Inspection on 20/10/05 for Dove House

This inspection was carried out on 20th October 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 49 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 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 Alison Ridge Unannounced Inspection 20th October 2005 10:20 Dove House DS0000024871.V259103.R01.S.doc Version 5.0 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.V259103.R01.S.doc Version 5.0 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.V259103.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dove House Address Monyhull Hall Road Kings Norton Birmingham West Midlands B30 3QF 0121 443 5470 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.V259103.R01.S.doc Version 5.0 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 14/07/05 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 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 standard of décor and furnishing in communal areas of the home is poor. 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 has recently been recruited. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection team consisted of two inspectors and an Expert by Experience “Exbyex”. The inspection was unannounced, and was completed over one day. Information used in this report was collected in a number of different ways, including spending time with the people who live in the home, talking to the staff and spending time looking at records such as plans of care, records of activities, menu planning, staff records, medication and health and safety records in the home. The inspectors looked at all the premises. The inspectors met with the senior carer and interviewed two staff. The inspection identified that the home needs to improve in many areas. The inspectors were particularly concerned regarding how the money of people who live in the home is managed, about staff recruitment records, and about staff taking breaks in people’s bedrooms. A letter of serious concern about these issues has been sent to the home. Inspectors have since received an action plan detailing how these serious concerns will be addressed. The inspectors would like to thank all the people who live the home and the staff on duty that day for the help and support they offered them during the inspection. What the service does well: The people who live in the home appeared to get on well with the staff that support them. The inspectors observed the staff interacting positively with the people in the home and spending lots of time supporting them with their needs and talking to them about things they wanted to do. The “Exbyex” observed one staff involve two people in the preparation of lunch. He said,” She chatted with the ladies as she made the sandwiches. I thought this was good as she was trying to keep them occupied as well as do her job.” The inspectors noted that there seemed to be an open and friendly atmosphere to the home, this was reinforced by the staff that worked in the home and noted by the Exbyex. The design and layout of the home was good and observed to meet the needs of the people that lived there. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 6 Each person had their own room decorated in pleasant colours and each room had lots of personal belongings, reflecting the interests and likes of the people living there. The “Exbyex” said it was good that one person’s room had lights and music in, as the person is known to enjoy this. The people who live in the home had been supported to wear clean attractive clothes. The home had a large choice of brand names foodstuffs for the people who live there to choose their meals from. The staff have supported people to undertake holidays both in the UK and abroad. What has improved since the last inspection? What they could do better: Although there had been some improvements since the last inspection the majority of areas inspected still need further work to meet the needs of people living in the home, and the previously made requirements. The environment of the home was poorly decorated and presented, there were areas of the home that were still dirty and would benefit from a deep clean, recordation or replacement. The “Exbyex” said, “The furniture and carpet in the living room needs cleaning or replacing. The wall paper in the living room and dining room needs replacing.” It was still not apparent that the people in the home were getting their meals presented in the way, they required, as some people have specific swallowing needs. The cupboards contained a wide variety of different food to choose from, this was not reflected in the meals served on a daily basis and the variety of Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 7 food offered to people at meal times needs to improve. The personal monies of the people who live in the home, is managed and administrated by the staff. Attention must be paid to ensure accurate record keeping of individual people’s money and the subsequent clear recording and receipting of when money is spent. The manager at the home must ensure that there are in place maintenance contracts and certificates of work, undertaken regularly in the home to check the safety of equipment used in the home. The staff in the home must ensure they respect the private space of the people who live there. The practice of staff taking their breaks in the bedrooms of the people who live there, must stop. The plans of care must improve. These must show that people’s wishes and preferences have been considered. The plans must show how all the person’s needs are to be met. The plan must be kept up to date, and reviewed when the person’s needs change. Evidence that ideas raised by people who live in the home are followed through must be provided. Activities must get better. People must be offered an interesting range of activities both in the home and community. Activities people are recorded to have liked, or which they have requested to undertake must be made available as far as possible. Healthcare must improve. People who live in the home must be supported to see attend the appointments they need. Staff must use the information from appointments to develop care documents, and when supporting the person. The manager must ensure that enough staff are provided, and that these are regular staff that know the needs of the people who live at Dove House. Staff must be supported to undertake their role and receive the training they need. Full recruitment checks must be made before the person starts work in the home. 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.V259103.R01.S.doc Version 5.0 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.V259103.R01.S.doc Version 5.0 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): Standards not assessed at this inspection. EVIDENCE: The inspectors concentrated on out comes for existing services users. The home has a stable service user group. There have been no new admissions and there are no residential vacancies. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 10 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,and 10 The care documents and risk assessments do not reflect all the needs of the service users, they are not well planned and delivered. This could leave service users at risk of harm, or leave needs unmet. It was not clear how decisions were reached or that the decisions which had been made were in service users best interests. This does not ensure that service users are being adequately supported to live the life of their choice. EVIDENCE: During the inspection four service users files were assessed, three in depth. The files assessed were organised with clear sections for different parts of the file pertaining to the service users plans, like care plans, risk assessments and daily record sheets. The pro-forma for daily record sheets were of a good format. There was space and prompts to communicate the service users needs to the following shift on a daily basis. However the quality of the information recorded varied. Some were completed well whilst others did not establish how people had spent their day, or if the required health care monitoring had been undertaken. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 11 The inspectors were pleased to see an example on one service users file of how the service user communicates. This included verbal and non-verbal communication. This indicated the staff teams “good knowledge” of the service users needs and is an example of good practice. Inspectors identified that service users would benefit from Speech and Language Therapy assessments that would identify the best way to communicate with individual service users. In one file, there was evidence of a multidisciplinary meeting on the 29/9/05 to review the care needs of a service user, however the recommendations from this meeting had not been followed up in the care plans and risk assessments. Furthermore the recommendations of the dietician had not been included in the care plans. Plans available were generally brief, and did not give clear guidance on how the care and support was to be delivered. Statements in the care plans like “needs to follow an nutritional diet” need to improve with clarity on what this means and how it is going to be achieved. The staff on duty said there were arrangements in place for staff to undertake training in writing daily record sheets, staff are still to be trained in the completion of care plans and risk assessments. There were examples of staff meetings and service user meetings, where as much as possible (considering the needs of the client group) there was evidence of consultation. The decisions from these meetings were not referenced in the care plans, and evidence of decisions made being followed through were not always available. This resulted in the plans not evidencing that service users had been consulted or that plans represented their wishes regarding the way in which they prefer care to be delivered. In one service user file, there had been a life goal set, but there was no explanation of how this had been decided upon. The home has not undertaken any lifestyle planning and the plans sampled reflected purely clinical and care needs. The risk assessments were not adequate and did not fully reflect the service users needs in respect of their care. The inspectors require this to be reviewed and the training in care plans and risk assessments, that is still outstanding from the last inspection, be completed for the staff team. Risk assessments had been reviewed regularly; they had not all been reviewed monthly as indicated on the risk assessment or as critical incidents occurred. Existing risks mentioned in the care notes, like challenges the service users present on a regular basis had not been included in existing risk assessments. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 12 There were manual handling needs relating to the service users, however risk assessments and care plans had not been completed, this is an outstanding requirement from the last inspection. On the day on the inspection, the inspectors did not observe any breaches of confidential information and the service users records appeared securely stored within the home. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 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): 11,12,13,14,15,16 and 17 There were few opportunities for service users to take part in a wide, varied and active opportunities inside or outside their home. The range of food offered and served was limited, and evidence it was served in the way service users require was not available. EVIDENCE: The activities offered to two service users in September were assessed. The care records demonstrated one service user went out only twice during the month and this included shopping and a drive. Staff explained that in this service users case it would have been due to ill health and the service user declining opportunities offered. This was not evident in the care notes. In the file examined there was no evidence of weekly planning of activities for this service user. Inspectors observed service users be offered activities that would contribute to their personal development during the inspection. Care records had not been written in such a way that promoted personal development, or facilitated evaluation of the person’s progress. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 14 The service users at home on the day of the inspection, were observed to be spending time around their home, listening to music, watching television, undertaking table top activities, staff actively supported service users to take part in the activities, Some of the service users seemed to enjoy the individual time and attention staff offered them in one to one activities. The “Exbyex” said that he couldn’t see much choice of things to do in the house. Two of the service users were reported to enjoy going to church regularly. It was not apparent that support for this activity was consistent with the risk assessment. One of the service users had some sensory equipment, which staff reported she enjoys. The staff supported her to listen to her music around the house in an appropriate manner so this did not impinge on the other service users who live there. The “Exbyex” identified that; ”Staff could take one of the service users to a disco. She loves music, and I think she might enjoy it.” The inspectors were pleased to hear of the holidays service users had undertaken this year. One person was away on holiday at the time of the inspection. The range of activities offered was very limited, and inspectors have recommended that activities with a therapeutic gain, such as hydrotherapy, massage or aromatherapy be explored. The decision on what to do with the room that was the office still had not been concluded. Staff on duty said they hoped it would become a snoozlun; this room was still incomplete and is outstanding from the last inspection. Information was available in the service users file about their family. Evidence of contact with family members was not noted in any of the files sampled. Staff informed the “Exbyex” that most service users see their family weekly. The record of food eaten by three service users was tracked. It was found that the planned menu included a variety of foods, including regular fruit and vegetables, but that actual meals served were not varied, and one service user had eaten fish 9 days out of 16. Service users have some complex health needs. The diets did not evidence effective planning to meet their nutritional needs, and it has been required that consultation with the dietician be undertaken. Some of the service users have very specific needs around swallowing. For one of the service users tracked there was evidence of a care plan to underpin this, but the menu and record of food eaten for that service user did not reflect the food was of the “custard like consistency” detailed in the care plan. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 15 The plan did not show liaison with dysphasia specialists. Staff reported this was an old care plan, and this information was not relevant any more. This must be confirmed with an eating and drinking assessment, and old information no longer relevant to the service users must be archived to prevent confusion amongst staff when carrying out individuals care. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 16 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 and 20 Service users personal care needs are met to a high standard. Evidence that it is in the way service users wish or prefer was not available. Service users health care needs were not well planned, and evidence that they had been met was not consistently available. Medication was generally well managed; ensuring service users get the right medication at the right time. EVIDENCE: Service users all appeared well presented at the time of inspection, and were dressed in a very individual style. The “Exbyex” commented that,” The residents were well dressed and seemed well cared for” The plans of care did not evidence how service users like to be supported with personal care, or any of their known preferences. The service users accommodated have a range of complex health needs. Evidence that specialist support is sought regards some of these were available, and the inspectors were pleased to hear of good practice regarding multi-agency working at a recent hospital appointment. Care plans to underpin all the complex needs were not available at the time of inspection, and plans for key areas including pain, mental health, diabetes, and epilepsy were not available. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 17 Some service users records showed that all health screening and routine checks had been offered and undertaken. These opportunities must be offered to all service users and a record maintained. The files contained two records on which to enter appointments, and it has been required these be rationalised. Weight monitoring had not been undertaken frequently or consistently, and was of particular concern where service users are known to be at nutritional risk. Plans of care had not all been updated as care needs change. Examples regarding one person’ pressure care was given as an example. Practice has and equipment available has changed; yet the plan remains unaltered. Other plans regarding constipation and epilepsy were given as examples, where the action to be taken has changed. The plan of care remains unaltered. Accurate guidelines on service users eating and drinking needs are urgently required. Some Service users at Dove House have some difficult to manage behaviour. Plans that inform staff of how to support the service user, and keep other service users and themselves safe were not available. Monitoring of incidents had not been undertaken, and inspectors were unable to fully establish if care needs in this area were well planned or managed. Medication management was generally good. Audits of non-blister packed medicines were consistent with the records of receipt and administration. All medication had been signed for. Requirements have been made regarding the development of As required medicine protocols (PRN), ensuring that all medicine prescribed is listed on the MAR chart, and that medicines or creams no longer prescribed are returned to the pharmacy. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 18 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 and 23 Service users are provided with information on how to raise concerns. Service users money was not well managed, and systems did not ensure service users were protected from financial abuse. EVIDENCE: There was evidence in each of the service users rooms of some accessible information on how to make a complaint and the role of the service users key worker. Staff at the home must better evidence that they have consulted with service users, and provided communication tools to enable people to make their views known. Information gathered from service users must be acted upon, and included in the development and running of the home. No complaints or concerns had been made. The inspectors were seriously concerned about the staff management of service users money. In recent months two large amounts of money have been stolen. Control measures implemented to reduce the likelihood of a repeat of such an incident had not been followed by staff. Inspectors auditing money and financial records found significant discrepancies and errors. It was of very serious concern that records of handover showed money had been checked daily, and yet no staff had identified the difference between records and actual funds available. This was raised with the provider in a letter of serious concern. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 19 Staff reported that one service user presents a risk to the other service users accommodated. The way in which the plan of care had been developed to underpin this and ensure safety within the home was poor, and requires further development. One staff that spoke with the “Exbyex” raised this behaviour as a concern. The ”Exbyex” said he was concerned that most people in the home were elderly or frail, and he wanted to be sure that they were safe. This is a requirement of the inspection. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 20 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): 24,25,26,27,28,29 and 30 The decoration and furnishing in the premises does not promote a comfortable, homely and pleasant living environment for the service users. The home requires redecorating in some areas and to be maintained in a clean condition. The provider has not supplied the aids and adaptations required by service users. EVIDENCE: Dove House was purpose built for the service users who live there. It has not been well maintained or subject to annual renewal and redecoration since it opened and in places paintwork is chipped, wallpaper is lifting and paint has faded in large areas in some rooms. Curtains, carpets and chairs in communal areas would benefit from being renewed as they look tired and faded and in some cases were observed to be heavily stained with food debris. The inspectors also found that underneath the sofa cushions in the lounge the sofa bases were very dirty with old food and tissues. The standard of décor in the communal areas of the home, and in some bedrooms has fallen below an acceptable standard, and also needs attention. The “Exbyex” said, “The furniture and carpet in the living room needs cleaning or replacing. The wall paper in the living room and dining room needs replacing.” Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 21 Whilst the home environment was cleaner than at the last inspection, it had not been cleaned to a satisfactory standard. Examples of this were shared with staff on duty, which included spills of food and drinks on the paintwork in communal areas and bedrooms that had not been cleaned, and debris on the floor and furniture that had not been vacuumed, or removed. The majority of the rooms required the paintwork to be cleaned, including service users bedroom wardrobe doors. The need to complete the transition of the office/snoozlun rooms remains a requirement from the last inspection. Most of the office equipment has now been moved to the new office off the lounge, the snoozlun room remains incomplete and needs redecoration to make it a usable space for the service users. The exterior of the premises require attention. Paving slabs around the home had become un-even, and presented a trip hazard. A review of security, and boundary fencing must also be undertaken to reflect the ongoing development of the surrounding estate. There was evidence in the service users files that personal money had been spent on things like Bedding, (in one case £159) This money must be reimbursed to the service user. Such items are the responsibility of the provider. A previous requirement that money spent by service users on such items be repaid remains outstanding. The inspectors found examples of many different types of specialist equipment for the service users in the home, however the shower chair advised to be purchased in the last inspection remains outstanding and the shower bed is in need of repair as the right side is noticeably rusty. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 22 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): 32,34 and 36 Staff demonstrates positive regard for the service users. Staff have not received the training and support required to undertake their job effectively. Service users are not protected by robust recruitment practices. EVIDENCE: The staff team on duty at the time of inspection showed a good knowledge of the service users needs. The interactions between staff and service users were positive, and staff made efforts to include and engage service users in household activities. The home has some staff vacancies, which are covered by temporary staff. One agency staff described her induction to the home, which included an introduction to the service users and their needs. The “Exbyex” commented that “Staff and residents get on well”, and that,” Staff on duty communicated well with the residents and seemed to understand what they wanted.” Evidence of staff recruitment was of serious concern. This was raised with the provider after the previous visit, and the CSCI is considering taking enforcement action in this area. The recruitment files of four staff employed in the home were assessed. No file contained the complete range of documents as listed in schedules 2 and 4 of the Care Homes Regulations. No staff file was available for one of the staff members. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 23 One staff file contained no recruitment records. Other files were short of references, identification, and evidence that a CRB check had been undertaken. Supervision records showed that supervisions undertaken were of a good quality, but the frequency with which they have been undertaken was unacceptably poor. One file sampled contained no supervision records since September 11 2004. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 24 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): 37,39,41 and 42 It is positive that a manager and senior care staff are in place at the home. The management of the home has not been effective to ensure that service users needs are consistently met, or that health and safety is well managed. EVIDENCE: The management arrangement at the home had improved since the last inspection. A manager has been recruited, and the CSCI are now awaiting application for registration. Two senior carers are now based in the home. As indicated throughout this report all areas of the home require further work to ensure it is operating at a satisfactory standard, which ensures the service users needs are consistently met. Work is required in the areas of improved service user consultation and Person Centred Planning, to ensure the service user are confident that their views underpin all the self-monitoring, review and development of the home. Work would be required to facilitate communication prior to such developments. The use of communication aids like photographs and objects of reference may benefit the service users, in areas of daily activities and key Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 25 workers and staff on duty, this needs to be explored with SALT to support the service users understanding and ability to express their views about choices they want to make in their home. There was a current certificate of registration and insurance on display in the home. Regulation 26 visits have not been undertaken with the required frequency. It is recommended that the acting manager review the number of records, storage of records and arrangements for archiving old material. Records were observed in a range of places, and no system for locating them was in operation. The homes Health and Safety records were inspected. PAT testing of electrical equipment had recently been completed, however the certificate could not be found on the day of the inspection. The premises are now over five years old, and a requirement, that the electrical hardwiring be tested has been made. The weekly fire tests and emergency light tests were up to date and there was evidence of a recent fire drill. It was not evident that such tests are undertaken routinely, and a significant gap of emergency light tests was noted between July and October 2005. Regular hot water temperature checks had been undertaken and records were available. The home has valves in place to ensure the water temperature does not go above 43°C. Evidence that the hot water system had been screened for Legionella was not available. Freezer and fridge checks had been undertaken daily records showed these were within safe ranges. Food hygiene has previously been identified as requiring improvement. At this inspection, vegetables passed their best and two unopened packets of processed meats were found to be well past the use by date. Fresh meat that is purchased and frozen must be dated when frozen. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 26 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 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 2 1 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 1 X LIFESTYLES Standard No Score 11 2 12 2 13 1 14 2 15 2 16 2 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 X 1 CONDUCT AND MANAGEMENT OF THE HOME 1 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 1 X 1 1 X DS0000024871.V259103.R01.S.doc Version 5.0 Page 27 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) Timescale for action Unmet from previous inspection. 01/02/06 Service users care plans must include details of service users goals and aspirations and how their social and leisure needs are to be met. Unmet from previous inspection. 01/02/06 Service users plans must be up to date. Information no longer pertinent to the individual must be archived. Daily records completed by staff 01/12/05 must be complete, and evidence the care and support given during the shift. Information collected from 01/02/06 service users, reviews or members of the Multi Disciplinary Team must be utilised in care plans. Unmet from previous inspection. 01/02/06 Clear guidance on how the care and support is to be delivered must be included in the plans. Unmet from previous inspection. 01/02/06 Guidelines on how service users communicate must be available and followed. Requirement 2 YA6 15(2)(b) & 17(3)(a) 3 YA6 12(1)(a) 17(3)(a) 12(1)(a) & 13(1)(b) 4 YA6 5 YA6 12(1)(a) & 13(1)(b) 12(2) 6 YA6 Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 28 7 YA6 12(2) 8 YA8 12(2) and 16(2)(mn) and 13(6) 9 10 YA8 YA9 12(3) 13(4)(a-c) 11 12 YA9 YA6YA9 13(4)(c) and 17(3)(a) 18(1)(a) Unmet from previous inspection. Evidence that service users or their representatives have been consulted in the drafting and reviewing of the plan must be available. Unmet from previous inspection. Evidence of the process by which decisions are made with or for service users must be available. This must evidence consultation with the service user, relevant others, and that the decision is in the persons best interest. Records must support how decisions made by service users are followed through Unmet from previous inspection. All risk assessments must be regularly reviewed and updated to reflect any changing needs. Risk assessments must be reviewed routinely and after critical incidents. Unmet from previous inspection. Staff awareness training on the purpose and development of care plan and risk assessments must be undertaken. 01/02/06 01/02/06 01/03/06 16/12/05 16/12/05 01/02/06 13 YA9 13(4)(a-c) and 13(5) 14 YA11 16(2)(mn) The content of such documents must be reviewed to ensure they are serving the required purpose. Unmet from previous inspection. 16/12/05 Manual Handling risk assessments must be reviewed at least six monthly, sooner if needs change. Unmet from previous inspection. 16/01/06 Opportunities for service users to undertake developmental activities within the home and community must be provided. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 29 15 YA13 16(2)(mn) 16 17 18 19 YA17 YA17 YA18 YA19 16(2)(i) & 13(4)(c) 16(2)(i) 12(1)(a) & 12(3) 12(4)(a) & 13(3) 20 YA19 12(1)(a) & 13(4)(b-c) 12(1)(a) & 13(1)(a-b) 12(1)(a) 21 YA19 22 YA19 23 24 25 YA19 YA19 YA19 12(1)(a) 12(1)(a) 12(1)(a) 26 27 YA20 YA20 13(2) 13(2) Unmet from previous inspection. Service users records must evidence that service users are participating in activities of their choice in the community on a regular basis. Food as required by service users for reasons of dysphasia must be provided. Service users must be offered a varied, and nutritious diet. Care records must evidence how personal care is to be delivered. Unmet from previous inspection. Service users must be offered healthcare appointments as required. A record of these must be maintained. Unmet from previous inspection. Eating and drinking guidelines must be available in the home and followed. Unmet from previous inspection. Relevant health care monitoring must be undertaken and records maintained. Service users must be supported to obtain a Health Action Plan as identified in Valuing People. Care plans must be developed for all assessed/known needs. Service users must be weighed monthly, or as required by the dietician. Care plans that direct staff regarding the management of difficult to manage behaviour must be developed. Evidence that behaviour is monitored and evaluated must be undertaken. Protocols must be available for all as required medicines. All prescribed medicine must be available. 16/01/06 16/12/05 16/12/05 16/12/05 01/01/06 16/12/05 16/12/05 01/03/06 01/02/06 16/12/05 01/01/06 16/01/06 16/12/05 Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 30 28 29 YA20 YA23 13(2) 13(6) 30 31 32 YA23 YA23 YA24 13(6) 13(6) 23(2)(b-d) 33 YA24 23(2)(b-d) 34 35 YA24 YA24 23(2)(o) 23(2)(o) 36 37 38 YA26 YA29 YA30 16(2)(c) 23(2)(n) 23(2)(d) 39 YA34 19 Schedule 2 18(2) 40 YA36 Medicines no longer required must be returned to the pharmacy. Unmet from previous inspection. Money stolen from one service user must be repaid, and confirmation of this sent to the CSCI. Management of Service Users money must ensure it is safe and accounted for. The home must ensure all possible action is undertaken to protect service users from harm. Unmet from previous inspection. The lounge, dining room and hallway requires redecoration. Lounge furniture must be cleaned, and covered, or replaced. Unmet from previous inspection. Carpets throughout the home must be cleaned. Provision to replace carpets must be made if cleaning is ineffective. Paving slabs around the exterior of the home must be levelled. A review of security and boundary fencing must be undertaken in light of neighbouring developments. Money spent by service users on bedding must be refunded. Equipment required by service users to be provided. The standard of cleanliness must improve to a satisfcatory standard in all areas of the home. Evidence of robust recruitment practices being utilised must be available in the home. All records as schedule. All staff must be supervised at least bi-monthly(pro-rata for part time staff) and a record of such maintained. DS0000024871.V259103.R01.S.doc 16/12/05 01/01/06 16/12/05 16/12/05 01/02/06 01/02/06 01/03/06 01/03/06 01/01/06 16/12/05 16/12/05 16/12/05 16/01/06 Dove House Version 5.0 Page 31 41 42 YA37 YA39 43 YA41 44 YA41 45 46 47 48 YA42 YA42 YA42 YA42 The acting manager must apply to the CSCI for registration. 24 Quality monitoring must be undertaken. Views of service users, staff and stakeholders must be obtained, and used to develop a annual development plan for the home. 17(4) Records no longer required must be securely archived. Records held in the home must be rationalised, and kept in good order. 26 Regulation 26 vists must be made to the home each month,and a record of such maintained. 13(4)(c) Portable Electrical Tests(PAT) and must be undertaken, and 23(2)(c) evidence of this obtained. 23(4)(a)(c) All fire tests must be undertaken and recorded at the required intervals. 13(4)(c) Legionella screening must be undertaken on the water system. 13(3) and Food must be used or discarded 13(4)(c) by the best before date. 8 and 9 01/01/06 01/02/06 01/02/06 01/01/05 01/01/06 01/12/05 01/01/06 01/12/05 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 Refer to Standard YA14 Good Practice Recommendations It is recommended service users be offered access to activities with a therapeutic value. Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 32 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. Extracts may not be used or reproduced without the express permission of CSCI Dove House DS0000024871.V259103.R01.S.doc Version 5.0 Page 33 - 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. 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