Inspection on 25/05/05 for Dove House

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dove House 21/05/08

Dove House 07/07/06

Dove House 14/12/05

Dove House 29/11/04

Dove House 29/06/04

Dove House 12/09/03

Dove House 21/11/02

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

CARE HOMES FOR OLDER PEOPLE Dove House Dovehouse Green Ashbourne Derbyshire DE6 1FF Lead Inspector Vanessa Davies Unannounced 9:30am 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 C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dove House Address Dovehouse Green, Ashbourne, Derbyshire, DE6 1FF 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) 01335 346079 Mrs J Hill Mrs J Hill CRH 16 Category(ies) of OP registration, with number of places Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29.11.04 Brief Description of the Service: Dove House is a 16 bedded care home providing personal care for older people, located close to the market place in Ashbourne. Dove House has a number of different levels, with service user accommodation located on the upper floors. Access to these floors is either via the stairs or shaft lift. Dove House has 10 single and 3-shared rooms. Ensuite facilities are provided in all but one bedroom. Service users have access to a dining room and two separate lounge areas on the ground floor. Service users also have access to a large well tended garden. A number of bedrooms have direct access to the garden. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. Both Mrs Hill, Registered Manager and Stacey Grocott, Deputy Manager, were present. The inspector examined 3 care files and spoke with 7 residents. Health & Safety files and the complaints file were also examined. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments are completed but need more detail to ensure staff are clear about the risk. A number of the residents access the community independently but there were no individual missing persons risk assessments in place. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 6 More detail is needed in the care plans to ensure that needs highlighted are met. The Registered Person must ensure that residents are involved with the preparation and review of their care plans, there was little evidence in files examined and this was confirmed when speaking with residents. 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 C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 7 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 C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 8 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) 1,3,4,5 The staff have detailed information about the needs of residents, but more information is needed in order to fully meet the needs of each individual. EVIDENCE: Dove House has a very detailed Statement of Purpose in place, giving prospective residents all relevant information needed regarding the home. There was evidence of completed assessments of need in the files viewed. The manager then develops a care plan to meet these needs. One file examined had detailed information about what the needs are but little information about how staff should meet the needs. All files examined had little evidence of input from the residents. The inspector spoke with 7 residents all stated that they assumed there was information about them in the office but were not involved with writing or reviewing. There was evidence of input from specialist services as necessary. Each of the residents spoken with stated that either they or a member of their family had the opportunity to visit Dove House prior to moving in. Dove House has an emergency admission procedure in place, although the registered person does try to have arranged moves to the home. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 9 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) 7,8,10,11 Residents’ health needs are met. All residents are treated with respect. A number of risks have not been highlighted or addressed. EVIDENCE: There are risk assessments completed for various risks highlighted, however more detail is needed for example, a resident is able to go to town alone, however his risk assessment says he needs supervision when in the garden. This needs to be clarified. As stated previously there are service user plans in place, however more detail is needed to address individual needs. There was little evidence of residents involvement within the files tracked and this was confirmed when speaking with the residents. The home has a missing person procedure in place but no individual risk assessments for service users. One service user smokes but there was no risk assessment on file. All files had a great deal of information no longer used, the registered person should archive this information making files easier to access. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 10 The inspector spoke with a number of residents all confirming that their health care needs were met. Appointments with relevant professionals are made as necessary. This was evident in the files examined. All residents felt that they were always treated with respect, this was observed on the day of inspection. Staff knock on doors prior to entering, staff use the residents preferred form of address. There was evidence of residents wishes regarding terminal illness and death being addressed in one file examined, however this information was not evident in the other files. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 The home offers a range of activities and supports residents to maintain family contact, which gives residents variety and choice in their social life. EVIDENCE: The residents stated that the home provides various activities and they are able to choose which to become involved in. Within the Statement of Purpose guide are statements from current residents all detailing the range of activities available. All residents stated that their relatives were able to visit without restrictions. All residents felt that they had a choice of what happens with their lives, one resident spoken with was planning a trip to Canada to see his family. The home has 2 cats and 2 dogs visit, all residents spoken with enjoy the animals being around. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 12 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 Residents and relatives spoken with were aware of who to make a complaint to if necessary. EVIDENCE: The manager keeps a clear record of complaints made and responses. All residents spoken with were aware of who to make a complaint to and were confident that their complaint would be addressed without any repercussion. There is a complaints procedure displayed in the home and another copy available with the Statement of Purpose. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 13 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) 19,20,21,23,24,25,26 Dove house is a very clean, pleasant home, providing a safe comfortable environment. EVIDENCE: Dove House is a converted residential home within walking distance of Ashbourne. It is relatively well maintained; the carpet in the hall needs to be re-fitted as explained, to prevent falls and the wall in the hall needs to be repaired. Dove House is well decorated. All radiators are covered. The home has 10 single and 3 double rooms, all with en-suite facilities. The inspector looked at 5 bedrooms and spoke with the residents, all stated that they had sufficient furniture, all rooms had items of the residents own furniture and were very nicely decorated. The home was very clean and tidy on the day of inspection. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 14 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) 28,29 The staff team are provided with training opportunities to ensure they are competent and have the necessary skills to meet the needs of service users. EVIDENCE: The home employs 14 care staff; 5 have achieved NVQ 2 Care and 4 are currently doing it. The Deputy Manager is currently completing NVQ Registered Managers Award. The inspector examined a number of random staff files, all had the relevant information necessary to ensure the safety of the residents. The home has procedures in place to ensure the safety of the residents. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 15 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) 31,32,33,37,38 The registered person completes relevant audits and checks to ensure the safety of residents. EVIDENCE: The inspector examined the fire records and accident book within this area, all other standards will be inspected during the next inspection. All fire records were up to date and the alarm tested weekly. All accidents are documented in the accident record. The home was visited by the Health & Safety officer April 2005, no issues were raised. The manager has a great deal of experience along with a nursing qualification. Records examined were up to date, however as stated earlier within this report more information is needed within some files in order to meet the needs of the residents. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 16 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 3 x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 x 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 3 x x x x x x x x x 3 Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 17 NO 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 4,7 7 Regulation 15 13.4 (b,c) Requirement The registered person must ensure that service users are invovled with their care plans. The Registered Person must ensure that risks to service users health & safety are highlighted and so far as possible eliminated. The registered person must ensure that services users wishes are documented. Timescale for action 31.07.05 31.07.05 3. 11 12.3 31.07.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 3 7 7 Good Practice Recommendations The registered person should ensure that the service user plan details how needs are to be met. The registered person should ensure that risk assessments contain the necessary details to address the risk. The registered person should archive information within service user files, no longer used. Dove House C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Cadinal Square Nottingham Road Derby De1 3QT 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 C52 C02 S19976 Dove House V230055 250505 Stage 4.doc Version 1.30 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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