CARE HOMES FOR OLDER PEOPLE
Dovecote Lodge Dovecote Lane Horbury Wakefield WF4 6DJ Lead Inspector
Susan Vardaxi Unannounced Inspection 23rd September 2005 08:10 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.V251911.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 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.V251911.R01.S.doc Version 5.0 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 Wakefield MDC Mrs Judith Anita Kimberley Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The work required to meet the recommendations of the latest Fire Officer`s report is completed by 31 March 2004 or within an earlier timescale if this is stipulated by the Fire Service 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 NCSC Respite provision for two service users. 2. 3. Date of last inspection 16th March 2005 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 Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection completed over a period of seven hours and consisted of talks with some service users, relatives, staff and managers, a walk round the building and checking some records. The inspector would like to thank all concerned for their cooperation and hospitality throughout the day. What the service does well: What has improved since the last inspection?
The kitchen staff said that the staffing arrangements in the kitchen had improved since a previous inspection and they were all much happier doing their job. The standard of care planning has improved, however the daily records do not show the needs have been met. The local authority has developed a new medication policy, the manager has included the level of assistance service users need to ensure service users they take their medication safely. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 6 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. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 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 Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 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. The pre admission assessment arrangements are satisfactory. EVIDENCE: The manager said she and her assistant managers complete pre admission assessments which include assessments for service users who need interim care. Intermediate care is not provided. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 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, The care plans and daily records do not ensure that service users preferred times of getting up and going to bed are respected. Service users’ health care needs appear to be met appropriately. EVIDENCE: The care plans seen included service users’ assessed needs and had been reviewed monthly. Risk assessments had been completed for pressure area care. A risk assessment had been completed following a service user falling out of bed and preventative action had been taken and an occupational therapist had been involved in a risk assessment. Records of GP and other health professionals’ visits had been recorded on the files seen, weights had been checked and special diets required had been recorded. Staff were seen taking two service users’ their breakfast on trays, attention had been given to the presentation of the meals on the trays, which looked attractive and appetising.
Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 10 Kitchen staff were see preparing fresh vegetables, service users said the meals are good. The medication administration, recording and storage arrangements were checked and no problems were seen. The manager had put a medication identity chart at the front of each service users’ medication sheets, this informs staff if a service user needs help to take medication or if they can manage, the chart gives information about allergies and service users diets. The manager said that the authority have introduced a new medication policy. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 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 Service users are not always able to exercise choice and control over their lives. EVIDENCE: Service users spoken with said that they are well cared for and “there is, plenty to do if you want to join in”. Meetings are held with service users who said “ they can air their grievances if they have any” records of the minutes were seen. Coffee mornings are held every week; the manager said these are well attended by people who live locally. Breakfast was served to two service users on trays in their bedrooms, a service user said that they need a special diet and this was seen in their care plan. The meal was not taken on this visit, however service users spoken with said that the meals are good. 18 service users were seen up, dressed and waiting for their breakfast in small lounges at 8.15am, 5 were in wheelchairs and some were asleep. Some care plans seen did not show service users’ preferences for getting up or going to bed, those spoken with said they would have liked a bit longer in bed. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 12 The daily records seen did not always state how the needs in the care plan had been met; one record did show a service user had chosen to go to bed. The manager said that she had raised concerns about the times that service users get up at a staff meeting in June 2005, the minutes were seen and showed “night staff were upset, as day staff felt that they were not getting enough service users up before 7am”. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 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. The arrangements for dealing with complaints are satisfactory and service users and relatives are supported when required. However staff need to be mindful that getting people up without their consent could be considered as abuse. EVIDENCE: A notice was seen displayed in the entrance hall-advising people how to raise a concern or to make a complaint if necessary. Five complaints had been made about the poor meals when an agency cook had worked at the home; the manager had dealt with the complaints appropriately. Relatives of a service user whose future care is under review by a hospital social care team said that “ the manager of the home and staff have been very supportive and they would have been in a mess without their support.” Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 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 Service users live in a pleasant, well-maintained and safe environment. EVIDENCE: A walk round the building showed the overall environment is maintained and decorated to a good standard, the two domestic staff spoken with are to be commended as a good standard of cleanliness has been maintained throughout a period of staff sickness. The manager said that all bed mattresses have been replaced. The fire officer had visited in March 2005; the manager said that work has been completed to address the recommendations in his report. This should be confirmed in writing to the fire service and the commission. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 15 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, The home is staffed appropriately. EVIDENCE: Staff rosters seen showed that there are four carers during the waking hours and this is only affected by short notice sickness. The manager said that she had calculated the care hours needed using the Department of Health Residential Formula. The pre inspection questionnaire completed by the manager shows that 13 carers have NVQ level 2 and 2 staff have NVQ level 3 qualifications. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 16 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): 33,38 Service users are involved in decisions affecting the service provided and the arrangements for ensuring service users safety appear to be adequate. The method of recording accidents does not ensure that confidentiality will be given to service users. EVIDENCE: Minutes of service user and staff meetings were seen, the meetings had been well attended and showed that service users opinions about the service are sought. Records seen showed that hot running water temperature and fire system checks had been completed. The pre inspection questionnaire shows hoists and adaptation equipment had been checked in April 2005, heating system and water checks for compliance with Legionella had been completed. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 17 Some accident records seen showed that accidents are not recorded individually; they are recorded onto one record sheet, which is sent to the authority’s head office weekly. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 18 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 1 Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 19 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 2 Standard OP14 OP38 Regulation 12(2)(3) 23(4)(c) (iii)(d) Timescale for action Staff routines must not affect the 23/09/05 times that service users prefer to get up and go to bed. 30/10/05 Fire training must be provided for night staff. The responsible individual must inform the Commission when work has been completed to comply with the recommendations made in the fire officer’s report dated March 2005. (Within the timescale agreed by the fire service) All accidents must be recorded as required by the Data Protection Act 1998. Requirement 3 OP38 23(4)(c) (iii)(d) 23/09/05 Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 20 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 OP7 Good Practice Recommendations The times that service users prefer to get up and go to bed should be included in the care plan. The daily records should record how the assessed needs have been met. Dovecote Lodge DS0000034928.V251911.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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