Inspection on 18/01/07 for Dovecote Lodge

This inspection was carried out on 18th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dovecote Lodge 24/02/06

Dovecote Lodge 23/09/05

Dovecote Lodge 16/03/05

Dovecote Lodge 01/09/04

Dovecote Lodge 11/02/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dovecote Lodge Dovecote Lane Horbury Wakefield WF4 6DJ Lead Inspector Mr Rob Curr Unannounced Inspection 18th January 2007 09:00 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 Dovecote Lodge DS0000034928.V323863.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. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dovecote Lodge Address Dovecote Lane Horbury Wakefield WF4 6DJ 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) 01924 302935 01924 302936 www.wakefield.gov.uk Wakefield MDC Vacant Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The care staffing hours are calculated by the provider using the Residential Forum staffing model and the number of full time equivalent staff appointed is in accordance with this calculation or otherwise as agreed in writing with the Commission. Respite provision for two service users. 2. Date of last inspection 24th February 2006 Brief Description of the Service: Dovecote Lodge is a local authority run home which provides accommodation, personal care and support for 28 older people. Set back in its own grounds the home is situated in a residential part of Horbury close to the park. All accommodation provided is single and all bedrooms personalised with service users surrounded by their own personal possessions. All areas of the home are maintained to a good standard and service users are provided with a safe, homely and comfortable environment. The home has disabled access and provides assisted bathing and a passenger lift for those who require it. There are local shops nearby and the home is close to a main bus route In January 2007 the fees were £494.51. The services Statement of Purpose is provided to each service user and the last inspection report was available from the office. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced visit. The site visit was from 9.00 am until 2.30 pm. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, rotas, staff training and recruitment and fire records. A number of staff were spoken to about their skills and experiences of working at the home. Discussions took place with the manager and an assistant manager of the service. A number of residents were interviewed along with two relatives. The methodology included a Pre-Inspection Questionnaire containing a variety of statistical information about the service. The inspector would like to thank the manager and her staff team for their support during the inspection process. What the service does well: What has improved since the last inspection? Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 6 Systems to improve records had been identified and were in the process of being implemented. The residents said that they could choose when they went to bed and rose in the mornings. Preferred daily routines were included in care plans. What they could do better: Improvements are needed in several areas to ensure that service users needs and welfare is met. The changing nature of the service is now offering less permanent support and providing increased respite and interim care, including emergency, unplanned support. The outcome of this means that permanent service users live with people that are constantly leaving the service. The service managers should be communicating regularly with current permanent service users and their representatives. The Statement of Purpose did not reflect the current service offered at the home and needs to be reviewed to ensure the information is accurate. On admission some service users primary care needs did not fall within the homes category of registration. And, the registered person must ensure that people are only admitted within the homes category of registration; should a change to this be planned it must not occur unless there has been a successful application to vary the registration categories. Not all care plans fully indicated the action to be taken by staff to meet service users needs. This requirement is outstanding for the previous inspection. Some plans did not contain all relevant information, which may result in service users needs not being met. All choices should be made clear when service users are offered meals from the menu. The auditing of the training records need to be completed in order to determine which staff required particular training to ensure service users get the level of care that they need. The Quality Assurance procedures need to be actioned and any outcomes from this process should be published annually, supplied to the CSCI and made available to service users, their family or representatives, and all stakeholders in the service. The acting manager was unable to access the electronic recruitment record and action is needed by the registered person to ensure the regulator can access these as the law requires. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 7 Notifiable incidents must all be made promptly, and some retrospective notifiable incidents, identified to the acting manager, must be reported to the CSCI. All staff must take part in the required number of fire drills to improve their skills in responding in the event of fire. The system of ‘recharging’ the batteries for the moving and handling equipment must be reviewed to ensure it is available for service users when needed. The ramp within the quadrangle area needs to be free from leaves and moss to reduce the risk of service users falling. 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. The summary of this inspection report can be made available in other formats on request. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 8 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 Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5,6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose did not reflect the current services provided. Assessments of needs were undertaken prior to admission, to ensure all identified needs of the prospective service user could be met. Service users and/or their representatives were able to visit the home prior to admission, to inform their choices. EVIDENCE: The acting manager said intermediate care was not provided. Copies of full need assessments were in the residents files. Not all the relevant information from the assessments had been built into the care plan Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 10 Two relatives said that they had been invited to view the home and attend a variety of meetings prior to their relative moving into the home. The varied needs of the service user group were discussed with the acting manager. It was stated that the organisation might need to be in discussions with the CSCI with regard to registering to care for other appropriate service user groups. Discussion found that some service users had been admitted to the home when their primary care needs were not within the homes registration categories. The acting manager stated that some residents had been admitted on an emergency basis. Staff also confirmed that one person arrived at the home unexpectedly one evening, and staff had no knowledge of the proposed admission although a pre-admission assessment had been carried out. The emergency admission procedures need to be reviewed in light of the service developing a more flexible approach to supporting people. Staff were now experiencing an unpredictable category of service user. Their needs being more diverse than previously experienced. Examples of this being service users with a diagnosed physical disability. Staff stated that on occasions they did not feel they had the appropriate skills to support service users. Training records read did not fully indicate that staff had undertaken relevant training required to assist them in caring for the people that reside at Dovecote Lodge. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident had a care plan, which did not indicate fully people’s individual needs and preferences. Residents’ health care was monitored and access to health care professionals was available, to ensure health needs were met. In the main medication policies and procedures protected residents. Residents felt respected by staff at the home. EVIDENCE: A number of care plans were inspected. These were not fully completed or up to date. Not all care plans had been reviewed on a monthly basis. The plans contained inconsistent information on individual needs and preferences. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 12 Daily notes and records read indicated that some service users required tasks and observations, but these were not transferred to the care plan for staff to follow on a daily basis. One previous entry into a daily record stated that ‘this person must have a blanket with them at all times’, in response to a medical condition. However, no mention of this was made within the care plan. Some of this information had been recorded on ‘scrap paper’ and again was not reviewed into the care plan. The plans did not always include details of the staff action required to ensure needs were met. Generalised statements were used to describe and indicate staff support required. For example ‘one staff to assist with’ or ‘minimal assistance required’. This could result in an inconsistent delivery of support. Risk assessments, in the care plans seen, had been undertaken. These assessments ensured that care practices were delivered safely. Health care was monitored. All contact with health care professionals was recorded. The residents spoken with confirmed that they met with their, doctor and district nurse when required, and always saw these people in private. Residents said that staff looked after them well. The care plans inspected recorded regular weight checks, nutritional assessments, skin care and other information covering aspects of health. However, four service users were in need of ‘barrier’ care. This was not highlighted or assessed in the identified care plans. Staff informed the inspector that they were carrying out universal practices when supporting these residents. Medication systems in the home were safe. The staff that administered medication confirmed that they had been provided with training. Medication was found to be stored securely. The medication administration records inspected were fully completed and up to date. The medication records corresponded with the drugs held. However, medication such as anticoagulants that needed constant monitoring did not have a clear permanent record of regular changes. ‘Post it’ notes had been used to indicate the next two dosages. These notes could be lost and compromise the wellbeing of the individual concerned. This was discussed with the assistant manager who stated another system would be employed. The interactions observed between residents and staff appeared respectful and caring. Staff were seen to knock on doors and wait for a reply before entering rooms. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A varied activities programme was provided to maintain residents’ interests and social opportunities. Contact with family and friends were supported to maintain relationships. Residents’ opinions were sought, to ensure they had a choice. A varied diet was provided to maintain health and give residents choices. EVIDENCE: All of the residents and relatives spoken with said that enough activities were provided. A record of all activities was seen. This evidenced that a choice was provided to residents; for example, trips out of the home to local pubs and restaurants, visiting entertainers, and ‘special interest talks’ regularly took place. Photographs of recent events were on display throughout the home. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 14 Residents spoken to said they were free to join in activities, or not, as they wished. The acting manager and staff reported good relationships with relatives. All of the residents spoken with said that their friends and family visited them freely, and they could see them in private if they wished. Staff were seen to ask residents opinions. All of the residents spoken with said that they were provided with choice. Residents were seen to freely move around the home and spend time in their bedroom, or communal areas as they wished. There was also a pleasant and well-kept smoking lounge. The homes menu was found to be varied and appeared healthy. All of the residents spoken with said the food was very good. The menu evidenced that choices were available. Staff and residents said that they could have different meals to the menu if they wanted. However, the inspectors noted that staff were only offering a limited choice on the day of the inspection so some service users would not have been aware of the choices available. The chef said that the menus were new and had not yet been re-printed. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure in operation ensured residents concerns were taken seriously. An adult safeguarding policy and procedure was in operation to protect residents from abuse, although some staff had yet to receive training. EVIDENCE: A written complaints policy was available to residents and staff. The policy was on display and included information on how to contact the local office of the CSCI. A record of complaints was kept. These detailed the action taken and the outcome of the complaint. All of the staff and residents spoken with had confidence that the homes registered person would listen to them and take any concern seriously. The written adult safeguarding procedure was seen and was available to staff. The staff spoken to were generally aware of the procedures to follow should they suspect abuse. The acting manager confirmed that a number of staff had yet to attend adult safeguarding training. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, well decorated and well maintained to provide residents with a comfortable place to live. EVIDENCE: An inspection of a proportion of the environment was undertaken. The home was well maintained. Furniture and fittings appeared in good condition Communal areas were well-decorated and provided with pictures and ornaments to create a homely atmosphere. All of the residents said that they were very happy with the accommodation provided. The home was very clean. Staff were provided with equipment, such as aprons and gloves, to enable them to adhere to hygiene procedures. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At times staffing numbers were below the agreed level despite the home being full and service users needs being varied. A programme of National Vocational Qualifications (NVQ) was in operation, to keep residents safe. The recommended levels of NVQ trained staff had been exceeded (79 ). Staff needed to undertake refresher training in moving and handling, safeguarding adults and in particular health and hygiene to ensure they were competent to carry out their role. The acting manager needs to develop a staff training and development plan, which should include the aspects of training relevant to the needs of service users. The recruitment and selection files were unavailable for inspection. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 18 EVIDENCE: The managements team stated that an annual staff-training programme had yet to be organised and planned, in order to ascertain that staff had the skills to meet the needs of service users. The cooks on duty confirmed that they had undertaken training in food hygiene. Staff recruitment records could not be inspected. The acting manager accessed the central electronic system for recruitment files. She tried to gain information regarding two members of staff, but she said no information was available. The inspector spoke with two recently appointed members of staff in relation to the recruitment process. They confirmed that application forms had been completed, which detailed full employment history. Two written references had been obtained, one from the most recent employer. Criminal Records Bureau (CRB) checks had been completed. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager’s leadership style benefited residents and staff. There was no comprehensive quality assurance system in operation, to obtain and respond to residents’ views. The inspectors considered it vital that service users, relatives and staff were continually informed of the progress of the service to enable the acting manager and her team to communicate a clear sense of direction and leadership that everyone understood. The procedures in operation safeguarded resident’s finances. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 20 A staff-training matrix needs to be developed so that the manager can identify when refresher training was required. A health and safety system was in operation, to protect residents and staff. However, the majority of training records, and one potential slipping hazard, required attention in order that safe procedures were followed. EVIDENCE: In discussion, the acting manager displayed a sense of commitment to her role. She had been in post a few months. The staff spoken with said that the acting manager was supportive and approachable. The management team stated that the quality assurance system was not fully operational. Although there was an opportunity for relatives and visitors to make entries in a ‘comments book’. The need for a robust quality assurance system was discussed at length with the management team. Staff declared that they felt uncertain with regard to the future of the service. The acting manager stated that the organisation had shared their initial plans to develop services within the city as a whole, ‘some time ago when changes were envisaged’. Records indicated that staff had not undertaken any awareness training in equality and diversity so that they could understand and promote any equal opportunities within the organisation as a whole. Residents ‘spending monies’ were kept. Records of these were inspected. All transactions were recorded and accompanied by two signatures. The records corresponded with the amounts of money kept and were stored securely. Three staff supervision records were examined. These evidenced that staff were provided with supervision at appropriate frequencies. Supervisions covered relevant topics such as the care workers role and training needs. Health and safety systems were checked and maintained. The fire records inspected evidenced that fire alarms were checked on a weekly basis from different call points. Not all staff had participated in a practice drill at the required frequency. This was discussed with the acting manager, who said she would action this immediately. A rolling programme of mandatory training was in operation. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 21 The majority of the environment inspected appeared safe, however, the ramp outside in the quadrangle was covered in leaves and moss, creating a potential slipping hazard. The potential hazard was discussed with the acting manager; was made aware of this hazard, who agreed to rectify this as a priority. The inspector observed that there were problems around the re-charging of batteries for moving equipment. The batteries were not holding their charge. This compromised the safe moving and handling of people because equipment stopped working whilst residents were in-situ. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 22 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 2 X 2 2 2 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 2 Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,16 Requirement The organisation must review the category of service users they support and approach the CSCI to amend the registration category if necessary. The responsible person must ensure that all service users are admitted to the home within the category of registration and as stated in the Statement of Purpose All staff must be provided with refresher training in food hygiene, moving and handling and health and safety at appropriate frequencies. Emergency admission procedures must be developed and adhered to. Care plan must be reviewed at least once a month, updated to reflect changing needs. The manager must arrange the auditing of the consistency and quality of care plan contents. Consistent information should be contained in the identified care plans of the service users in need of ‘barrier’ care. DS0000034928.V323863.R01.S.doc Timescale for action 20/03/07 2 OP3 4,14 20/03/07 3 OP4 OP38 4,16 20/04/07 4 5 6 7 OP5 OP7 OP7 OP7 OP38 12 15 15 37,Sch 4 20/03/07 20/03/07 20/03/07 20/03/07 Dovecote Lodge Version 5.2 Page 24 8 OP7 14,Sch 3 9 OP7 15(1) 10 11 12 13 14 15 16 17 OP7 OP9 OP9 OP15 OP15 OP18 OP27 OP29 OP37 15 13 13 16 16 13 18,19 17 18 19 20 OP30 OP33 OP33 17 37 24 All appropriate information in full needs assessments must be incorporated in the care plan. Plans must contain sufficient detail on the staff action required to ensure needs are met. Changes in service users’ assessed needs must be recorded at the time that care plans are reviewed. Previous timescale of 30/04/06 not met. Important information recorded in daily notes must be reflected within the care plan. ‘Post-it’ notes must not be used to indicate dosages of mediation. A more reliable system must be introduced to indicate the regular changes in medication. The recently revised menus should be printed and made available to service users. All choices available on the menu must be offered to residents. All staff must undertake Adult Protection training. Care staffing levels must not fall below 4 in the mornings and 4 in the evenings. All recruitment records must be available for inspection. The previous timescale of 30/04/06 has not been met. All training and development records must be up to date. The identified notifiable incident reports must be forwarded to the local office of CSCI. The quality assurance process must be actioned. The outcome from this process should be published annually, supplied to the Commission for Social Care Inspection (CSCI) and made available to users, their family or representatives, DS0000034928.V323863.R01.S.doc 20/03/07 20/03/07 20/03/07 18/01/07 18/01/07 20/03/07 20/03/07 20/04/07 18/01/07 20/02/07 20/03/07 20/03/07 17/04/07 Dovecote Lodge Version 5.2 Page 25 21 OP38 22 OP38 23 24 25 OP38 OP38 OP38 and all stakeholders in the agency. 23 All staff that have not taken part in a fire drill lead by the ‘responsible individual’ must do so on there next duty (if not before) 23 Staff that are left in charge (including night staff) must conduct a fire drill on or before their next duty 13 The leaves and moss must be removed from the identified ramped area. 13 All batteries for specialist moving equipment must be fully charged and available at all times. 23(4)(c)(ii All night staff must receive fire i)(d) training. Previous timescale of 30/04/06 not met. 18/01/07 18/01/07 18/01/07 18/01/07 18/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP7 OP7 OP30 OP32 OP33 Good Practice Recommendations The daily records should record how the assessed needs have been met. Use all daily recordings to influence the outcome of care planning Staff should have an individual training and development plan. Those that do have one should be reviewed. All staff should undertake Equality and Diversity awareness. The organisation should continue to actively communicate the current and future development of the service provided at the home to residents, family, friends, staff and any other stakeholders in the community. Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Dovecote Lodge DS0000034928.V323863.R01.S.doc Version 5.2 Page 27 - 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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