CARE HOMES FOR OLDER PEOPLE
Dovecote Lodge Dovecote Lane Horbury Wakefield WF4 6DJ Lead Inspector
Susan Vardaxi Unannounced Inspection 24th February 2006 9:15
09:15
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.V280807.R01.S.doc Version 5.1 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.V280807.R01.S.doc Version 5.1 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.V280807.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The work required to meet the recommendations of the latest Fire Officers 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. 3. Date of last inspection 23rd September 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.V280807.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection completed on 24 February 2006 over a period of 5.5 hours. The process included talking with service users, the manager, assistant manager and staff, checking some records and compliance. There were 8 service users receiving respite or interim care and 19 service users who live at the home permanently. Thanks are extended to all concerned for the support, co-operation and hospitality. What the service does well: What has improved since the last inspection?
A new method of recording accidents has been introduced which complies with the Data Protection Act. The assistant manager said most night staff have had fire training, the two staff on sick leave will be trained on their return to work. The manager and staff have worked hard to maintain a good standard of care
Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 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.V280807.R01.S.doc Version 5.1 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.V280807.R01.S.doc Version 5.1 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 admission arrangements are not within the home’s category of registration. EVIDENCE: The manager said there were 19 service users living at the home including 8 service users for interim or respite care. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 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): 7,8,10,11 There is a risk that service users needs would not be fully met if changes in needs are not recorded when care plans are reviewed. Health care arrangements are satisfactory and service users are treated with respect. EVIDENCE: Service users spoken with made some very positive comments about the care they receive and the staff. The care plans seen had been generated from needs assessments however changes in needs had not been carried forward onto the monthly review records. Records of risk assessments were seen and were appropriate. The daily records do not record that all needs have been met. The service users’ records seen showed that health care providers visit as required.
Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 Page 10 Staff were observed speaking with and assisting service users with respect throughout the inspection. Records seen showed eight staff have been provided with Palliative care packs and training. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 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): 15 The provision of meals are satisfactory EVIDENCE: The service users were joined for lunch, which was cooked to a good standard, service users spoken with said they had enjoyed the meal. Staff were seen assisting service users appropriately, a service user was given time to eat their meal at their own pace. The menus seen show a choice of meals and special diets are available. A record of meals provided was seen. Good records have been maintained. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 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 the following standard(s): 17,18 Service users legal rights appear to be protected. The arrangements to ensure service users are protected from abuse are satisfactory. EVIDENCE: The manager said all service users have the opportunity to vote, some go to the polling stations. She said a “polling station” is set up in the home and service users post their votes into a box and then staff post the votes for them. The manager said adult protection training is provided, staff spoken with were aware of the home Whistleblowing procedure. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 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 the following standard(s): 25. The home provides a clean, comfortable and pleasant environment for service users to live in. EVIDENCE: These standards were not fully assessed on this visit. However the communal areas visited were clean, and decorated to a good standard. The providers unannounced visit report for December 2005 shows that all bedrooms and lounges had been redecorated. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 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 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): 29,30 All records relating to staff recruitment must be available for inspection so as to ensure the protection of vulnerable service users by way of satisfactory recruitment processes. The provision of training is satisfactory. EVIDENCE: The staffing levels were not fully assessed on this occasion however staff spoken with said staffing levels were satisfactory and were only affected by short notice sickness. A newly recruited staff’s records could not be checked, as the electronic system was inaccessible, the manager said the current system was in the process of being changed. The assistant manager is a NVQ internal verifier, staff spoken with said she was committed to assisting them to obtain NVQ qualifications. The assistant manager said some staff have had mandatory training and the Health Service Mental Health team provided some training in 2005. Staff spoken with confirmed that staff induction and ongoing training is provided. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 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 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): 31,35, 36 The manager has the appropriate qualifications and experience required. Service users’ interests appear to be safeguarded Staff are appropriately supervised. EVIDENCE: The manager said she had achieved the NVQ 4 management and Registered Managers qualifications. Staff spoken with and records seen show that formal supervision is provided regularly. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 Page 16 Some records of money held by the home on service users behalf were checked and no discrepancies were seen. A new method for recording accidents has been provided as required at the last inspection. The assistant manager said some night staff have had fire training and training for two staff on sick leave would be provided on their return to work. The providers unannounced visit report for December 2005 showed that fire alarms are tested weekly and four fire drills are held annually. The assistant manager has said since the inspection that the work recommended by the fire officer has been completed. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 Page 17 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 X X X X X X 3 X STAFFING Standard No Score 27 X 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 X X Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 Page 18 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 OP3 Regulation 4(1)(C) 14(1) Requirement 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 Changes in service users’ assessed needs must be recorded at the time that care plans are reviewed. All night staff must receive fire training. The responsible person must ensure that staff recruitment records include all relevant information required by regulation and are available for inspection. Timescale for action 30/04/06 2 OP7 15(1) 30/04/06 3 4 OP38 OP29 23(4)(c) (iii)(d) 19(1) 30/04/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 Page 19 No. 1. Refer to Standard OP7 Good Practice Recommendations The daily records should record how the assessed needs have been met. Dovecote Lodge DS0000034928.V280807.R01.S.doc Version 5.1 Page 20 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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