CARE HOMES FOR OLDER PEOPLE
Dovecote Nursing Home Hugar Road High Spen Rowlands Gill Tyne & Wear NE39 2BQ Lead Inspector
Sam Doku Key Unannounced Inspection 09:50 15th and 28th June 2006 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 Nursing Home DS0000018172.V299104.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 Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Dovecote Nursing Home Address Hugar Road High Spen Rowlands Gill Tyne & Wear NE39 2BQ 01207 544 441 01207 544 171 dc1eurodeancare@aol.com 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) European Care (UK) Limited Jon Barnett Care Home 61 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (61) of places Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd March 2006 Brief Description of the Service: Dovecote Care Home has 61 places for older persons. The home is split into two separate units; the first floor providing care for people with dementia and the ground floor for older persons only. Both units provide nursing and personal care. The home is purpose built and the internal space is generous. The bathrooms and communal WC’s have handrails and appropriate lifting equipment for disabled service users. The home is constructed in a traditional style of brick and tile and has a variety of lounge / dining areas. There is passenger lift access to the first floor. The access is level from the ground floor entrance. It stands in it’s own grounds, which are well kept. There is a generous amount of parking space. The home is located in a village, in a rural area. It is a quiet setting with local facilities close to the home including shops and a pub. The current of charges for the service users are £359.00 for residential and £575.00 for nursing. The home does not provide intermediate care. Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two days on 15 and 28 June 2006 and was carried out by one inspector. Records were examined and a tour of the premises took place. Discussion took place with the manager. The midday meal was observed on both inspection days and the inspector spoke to service users, staff, and visitors throughout the inspection period. Prior to the inspection date, questionnaires were sent to the service users and relatives for completion. Five responses were received form relatives and four from a service users. All the responses were positive about the quality of the service. The home reasonably well equipped with aids and adaptations suited to the client group’s age and lifestyle preferences. The home has plenty of space in all areas. It is popular with service users and their families, and there is a great deal of involvement by the local community. What the service does well:
There are good relationships between the staff of the home, families and the local community. Relatives confirmed that the staff keep them informed about any changes to their relatives’ condition and also on any activities that were going on or planned for the future. The home maintains good contact with the local community. The weekly bingos that are organised by the home are often attended by members of the local community. The activities coordinator confirmed that those who attend the bingo have known a number of the service users and this provides the opportunity for some service users to meet with old friends or people they know. The home provides a wide range of social activities for service users. This includes outings to local places of interests. The activities coordinator uses resources of volunteers in providing recreational and social activities. The service users and relatives confirmed that the musical entertainer is a frequent visitor to the home to engage the service users in musical concerts. There is a commitment to training and development for staff by the company. Examination of the staff training details indicate that training on the whole is good. Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 6 Care Plans are generally good, setting out care needs and how those needs are to be met. These care plans are particularly good for those receiving general personal and nursing care. Following risk assessment about falls in the home, the company has embarked on the purchase of profile beds with high specifications to meet the needs of the service users who have been identified as requiring such beds in order to ensure their safety and wellbeing. What has improved since the last inspection? What they could do better:
The training record provided by the manager indicate that a number of staff require refresher training in food safety, infection control, moving and handling and COSSH. Although most staff had received the training in the past, these were more than three years ago and staff must have a refresher training in these areas to bring them up to date with the latest safety measures and current working practices. The staff confirmed that individual supervision is not happening but the manager indicated that arrangements are underway for each staff member to receive regular supervision. This would further enhance the skills of the staff team for the benefit of the service users. Staff induction is poorly documented and there seem to be lack of understanding by those supervising the induction programme. Supervision records were examined were noted unsigned by the mentor. Some were not dated and there was inconsistency in the scoring/rating as there were no clear guidelines about the scoring system. The care plans for the service users on the dementia care unit are generally good but the care plans do not fully address their mental care needs in the same way as their general care needs such as weight loss, diet, mobility, assistance bathing, moving and handling had been done. There is a pro-format for carrying out a pre-admission assessment with provision for carrying out a risk assessment during the pre-admission visit.
Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 7 However, in one case where there was the need to carry out a risk assessment before admission was arranged, this part of the assessment was not carried out. This meant a full assessment had not been carried out in this case, which would provide the basis for managing the particular behaviour and promote her welfare and that of others. The dining arrangements on the dementia unit were less than satisfactory. Space was very limited and service users were having to move their chairs or stand up for other to pass by. While the inspector was having lunch with the service users, it was noticed that none of the service users were offered sugar in their tea. No one was offered salt, pepper or other condiments such as mint sauce to go with the lamb dinner that was served. The dementia care unit could not be described as a stimulating environment. There are orientation signs on doors to direct service users to their rooms, toilets or communal areas such as lounges and dining room. The environment does not demonstrate an understanding by the staff about the importance of the environment in the care of people with dementia. On the dementia care unit the staff pointed out the possible hazard with the carpets along the corridors. There are large green squares on the carpet and service users have been noticed to step over these, mistaking them for an object that is in their way. This is a potential hazard, which could lead to fall and should be addressed. The carpets on the dementia unit are badly stained and unsightly some places. Other areas also suffer from intense urine odour, which has been a longstanding problem on the unit. The enclosed garden next to the kitchen was at the time of the inspection not considered suitable for service users to use. It was overgrown with grass and the grounds were uneven which could be tripping hazard for service users particularly to those with mobility problems. 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 Nursing Home DS0000018172.V299104.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 Nursing Home DS0000018172.V299104.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Initial pre-admission assessments of individual needs are carried out before admission is arranged. This ensures that their needs can be met. However in one case the risk assessment for the person whose has challenging behaviour was not carried out at the point of pre-assessment thus providing an incomplete view about the needs of the person. EVIDENCE: Full assessments have been carried out by the social workers and copies made available to the manager before admissions are arranged. The home also carries out their assessments of the individual in their own setting to make sure Dovecote Care Home has the necessary skills and facilities to meet the needs of the prospective service user. These arrangements ensure that the social worker, the home, the prospective service user and the relatives are confident that the home is able to support and care for the person before they move in. Two service users and three relatives confirmed that the assessment by the social worker and also by the home gave them the opportunity to ask
Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 10 questions about the home which gave them the confidence in the ability of the home to meet their care needs. However, in one case where the service user has challenging behaviour the home did not carry out the necessary risk assessment to satisfy themselves that the need of the person can adequately be met in the home. The home has suitable arrangements in place for inviting prospective service users and or their relatives to visit the home before admission is arranged. Three service users who were spoken with commented positively on these arrangements by the home to allow them to visit and for the opportunity to meet with other service users and staff. The relatives who were interviewed also found the exercise helpful and said it made it easier for them to decide on the home as their preferred choice. Dovecote Nursing Home DS0000018172.V299104.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Staff provide personal care and healthcare support which are consistent with the expressed wishes of the service users. However, in the case of the dementia unit, the there is limited information in the care plans to address the individual’s orientation and psychological needs. Addressing these would greatly enhance the quality of life for the service users on the unit. EVIDENCE: The service users care plans set out their care needs and action plan for meeting these needs. Care plans are regularly reviewed thus ensuring that the current care needs of the service users are being addressed and changes made to those needs where necessary. However the care plans for people on the dementia care unit are mainly physical and task oriented. The care plans lack details about the mental and psychological care that would enhance the quality of life for some of the individuals.
Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 12 The home maintains record of contacts with healthcare professionals, including GPs, psychiatrist, chiropody service, dentist, optician and other healthcare services. Entries in the report books provide evidence that the home continues to engage the services of community medical practitioners and other professionals in the in the provision of care and for general advice and support. This ensures that the service users rights to proper healthcare are being safeguarded by the home. Relatives and service users confirmed that the healthcare needs are met through the arrangements for them to have access to healthcare facilities. There are suitable arrangements in place for the storage and administration of medicines in the home. The drugs administration system was examined and there were no discrepancies. The proper drugs administrative system that is being implemented ensures that the health and welfare of the service users are promoted. Service users confirmed that the staff treat them with respect and dignity. This was also confirmed by relatives and also by the three respondents of the survey. Staff were noted to treat service users with respect. Staff were observed to speak quietly and discreetly with service when they were offering assistance with personal care. Staff were observed to knock on service users door before making entry thus promoting their privacy and dignity. Dovecote Nursing Home DS0000018172.V299104.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides activities that meet the social and cultural needs of the service users. This ensures that the service users interest are maintained and the opportunity for them to continue to engage in meaningful social activities. The environment on the dementia unit lacks stimulation for the service users. There is lack of orientation cues to help the service users find their way round the unit. This contributes to their confusion and wellbeing. There is evidence of family involvement in social events run by the home and with individual service users. Service users use community facilities and are able to feel part of the local community. The arrangements for serving meals do not promote a relaxing and enjoyable experience for the service users on the dementia care unit. The arrangements are chaotic and afford little choice and dignity for the service users. EVIDENCE: The home has an activities coordinator who organises recreational activities for the service users. Service users commented positively on her role and felt that
Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 14 she is enthusiastic about her work. She continues to explore community facilities and contacts to support social events in the home. Relatives commented positively on her work and said that there is always something going on in the home. On both days of the inspection, there were entertainers in the afternoon to engage the service users in singing and comedy. The service users spoke about the regular contacts with friends and people they know from the village during bingo nights and other social activities. Such contact with the local community has a positive impact for a number of service users. The dementia unit lacks general stimulation and signs to help orientate those who are confused and cannot find their way round the unit. The lack of signs to help with orientation further compounds the memory problems that the service users have. A number of staff commented on this and described instances with individuals where such signs or notices would have helped the individual orientate better thus improving on their quality of life. Service users and relatives confirmed that the minister of religion conducts service regularly for those who wish to take part. This offers the opportunity for individuals to maintain their faith and promote their spiritual well-being. Service users continue to enjoy contacts with friends and relatives. On the days of the inspection, there were a number of relatives visiting and they all confirmed that they are able to visit at any time and that there are no restrictions on them regarding when to call to see relatives and friends. Some relatives are supported to continue to be involved in the care of their loved ones. The mealtime arrangements were good on the ground floor. The atmosphere was calm and service users were given sufficient time to finish their meals. The arrangements on the second floor were chaotic and the experience could not be described as enjoyable. The dining room was congested and service users were having to move their chairs or stand up for others to pass by. None of the service users was asked if they wanted sugar in their tea. They were all provided tea without sugar. No one was offered pepper or salt during lunch. There were no condiments offered including mint sauce to go with the lamb that was served. Dovecote Nursing Home DS0000018172.V299104.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The policies and practices in the home ensure that the service users are protected from all forms of abuse. EVIDENCE: The home has in place a satisfactory policy and procedural guidance on abuse and staff are aware of how to use the ‘Whistle Blowing’ policy should this become necessary. The Service User Guide and Statement of Purpose have summaries of the complaints procedure. Copies of these are available to service users and their relatives and are also displayed and made accessible to the general public by being displayed in different parts of the home. This provides the opportunity for service users, relatives and the general public to complain or raise concerns if they wish. Service users and relatives confirmed that any concerns or complaints they may have would be treated seriously with the view to safeguarding the welfare of the service users. This was reflected in the questionnaires that were received and in discussions with visiting relatives. Staff have received training in protection of vulnerable adults (POVA). The staff showed good understanding of the POVA procedures and awareness of the need to protect service users from all forms of abuse. In discussions with relatives, it was obvious that any concerns raised were appropriately dealt with under the home’s protection of vulnerable person’s procedure, thus providing further confidence amongst service users and
Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 16 relatives that all concerns are taken seriously and appropriately addressed. The relatives confirmed that they have confidence in the complaints system and feel that any concerns would be appropriately dealt with by the home. Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 17 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, 20, 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally clean and maintained to good standard. However, some areas suffer from odour problems which impacts negatively on the self-esteem of the service users. EVIDENCE: The home is adequately maintained and provides a comfortable environment for the service users. Access into the home and within it is good. The first floor is accessed by staircase and a passenger lift. The corridors are wide enough to allow easier access for people with walking aids or wheelchairs. However, at the time of the inspection the enclosed garden near the kitchen was overgrown with grass and the grounds were uneven, presenting a potential tripping hazard for service users. This also deprived the service users of the opportunity to sit out in the garden at a time when the weather was good.
Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 18 The carpets on the dementia unit are badly stained in places and unsightly. Some areas also suffer from intense urine odour, which has been a longstanding problem on the unit. This impacts negatively on the self-esteem of the service users who live on that unit. There is a potential tripping hazard with the carpets along the corridors on the first floor. There are large green squares on the carpets and service users with poor vision have been noticed to step over these, mistaking them for objects in their way. This is a potential hazard, which could lead to falls and should be addressed. Records showed that safety measures regarding fire safety and the environment are being observed. The records show regular fire drills, alarm tests and equipment checks. Fire risk assessment of the building has been carried out. The fire risk assessments include detection devices, chemicals, gas installation, electrical equipments and devices. The home has detailed written policies and procedures relating to safe handling of hazardous materials for staff to follow. The manager indicated that staff have had training in health and safety, infection control and food hygiene but the training record show that a number of staff require refresher training in these areas. Regular update on mandatory training is necessary in ensuring that the staff are up to date with current practice and to improve their practice in promoting the safety and welfare of the people in their care. Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home maintains sufficient staffing levels to meet the needs of the service users. However, a large number of staff need an update on mandatory training to ensure that the staff are adequately equipped in providing care and support programmes that are current and up to date. . The good recruitment procedures in the home safeguard the safety and welfare of the service users. EVIDENCE: Past staff rotas were examined and the staffing numbers were found to be sufficient to meet the needs of the service users. The manager confirmed that the required staffing levels have consistently been maintained to ensure that the care needs of the service users are met. He also indicated that in recent months the staffing levels have been increased to take account of the busy hours of the day and also extra staffing provided if escort duty is required. Service users and relatives indicated that they feel that the staffing levels are adequate to meet their needs. However, in discussions with both nurses and care staff, they confirmed that at times they hardly have time to sit and talk to service users. They indicated that their time is often spent carrying out physical tasks and not having sufficient time to engage in therapeutic activities with service users.
Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 20 The company’s employment policies are being adhered to by the manager. The files of the most recently appointed staff members were examined. Appropriate references have been obtained and the necessary checks have been conducted, including CRB enhanced checks. Staff confirmed that they have all had CRB checks done on them. Overseas nurses have had all the necessary check done and appropriate work permits have been obtained for them. The training provided for the staff included moving and handling, first aid, fire safety training, food hygiene, falls prevention and protection of vulnerable adults awareness training. However, a number of staff are due for refresher training in these areas. An up to date training in these areas would equip the staff in carrying their tasks more efficiently and also ensure that the safety and welfare of the service users are promoted. Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home manager by is a competent trained nurse with good management experience. This ensures competent management of the home. The home has suitable arrangements that ensure service users monies are safe and properly accounted for. There are good care practices in place that protected the safety and welfare of the service users and the staff. There is general lack of one-to-one supervision for the staff although arrangements are underway to implement a supervision programme for all the staff. EVIDENCE:
Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 22 The manager is registered with the Commission. He has good management experience and is a qualified nurse. The staff indicated that the new manager runs the service in a way that benefits the service users. They commented that he has positive relationship with them and the service users. Similar comments were also made by service users and relatives. There is lack of supervision of staff. The trained nurses acknowledged this and attributed it to the shortage of trained nurses who would have been responsible for the supervision of the care staff. The manager has however planned these and they are to be implemented by the responsible nurses. This would enhance the skills of the staff for the benefit of the service users. Details in the service users files indicate that the system for managing the personal allowances for service users is good. Receipts for purchases made on behalf of service users are available on individual files. Withdrawals or payments made on behalf of service users are counter-signed by the service users, their relatives or staff member. The company has produced detailed Health and Safety policies and copies of these were made available for inspection. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The records indicated that the staff have had training in food hygiene, fire precaution, moving and handling and first aid, although a number of the staff require refresher training in these areas. This kind of training ensures that the staff maintain safe working practices which safeguard the safety and wellbeing of the service users. All portable appliances have been tested. A record is maintained of monthly water temperature tests in the home. All the servicing records that were examined were up to date. These included fire fighting equipments, servicing of hoists, water treatment, electrical installation and gas servicing. Up to date servicing and maintenance of these services and equipments ensure a safe environment for the service users and the staff who work there. Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 23 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 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 24 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 OP4 Regulation 15(1) Requirement Care plans must reflect the mental care needs of those suffering from dementia based on current good practiced, and reflect relevant specialist and clinical guidance. Where it is necessary, risk assessment must be carried out during pre-admission assessment to ensure that the care needs have been properly identified before admission is arranged. Strategies must be put in place to assist service users with poor vision to avoid danger of falls due to perceived obstruction on the carpets. This must take account of current good practiced, and reflect relevant specialist and clinical guidance. Dining room arrangements must be reviewed to ensure that service users have adequate space and comfort during mealtimes. Service users must be offered the opportunity to make choices regarding the use of sugar, salt,
DS0000018172.V299104.R01.S.doc Timescale for action 30/09/06 2 OP4 15(1) 30/07/06 3 OP4 12(1)(a) 30/09/06 4 OP15 23(2)(h) 30/09/06 5 OP15 12(4)(a) 28/07/06 Dovecote Nursing Home Version 5.2 Page 25 6 OP19 23(2)(o) 7 OP19 16(2)(k) 8 OP23 16(2)(c)2 3(2)(a)(n) pepper and other condiments during meal times. The enclosed garden must be properly maintained and all obstacles such as uneven floor must be removed in order to make it safe for the service users. The intense urine odour, which has resulted in the carpets being badly stained must be replaced to enhance the dignity of the service users. The home must provide suitable equipment for service users with sensory deficits and those who are prone to confusion. Refresher training on mandatory course must be provided to all the staff who require them. Induction training must be properly documented and signed by both the trainee and the trainer and appropriately signed. All staff must receive regular supervision from the senior staff. 30/10/06 30/01/07 30/09/06 9 10 OP30 OP30 18(2)(a) 18(1)(i) 30/09/06 28/06/06 11 OP36 18(2)(a) 30/08/06 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 Dovecote Nursing Home DS0000018172.V299104.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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