 YA23 YA33 Good Practice Recommendations Personal needs of service users should not be discussed during service users meetings. Food records should state what fruit and vegetables have been offered. Compliments made about the home should be recorded. Inventories of service users belongings should be regularly updated. Staff meetings should be held at least six times a year. Dove House DS0000024871.V289730.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham 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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