Inspection on 07/07/06 for Dove House

This inspection was carried out on 7th July 2006.

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 14/12/05

Dove House 25/05/05

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 Angela Kennedy Key Unannounced Inspection 7th July 2006 11:00 X10015.doc Version 1.40 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 DS0000019976.V297684.R01.S.doc Version 5.2 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 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 DS0000019976.V297684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dove House Address Dovehouse Green Ashbourne Derbyshire DE6 1FF 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) (01335) 346079 Mrs Kathleen Janet Hill Mrs Kathleen Janet Hill Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 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. The current range of fees on the 07/07/06 was from £ 345 to £ 375 per week. Further information regarding the home can be obtained by contacting the provider by telephone or email at: dovehouse1@tiscali.co.uk. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced key inspection (which means all the key standards were inspected) and took place over a four-hour period. The provider/ manager of the home was at the home at the commencement of the inspection to provide the required documents, and senior care staff were available to assist the inspector with any further documents required during the inspection. Several of the residents living at the home were spoken with and two of the staff team were also spoken with in some detail. The inspector sampled the lunchtime meal with the residents. 14 people were living at the home on the day of inspection and one potential resident was visiting the home that day. 2 residents files were seen and care plans and risk assessments were examined in detail within these files. The homes documents regarding medicine administration and the health and safety practices at the home were also seen. 2 staff files were examined, looking in detail at the recruitment practices and training provided. What the service does well: The care provided to the residents was person centred, which means that each individual’s needs and preferences are catered for with staff support as required. This demonstrated that staff at the home, work in partnership with the residents to ensure their needs are met. The rapport between staff and residents was observed and was found to be positive, friendly and relaxed. The meals provided where wholesome and nutritious and alternative choices were provided as required to meet the tastes, preferences and dietary needs of each resident. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 6 Staff training was ongoing and the variety of training undertaken ensured that the residents were catered for by a trained and competent staff team. The staff team had undertaken had undertaken medication training and the medication was stored, administered and recorded appropriately. What has improved since the last inspection? What they could do better: 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 DS0000019976.V297684.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Dove House DS0000019976.V297684.R01.S.doc Version 5.2 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 the following standard(s): 3 Residents had a full assessment of need undertaken before moving into the home, to ensure their needs could be met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: 2 residents files were seen and both demonstrated that a full assessment of their needs had been undertaken prior to admission and this included assessing their personal care needs, physical well-being including general medical history, dietary needs and preferences including weight, medication, history of falls and mobility, sight, hearing and dental needs and social needshobbies including significant person. This demonstrates that the home not only ensures that they are able to meet each individuals needs but also strives to gather as much information as possible to enable each individuals care package to be person centred. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10 Resident’s personal, social and health care needs were set out in a plan of care and clearly indicated the level of support each individual required to enable their needs to be met, thus ensuring their independence was maintained. Medication practices in general were good but required development to evidence that residents who self-administer have the capacity to do so. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Risk assessments were in place within the two residents files seen that looked at; the environmental risk for each resident both within the home and the local community, moving and handling, tissue viability, history and risk of falls, physical health, personal care needs, physical well being, missing persons, diet and allergies, dietary preferences, sight, hearing, communication, oral health, foot care, mobility, dexterity, continence, weight on admission and monthly weight. An assessment of each individuals risk to others and to themselves Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 10 was in place. A heading within the assessment regarding the individuals risk to themselves included information with regard to medication and said “capable of understanding drug therapy”, which, in one residents file stated ‘no risk’, however further detail is required to demonstrate how this person has been assessed as safe to administer their medication. Of the two residents files seen the care plans in place were detailed and informed the staff of the support each resident required. This ensured that each resident maintained the skills they had and only received the support necessary to meet their needs. All areas of health, social and personal care were identified; this included each residents 24 hour preferred routine, which included ‘ what we need to do for…each day’, this demonstrates that the home strives to ensure the care provided for each individual is centred on their needs and preferences and ensures their independence is maintained. Evidence was in place within the two residents files seen to demonstrate that care plans were reviewed on a monthly basis and any changes in the care and support required were documented. The medication practices of the home were examined this included; the medication cabinet, medication administration records and controlled drugs record of supply and administration, all of these were satisfactory. A resident who self-administered their medication had a disclaimer in place to confirm that they took responsibility for their medication and the administration of their medication; this was dated and signed by the resident. However there was no detailed risk assessment in place which demonstrated that this resident was physically and mental able to store and administer their medication safely and accurately as prescribed. Residents spoken with spoke highly of the care and support provided to them at the home and confirmed that the staff team maintained their dignity and privacy at all times. The resident’s preferred name was documented within the two files seen and information had been sought from these residents on their wishes regarding terminal care and post death arrangements. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15 Residents were able to exercise control regarding their daily lives, routines and social activities and where able to maintain contact with their families and friends as they wished. Meals at the home were wholesome, nutritious and varied and were positively accepted by the residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The activities provided at the home included: • Quizzes • Meals out • Visits to local and surrounding pubs • Shopping in Ashbourne • Rides out within the local countryside • Garden centre trips • Arts and crafts • Holy Communion within home once a month. • Hairdresser once a week Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 12 Several attractive and framed pictures were on display within the home; the residents had designed these. Residents spoken with were happy with the activities provided and stated that they were very comfortable at the home saying that there was a nice relaxed atmosphere. Many residents agreed that they preferred to go out for rides and said that this was there preferred activity. None of the residents attended the local churches but Holy Communion was offered on a monthly basis (with alternating religious denominations) for residents who wished to partake. Visiting at the home was open and residents confirmed that they were able to entertain their visitors within the communal areas or within their private accommodation as they wished. Residents had access to a telephone either by using the pay phone available or by having their own private telephone line installed within their rooms. The manager also confirmed that residents were able to use the office telephone. None of the residents used an independent advocate but information regarding local advocacy services was available to the residents. The inspector sampled the lunchtime meal with the residents and found it be wholesome, nutritious and of a high quality. Residents spoken with during the meal were very complimentary and informed the inspector that all the meals served were of a high standard. Alternative choices were available for any resident who required them and this was confirmed with the residents spoken with. The dining room was attractive in appearance and tables were laid attractively with suitable condiments. Water and fruit cordial were provided with the meal and tea and coffee were served following desert. Residents who did not wish to eat their lunch in the dining area were able to eat their meals within their private accommodation. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 16,18 The homes complaints procedure is clear, accessible to residents and their visitors and all complaints are managed promptly and effectively. The policies, procedures and practices in place regarding adult protection promote the safety of residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The complaints policy was seen and contained the required information and timescales in a clear format. The record of complaints was seen and all complaints had been documented, including minor concerns and all clearly explained any action that was undertaken and who by. The home has received 9 complaints within the last 12 months; including minor concerns all of these have been responded to within the 28-day timescale and satisfactorily resolved. The practices and procedures used at the home regarding adult protection are satisfactory and in line with Derbyshire’s local authority adult protection policy. Staff had completed adult protection training. No protection of vulnerable adult referrals had been made by the home within the last twelve months. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 19,26 Residents live in a safe, clean, well-maintained environment. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: A tour of the building was undertaken and this included viewing the laundry area, some of the resident’s rooms, communal living rooms, kitchen and some of the outside grounds. Resident’s private accommodation was personalised in décor and included resident’s own personal items of furniture and furnishings. The kitchen and laundry areas were kept clean and tidy. All communal areas seen were clean and attractively decorated. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 15 The grounds were accessible to residents and a shed was provided for a resident who liked to spend some of their time there, this was suitably furnished to meet this residents needs. On the day of inspection work was underway to upgrade the boilers and heating system of the home. The manager of the home had left a notice to this effect to ensure all residents and visitors were aware of the work being undertaken. Resident’s spoken with were happy with their private accommodation, this included two residents who shared accommodation and stated that they enjoyed each others company and were able to assist each other in various tasks which they felt promoted their independence. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 16 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Sufficient numbers of trained staff are on duty within the home to meet the needs of the residents. The recruitment practices of the home were generally good but require further development to ensure residents are protected and safeguarded. Quality in this outcome area is adequate. This Judgement has been made using available evidence including a visit to the service. EVIDENCE: The home is registered for sixteen residents, however on the day of inspection there was 14 residents and one potential resident who was visiting the home for the day. 3 staff are on shift each morning along with 1 cook, 1 domestic and 1 maintenance person. In the afternoon 2 care staff are on duty until 9.30pm, when 1 night staff and one sleep-in staff are on duty until 7.30am when the morning shift begins. The manager is also available throughout the day on the majority of days. 4 staff had achieved their National Vocational Qualification (NVQ) at level 2 in care. A further 5 staff had commenced NVQ2 training and 4 staff had commenced NVQ3 in care. 2 staff files were examined to look at the recruitment practices of the home. Both files had evidence in place to show that criminal records bureau checks Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 17 had been undertaken and were satisfactory, 2 satisfactory references had been obtained and the required identification documents were in place. The employment application forms were in place within both files seen but did not contain the required full employment history with any gaps in employment being explored. Within the last twelve months staff had undertaken training in health and safety, fire procedures and practices, medication, adult protection and a diabetic seminar. Future training planned included, medication certification, diabetic training, fire training and first aid. 2 staff members were spoken with and confirmed the training they had undertaken. Both staff confirmed that they received supervision/appraisals from the manager every three months but stated that the manager was available at any time if they had any concerns or issues. Both staff demonstrated a good knowledge and understanding regarding the care and support needs of the residents and a good understanding of adult protection. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 18 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Residents live in a home that is managed by a suitably qualified, experience and competent person who demonstrates that the home is run within the best interests of the residents and ensures their welfare is promoted and protected at all times. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The manager has achieved a National Vocational Qualification in care at level 4 and the Registered Managers Award. The manager has being running the home for the last 9 years. The quality assurances systems at the home were examined and included residents meetings twice a year and annual satisfaction questionnaires that were sent to residents, visitors and visiting health care professionals. Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 19 It was apparent from looking at the provision of care for residents that individual needs are catered for on a daily basis, which demonstrated that residents views and wishes are continuously and any action required is taken to meet their needs and wishes. Resident’s finances were not kept for them by the home. Residents and/or their representatives retain full control of their finances. Some of the health and Safety practices of the home were examined, this included; • Fire log book-, which looked at the possible need of wheelchair evacuation for some residents and the routes that were to be used. • Fire drills- done twice yearly with the local fire safety officer during fire training- last done April 06 • Fire risk assessment- regarding the building and escape routes and position of gas and electrical appliances • Fire fighting equipment check- June 06 • Gas installation service- April 06 • Electrical wiring certificate- July 05 (due every 5 years) • Lift engineer service- March 06 • Central heating system - May 06 (upgrade in process) Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 20 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 3 Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 (2) Requirement A risk assessment demonstrating the resident’s capacity must in place for any resident wishing to retain and self-administer their medication. A full employment history must be obtained for all staff prior to commencing employment, together with a satisfactory written explanation of any gaps in employment. Timescale for action 01/09/06 2. OP29 Schedule 2 (6) 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dove House DS0000019976.V297684.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal 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 DS0000019976.V297684.R01.S.doc Version 5.2 Page 23 - 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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