Inspection on 20/06/05 for Dove House

This inspection was carried out on 20th June 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Dove House 29/05/08

Dove House 01/06/07

Dove House 18/04/06

Dove House 19/12/05

Dove House 14/10/04

Dove House 08/06/04

Dove House 21/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Dove House Sudbury Nr Ashbourne Derbyshire DE6 5GX Lead Inspector Rachel Davis Announced Mon 20 June 2005 09:00 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 House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dove House Address Sudbury Nr Ashbourne Derbyshire DE6 5GX 01283 820304 01283 820220 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) Midland Healthcare Ltd Care Home 42 20 42 7 2 5 Category(ies) of DE(E) registration, with number OP of places PD(E) PD MD(E) Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 October 2004 Brief Description of the Service: Dove House is a residential home set in the countryside near to the Derbyshire village of Sudbury.The two storey Victorian house is registered to provide residential care for forty-two older people. Their needs may range from mental health, dementia and/or physical disabilities. The registered provider is Midland Homes Ltd who have overall responsibility for the home. The manager, Karen Betts, is presently going through the registration process with the Commission for Social Care inspection. Due to the homes position local amenities are limited but the home is well placed for the use of public transport. The premises have been sympathetically extended and have substantial grounds and parking facilities. Gardens were extremely well maintained and a patio area with seating was available and easily approached. Communal areas have been redecorated and are comfortable. The home also has two large conservatories offering substantial views of the gardens and countryside. There is a no smoking policy for service users and staff within the home. The majority of bedrooms were single and met the required sizes set out by the national minimum standards; these were equipped with suitable fixtures and fittings. Twenty-seven of the thirty-six single rooms had en suite facilities. Communal bathrooms and toilets were well-located and offered appropriate equipment and facilities. Adequate parking is available for staff and visitors. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 8 hours by 1 inspector. Making it an announced inspection afforded the guarantee of the manager being on duty, this was important as Karen is presently going through the registration process with the Commission. A tour of the home and grounds was undertaken. Four service users chatted to the inspector for some time throughout the day and 10 questionnaires from service users were also returned to the inspector. The manager and 4 staff were on duty at the visit. Full discussion was held with the manager and 3 staff were spoken to in varying degrees. The inspector also saw two visiting professionals on this visit. A further 9 questionnaires were completed by service users relatives and visitors. The care plans of 3 people were examined in detail. The information contained in them was cross referenced with the service users to further confirm this evidence, and further clarification was sought from the manager about their role in supporting the service users. In this way a full picture of the service users’ needs and if these were being met was built up. Staff practice was observed throughout the inspection. Staff records regarding training were seen, as were records relating to medication, food, staff rotas, complaints and maintenance. What the service does well: Information is made readily available for staff, service users and visitors including the complaints procedure, meals of the day, Statement of Purpose and Service User Guide. Resident meetings are held on a quarterly basis and written records are made. A weekly activities programme is in place and information relating to these is suitably recorded. The activities co-ordinator is well motivated and covers a broad range of interesting activities. It was ascertained that service users with complex needs received stimulation on a one to one basis. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 6 People who use the service said that they were happy with the care they received. ‘We are well looked after’ ‘staff always knock on my bedroom door before they enter’ and ‘the laundry service is good and my bed is always changed weekly’, were some of the comments service users made. Privacy and dignity are upheld within the home, direct observation, service users comments, information from visitors and staff practice confirmed this to be so. Care planning records contain all the required information and were reviewed on a regular basis. Service users were involved with the content and have signed the enclosed risk assessments. What has improved since the last inspection? The home has worked hard to meet the requirements made, only two have been carried over to this report; one of those is regarding quality assurance details and the other is to offer the manager regular structured supervision. All environmental issues have been addressed and the home now presents well, the management of Control of Substances Hazardous to Health (COSHH) has also improved, as has the management of infection control issues. The Statement of Purpose and Service User Guide now meet requirements, the latter just needs to also contain information as to the whereabouts of the latest inspection report. Each service user is provided with a robust statement of terms and conditions at the point of moving into the home. The manager has identified the training deficiencies and has organised some courses for the staff. The manager and one other staff member have been trained to deliver manual handling training. The manager, Karen Betts has grown in confidence since the last inspection, she has demonstrated her commitment to the service users, staff and her own personal development. One person spoken to during the inspection stated that communication had improved. Staff confirmed they were very happy with the manager and her management style. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 7 Communications between the District Nurses and the home have improved, this was confirmed by both parties, the home has received training on falls prevention and pressure care, the manager is also fully aware of the referral systems and registration categories available at Dove House. What they could do better: The medication procedures in the home need improvement. The information offered by the pharmacist on bottles is inadequate as is the recording of ‘as and when required’ information on administration records. The manager needs to ensure that the home’s procedures comply with The British Pharmaceutical Society Guidelines. Although the home is using risk assessments the information within them needs strengthening, the staff must be aware of what is required of them to minimise or remove the risk. There have been improvements with the management of clinical waste but further steps must be taken to minimise the risk of cross infection. The manager works full time but on many occasions has to work on the floor to cover a shift due to staff annual leave or sickness. The manager must be offered the time to fulfil her role and complete the tasks expected of her. The manager needs to record and investigate complaints of any nature; presently the home only does this with formal complaints. Although all the mandatory training is provided and over 80 of staff have received dementia training the home is registered to accept people with a mental health condition and therefore staff should be offered training in this area. The medication procedures in the Home need major improvement. The storage, administration and stock control of medication are all inadequate and a number of requirements have been made. The manager must ensure that the Home’s procedures comply with The British Pharmaceutical Society Guidelines. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 8 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 E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 , 3, 4 and 5. The written information provided and the training offered to staff by the home ensures service users can make an informed decision as to whether Dove House can meet their needs. EVIDENCE: A copy of the new Statement of Purpose was seen at this inspection. It has been amended as per the requirements of previous inspections by the Commission for Social Inspection. The Service User Guide also meets requirements except for the fact that it must make reference to the latest inspection report and its whereabouts. Each service user has a written contract/statement of terms and conditions that are within the Service User Guide. These are evident in service users bedrooms or information is stored within the care plan if they are with the family. On the day of inspection the manager was in the process of organising an emergency admission. The inspector spoke with the placement worker who revealed that Dove House was, ‘very good and supportive.’ She confirmed that Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 11 the home was able to accommodate complex needs and the staff team were very friendly and caring. The placement officer added that Karen was ‘very knowing’; she was astute at recognising change and would contact the GP where necessary. Confirmation that a multi disciplinary review would take place within 4 weeks was also verified. The homes Statement of Purpose clearly states that emergency admissions will be accepted and offers the terms around this. Responses from the service users confirmed that staff react flexibly to their day-to-day needs. The pre inspection questionnaire completed by the manager confirmed that staff have received training in visual impairment, first aid, dementia awareness and management of falls. It is recommended that further training be offered in mental health and sensory impairments. Mandatory training in manual handling, fire training and basic food hygiene has been provided. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 12 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 Care planning is of a good standard but risk assessments should be further developed and strengthened, relating specifically to each service user. Health care needs are well recorded and communication with the district nurses has improved. The systems for the administration of medication are poor and potentially place service users at risk. EVIDENCE: Care plans were in place for all of the service users and they contain information required to meet the individuals assessed need, which is listed in National Minimum Standard 3.3. The care plans are reviewed monthly and a summary completed. Personal risk assessments were in place but must be strengthened as without full information on how to deal with an individual risk service users and staff are duly placed at risk. The manager must be offered training in relation to risk assessments. Observations of the staff and service user interaction indicated that service users are treated with respect. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 13 Comments made by service users included: ’You can have a drink anytime, the food is very good.’ ‘The bell is answered quickly, my dignity is respected.’ ‘The staff are nice, not rough, they are kind.’ Health care needs are recorded and since the last inspection the manager has introduced individual toileting programmes. One service users relative has commented on this on a returned questionnaire and said; ‘ My relative relies on staff to take her to the toilet, one of the staff said they would ask every two hours which I think is a very good idea.’ Since the last inspection the District Nurse has offered training to the care staff on fall prevention and pressure care. It had been identified that communication between the home and the district nurses was lacking in some instances. It was confirmed by both parties that ‘things had improved’ none of the service users have pressure sores and the manager is aware of the referral system to nursing services. Service users who are vulnerable are provided with pressure mattresses and the home are aware of the importance of requesting nursing assessments if they cannot meet an individuals needs. The home should consider the appropriateness of service users sitting in a wheelchair at mealtimes. Assessments should be undertaken with these individuals to ascertain if there are suitable double armed dining chairs available. A recommendation to audit wheelchairs was made as it was felt some were too old and out dated. The home holds policies and procedures that identify the parameters and limits for assisting with medication. The home is also in the process of updating their homely remedies policy. Discussion with the manager and observation of storage and administration confirmed that safe practices are not always in place. In a large number of instances medication bottles did not specify the times of administration and would state ‘twice a day’ or ‘to be taken once daily’. Some of the medication administration records for an individual and the information on the bottle differed, i.e. one stated mcg and the other mg for the same tablets. As and when medication (PRN) was not being recorded as necessary, the medication administration records were blank and did not show if a service user had been offered their medication. One medication was recorded on the PRN sheet but the bottle said take half a tablet daily. The home is recording the receipt and returns of drugs correctly. Controlled drugs are suitably stored and on checking were counted in correctly. A recommendation to confirm if it is appropriate to log all service users on a single page or if they should have individual pages was made. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 14 The responsible individual must make arrangements for the recording, and safe administration used in the course of the provision of care to service users. A large number of service users spoken to revealed that they were satisfied with the care provided, the Commission for Social Care Inspection witnessed staff knocking on doors, offering service users choice and allowing them to complete tasks in their own time. At lunch time the majority of service users ate in the dining room and 4 ate in their own bedrooms. Service users revealed they were able to come and go freely, the post was seen delivered to service users unopened, and service users spoken to either had, or had been offered a bedroom door key. These findings confirm that service users are treated with respect and their right to privacy is upheld. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 15 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 and 14. Visitors are made welcome and various avenues for encouraging service user choice are in place. A strong emphasis is placed on structured activity planning and the recording of such. EVIDENCE: An activities plan has been well developed and records are kept, the names of attendees are also noted. On the day of inspection some service users were involved in a quiz and others were receiving hand care. A collage for each individual has been undertaken which identifies each person’s interests and lifestyle. One service user said: ‘It is very friendly here, there is plenty of activity and entertainment.’ It was confirmed that the hairdresser visit weekly and an informal church service is held monthly. Service users are invited to a residents meeting monthly and minutes are taken. Relatives are able to dine with the service users and one visitor does this on a regular basis. The home does not place restrictions on people and they can maintain contact with the local community as they wish. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 16 The home offers open visiting and service users relatives’ comments included: ‘I find all the staff to be very friendly and caring. My mother is very happy and settled.’ ‘I cannot recommend the staff highly enough. The care they have taken to settle mum has been fantastic.’ The home has the required visitors book and has also introduced a residents signing out book to ensure they are aware of peoples whereabouts. Service users are able to take control of their lives and evidence seen by both observation and reading records confirmed this to be so. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 17 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 Evidence confirmed that in some instances complaints were not being handled objectively, however, service users were confident that their concerns would be listened to. EVIDENCE: The home has a detailed complaints procedure that is in line with the requirements; the appropriate complaints log was also in place. It was revealed during the inspection that not all complaints had been recorded and this is a requirement of the inspection. Further discussions took place with the manager and administrator to ensure the complaint is dealt with as required. The home should consider offering a grumbles, comments and compliments book. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 18 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, 21, 22, 24, 25 and 26. Since the last inspection the standard of the environment and the cleanliness within this home has improved, thus offering service users a more homely and comfortable place to live. EVIDENCE: Much work has been done to improve the interior of the property since the last inspection. All of the issues raised at the last inspection regarding the environment, including health and safety matters, have been addressed. • • • The home has guarded a further 10 radiators. Communal water temperatures are being recorded on a monthly basis. The carpet join by room 10 has been repaired. E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 19 Dove House • • • • • • • • • • A full audit of beds has been undertaken and 10 new beds, mattresses and headboards have been purchased The lounge has been redecorated 20 new nurse call bells are in place The kitchen corridor has been repainted New bedding and towels have been purchased Crockery, cutlery and saucepans have been replaced. The window restrictor in room 42 has been repaired Foot operated bins are in all bathrooms and toilets The windows are now cleaned outside on a 4 monthly basis Control of Substances Hazardous to Health (COSHH) products are labelled and now stored securely. A partial tour of the environment was undertaken during this inspection visiting all of the communal areas, some bedrooms and the gardens. The home is much cleaner than previously and the domestic staff are commended on this. A regular visitor to the home said ‘there’s no smell anymore’ All the bedrooms are provided with the required storage facilities and service users are offered a key. Bedrooms seen reflected individuals choice and preference with their own possessions around them. During a walk around the home room 11 on the first floor was inspected. This area was being used for storage and it was not possible to fully open the door, this room needs to be reorganised and de-cluttered. Externally, the building presents well. Dove House is located on a shared drive in a tranquil location with beautiful lawns, established trees and gardens, and plenty of seating areas. The home employs 2 gardeners who visit the home on a weekly basis and ensure everything is kept in hand. Access to both the property and gardens is kept safe and secure. The bathrooms and toilets were inspected on this occasion; on the whole the toilet, washing and bathing facilities meet the needs of service users. It was noted on one bathroom and one toilet door that locks were not in place, this compromises the service users privacy and must be addressed. One toilet was in need of a lampshade and a toilet roll holder, the shower room’s thermometer was missing and two floors were in need of sealant around the toilets. Liquid soap and paper towels were available in all communal areas. The home offers service users access to all areas by the use of stair lifts, grab rails and/or a lift. Aids, hoists and assisted bath hoists are in place; these were serviced on a 6 monthly basis as required. Call systems have recently been replaced where necessary. The Commission for Social Care have requested the home to refer one service user to the occupational therapist, as Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 20 their chair did not appear to offer enough support. A professional assessment is therefore required. The home continues to guard radiators as required and another 10 have recently been completed. The manager confirmed risk assessments were in place for those not guarded. Confirmation by letter that the Environmental Health Officer is satisfied with the standards at Dove House has been forwarded to the Commission. The home has purchased foot operated bins for the safe disposal of clinical waste, a sharps box is kept safely within the office. The home have the required ‘yellow bags’ but need to place these within the foot operated bins. The clinical waste bin sited on the staff car park is in need of a lock. Staff confirmed that they were able to use disposable gloves and aprons freely; kitchen staff were seen to be wearing appropriate clothing. The home are still using latex gloves and these need to be replaced with non- latex gloves to avoid an allergy, it was confirmed during the inspection that some staff did have an aversion to latex. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 21 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, 28 and 29. After a period of instability in staffing there is now a good match of trained staff offering consistency of care within the home. EVIDENCE: Dove House has an appropriate recruitment procedure, which ensures that their staff are suitable to work with vulnerable people. Staff files examined showed that thorough pre employment checks were carried out. Criminal Record Checks had been undertaken; the home ensures there is evidence to confirm that the staff are both physically and mentally fit for purpose. Staff files and discussions revealed that the establishment undertakes induction training promptly so the staff are guided and given the confidence to undertake their role. One new member of staff was spoken to and confirmed that the above procedure was so in her case, when asked her views on the home, staff and management team she felt that the home was run in a calm manner, ‘everyone knows what they are doing, there is no rushing and jumping, it is really nice.’ The home is strongly recommended to further increase the number of care staff with a National Vocational Qualification (NVQ2). Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 22 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, 37 and 38. The new manager has made some improvements and met the majority of the requirements made at the last inspection. This should continue and be developed to ensure the safe, smooth running of the home for the service users and staff. The new manager must ensure she is well acquainted with the legal responsibilities placed upon her. EVIDENCE: The manager is in the process of registering with the Commission; Karen’s interview is scheduled for 7.7.05. There have been a couple of instances the Commission are aware of where Karen has been unclear of procedures, it is a requirement that Karen is offered regular supervision by Midland Healthcare to ensure her personal development and training needs are being identified. Karen has enrolled to start the Registered Managers Award (RMA) as required. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 23 Following the inspection it was agreed that the administrator would ensure all policies and procedures are reviewed and available for Karen on site. Karen confirmed that she is committed to ensuring tat the best quality of care is offered to each individual, service users spoken to confirmed that they were happy with her management style and comments included: ‘Since Karen took over as manager she has been very good at her work, she is a caring person.’ ‘Karen is a grand girl’ ‘We can go and see Karen if we need to, for example if we are worried about something.’ The health and safety of service users and staff were promoted with the improved storage of hazardous substances. The pre inspection questionnaire confirmed the regular servicing of electrical and gas appliances, hoists were serviced and regular fire training was in place. Following induction one new member of staff confirmed they were confident with procedures and had received training, a certificate on the staff file was also seen. Health and Safety notices were available throughout the home. The administrator visits the home, unannounced, and forwards the regulation 26 reports to the Commission on a monthly basis. Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 24 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 3 2 2 x 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 2 3 x x x x 2 3 Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 25 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. 2. Standard 1 9 Regulation 5(1)(d) 13(2) Requirement The Service User Guide must contain information about the latest inspection report. The registered person shall make suitable arrangements for the recording and safe administration of all medicines used including as and when requiredmedicines. The registered person shall ensure that any complaint made under the complaints procedure is logged and fully investigated. Room 11 ( storage room) must be de-cluttered to ensure safety. Bathroom 29 requires a lock and the flooring requires sealant around the toilet. Toilet 14 requires a toilet roll holder a lock 2 lampshades and the flooring requires sealant around the toilet. The shower room upstairs requires a thermometer. A referral for an occupational therapist to undertake an assessment for one particular service user must be initiated. Clinical waste must be disposed of in yellow bags located in foot operated bins, the clinical waste Timescale for action 1.7.05 1.7.05 3. 16 22(3) ongoing 4. 5. 19 21 23(2)(l) 12(4)(a) 23(2)(b) 12(1)(a) 27.6.05 1.7.05 6. 22 24(2)(b) 1.7.05 7. 26 13(3) 1.7.05 Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 26 8. 9. 31 31 18(1)(a) 18(2) 10. 31 37 and Schedule 4(11) 24(2) 11. 33 12. 37 10(3) bin located on the car park need of a lock. The manager must be offered the required time to fulfill the responsibillities of her role It was noted that the registered manager has not been in receipt of supervision and this is a requirement of the inspection. The manager must ensure she complies with all aspects of regulation 37 and records all complaints made as listed in Schedule 4 The home is required to publish the results of quality assurance surveys and make them available to current and prospective service users and forward a copy to the Commission. The manager must be offered training in relation to risk assessments. The responsible individual needs to ensure all Policies and Procedures are in place, updated and reviewed for the new manager to refer to. 20.7.05 20.7.05. ongoing 20.7.05 20.7.05 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. Refer to Standard 4 9 Good Practice Recommendations A recommendation to further develop training to include sensory impairments and mental health issues should be sought. The manager should seek advice to confirm it is suitable to record a number of service users on one page within a controlled drugs register or if they should be individualised. The home should consider offering a grumbles, comments and compliments book. The home should consider the appropriateness of service E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 27 3. 4. 16 20 Dove House 5. 6. 22 28 users sitting in a wheelchair at mealtimes. Assessments should be undertaken with these individuals to ascertain if there are suitable double armed dining chairs available. The home should scrutinise all their wheelchairs to ensure they are not too old or outdated. It is strongly recommended that the home should increase the numbers of care staff with NVQ2 to meet the future requirement of 50 Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dove House E51 E09 S44218 Dove House V210519 200605 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!