CARE HOMES FOR OLDER PEOPLE
Dovecott Care Home 83 Weelsby Road Grimsby North East Lincs DN32 0PY Lead Inspector
Theresa Bryson Key Unannounced Inspection 12th March 2008 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 Dovecott Care Home DS0000002852.V360638.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. Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Dovecott Care Home Address 83 Weelsby Road Grimsby North East Lincs DN32 0PY 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) 01472 878133 r.farenly@ntlworld.com Mr Stuart Peter Farmery Mrs Rita Ethel Farmery Mrs Rita Ethel Farmery Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Care plans and risk assessments must reflect the specific needs of the service users accommodated under the category of registration DE(E) and be maintained up to date. 29th January 2007 Date of last inspection Brief Description of the Service: Dovecott provides care for 20 people in the category of old age and dementia. The accommodation is set over two floors. The home has completed a first floor extension providing a further 7 single ensuite rooms and reconfiguration of an existing double bedroom into a single ensuite bedroom. The extension also provides an assisted shower and a separate Jacuzzi bath. The home is set close to the centre of Grimsby and local parks and other amenities. There is parking to the rear of the building and in side streets next to the home. The owners are developing the garden area and courtyard for service user use. The home has 3 communal areas including a dining room and service users can smoke in a designated area. There are ample toilet and bathroom facilities. Domestic and kitchen staff and a handyman support the care staff. The weekly fees range from £329 to £367, extras include hairdressing, chiropody and toiletries charges, which are based per item. The home will accept local authority funded persons and privately paying individuals. Fees are reviewed annually. Information on the home is provided by a service users’ guide and statement of purpose, which is available on request and is given by hand or sent to prospective service users and/or their relatives. Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This site visit took place over one day in March 2008. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes.
Prior to the site visit surveys were sent to relatives, health professionals and staff. There was a poor response. Several people were spoken to at the site visit, including people who use the service, health professionals, staff and other visitors in the home. We also checked the service history on the home, which is kept by us, from the time of the last inspection. The home also submitted their Annual Quality Assessment Audit (AQAA) prior to the visit. This was checked along with other records and documentation in the home. Both the owners and the manager were present during the time of the site visit. What the service does well:
Staff are very friendly and helpful when you enter the home and appear to have a good knowledge base about the people they look after. The majority of staff have worked in the home for a long time and have seen it develop over the years. This has given them a good idea of what works in the home and how people are going to fit into the family atmosphere. Each person seen was spoken to with dignity and respect, and care taken during the day, of the visit, that their individual needs were being met. This can make them feel at home and that they are valued as individuals. There were adequate numbers of staff on duty to ensure that all the needs of people could be met. Extra staff are also brought into the home for special events, outings and when people need an escort, for example for hospital appointment. This ensures the basic care needs of people are not compromised. Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
Some areas of improvement still need to be completed to ensure people living in the home are free from harm and abuse. There must be more expansion and attention to detail in the care plans kept on each person. For example regular reviews need to be completed to ensure current needs of people are being met and the audits by the management team need to pick up details and action points for staff to adhere to. This must include more care to be taken over the medication audits to ensure drugs are given safely, when prescribed and are always in stock. This will ensure they have all their needs met at all times. A recent environmental health officer’s report picked up on certain aspects of cleanliness and repairs in the kitchen area, which 3 months on had not been rectified by the home. Food must be prepared in a clean and safe environment to ensure people are free from harm. The cleanliness aspect of the home also involves the laundry area and use of wheelchairs. All machines must be running correctly and more adequate provision put in place to prevent risk from cross infection in the laundry area. Wheelchairs also used for people living in the home must be clean to also prevent people from being harmed and preserve their dignity. Staff must be more adequately supervised to ensure they are safe to work with people in the home and are being monitored on a regular basis. There were insufficient details in the supervision records to show this has been occurring
Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 7 and where staff problems had been notified to us, they had not been recorded. A failure to do so could put people at considerable risk from harm. Although some mandatory training had been completed in the last year there was insufficient evidence to show that more detailed training on some specific needs of people, had been accessed. For example diabetes and continence needs. Several aspects of the general management of the home had not been completed and there was a lack of attention of details in some of the audits seen. For example, a home is required to notify us when deaths and any other untoward incidents occur and the home had failed dramatically in doing this. This has not enabled us to track incidents and monitor whether the home has made the correct choices when dealing with events and could have put people at risk from harm, if incorrect decisions had been made. There was a lack of evidence on the monthly audit sheets that water temperatures on all outlets used by people in the home are running at the correct temperature and that the fire alarm is sounded to ensure it is working order. This could leave people living in an unsafe environment. Some progress had been made in trying to get the views of people living in the home, but there was insuffiecnt evidence to support this was broad enough to ensure the home is being run for the benefit of those who live there. 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. Dovecott Care Home DS0000002852.V360638.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 Dovecott Care Home DS0000002852.V360638.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): Standards 3 and 6 were checked. Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Adequate assessments are completed prior to admission to the home to enable staff to prepare for each person’s arrival. EVIDENCE: The home now uses a holistic tool to assess people prior to admission, which enables staff to prepare for their arrival. Written evidence on new arrivals in the home showed that this had been well completed and was being used as a base line assessment to develop an on going care plan.
Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 10 The manager assesses each person and has begun taking a senior member of care staff with them for experience and as a contact person for when the person arrives in the home. This enables each person to feel more at home on first arrival. The home does not provide intermediate care and therefore Standard 6 is not applicable. Dovecott Care Home DS0000002852.V360638.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): Standards 7,8,9 and 10 were checked. Quality in this outcome area is adequate. People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The records kept on people living in the home have improved but require more accurate details to be recorded and each one to be reviewed more regularly, to ensure all needs are being met. Auditing of medication needs to be more thorough to prevent people from being harmed. EVIDENCE: Prior to the site visit a number of surveys were sent to relatives, health professionals and staff. There was a poor response, but the comments received were mixed. Some offering suggestions for improvement and others making positive comments of the care delivered to people in the home.
Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 12 During the course of the site visit 5 staff were spoken to, 1 health professional and 2 other visitors to the home. 4 people living in the home were capable of making informed decision to speak to us but only 2 were available on the day. Most made positive comments about the staff in the home. Stating, “staff are cooperative” and another “staff help with the more difficult people when I ask them”. On the site visit 4 care plans were tracked in depth. There has been an improvement in the lay out of the documentation and better recording of daily events, generally giving a reasonable picture of the day to day care delivered to each person. There were a few gaps in the care plan recording and in the monthly evaluations. Some auditing by the manager had taken place, but this needs to be more structured and give staff more assistance in what is required to be recorded. There was a lack of evidence that the total care plans had been reviewed at least annually. In the 4 care plans tracked 1 had no review sheet, 2 were dated in 2006 and 1 person was new to the home. Attempts have been made to have families involved in the care planning process but when they are not available there was no written evidence to support conversations or requests had been made. As the majority of people living in the home cannot make informed decision about their care, it is vital that the home seeks assistance to ascertain whether needs are being meet by other sources including family, visitors and other health professionals, plus regular reviews by staff in the home. This will ensure people are living their lives to their expectations and all needs are being met. During the tracking of the accident records and admissions/discharge list it was discovered that the information kept by us on the home was inaccurate. The CSCI inspection record only listed one death reported to us by Regulation 37 notices since the last inspection and no admissions to hospital or other untoward events. When staff were questioned they were not aware these needed to be completed as this was stated as normally “a management job”. The manager stated that they had forgotten to complete these and the deaths were subsequently tracked on the day and all information taken to add to our records. The home was informed it must ensure that all documentation is completed accurately and they must check on the latest guidance to send Regulation 37 notices when the need arises. This will ensure that we can track events in the home and ensure all processes have been followed to prevent people from being harmed. During the course of the day staff were observed giving personal care to people, taking part in social activities and assisting people at meal times.
Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 13 These tasks were performed with dignity and respect and care was taken to ensure peoples individual needs were being met. For example a person who was blind was informed what was on their plate at meal times and someone with physical needs was placed in a special chair for comfort. Comments from surveys included “staff create a warm, friendly atmosphere” and “staff are caring and supportive. They treat the residents with respect and care and are sympathetic to their needs”. The medication records were tracked with the assistance of some senior care staff. Most sections on the administration records had been completed, but there were some gaps and some inconsistencies about medication not in stock, which had not been picked up at a recent audit by the manager. Any possible errors or inconsistencies were mainly corrected at the time of the site visit. Staff spoken to had a good knowledge base of peoples needs and were able to give a good account of what constitutes good practise when administering medication. The records for the medication audit were brief and need to include when action has been completed and what improvements to the system and/or training of staff has occurred. This will ensure people are not put at risk from unsafe practises and receive medication when it is required. The management team must also ensure that the medication storage trolley is firmly attached to a wall when not in use and records are also kept of storage temperatures for medication stored in the trolley, store cupboard and fridge. This will ensure any medication given is safe to use and there can be no instances where medication could be stolen. Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 14 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): Standards 12,13,14 and 15 were checked. Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some variety of social activities are now provided in the home, to meet peoples expectations. Food needs to be prepared in a cleaner environment and storage must be checked to ensure items are stored in a safe way to prevent people from being harmed. EVIDENCE: A more varied programme is now on offer to ensure peoples social needs and expectations can be met. The written evidence in the care plans showed that each person has now been assessed and when they take part in activities these are itemised in the
Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 15 records. This can provide a basis for providing more variety if required and show peoples progress or decline in events. The home engages the services of outside agencies to provide such diversions as mental stimulation therapy, exercises and reminiscence. This helps for those with memory loss. The management team have also been liaising with the Local Alzheimer’s Disease Society to access outside events and help with choices for people in the home. The home also has an active programme of singers and other entertainers in the home. One relative stated “arrangements have been made for Dad to go to the local church now”. Another person stated, “it’s my choice where I sit in the home and I like my room”. There was also ample evidence that people living in the home can personalize their own rooms, which as one person said, “helped me settle in with my bits around”. The Environmental Health Officer had visited the home in January 2008 and left a list of items to be corrected. This information had not been included on the Annual Quality Assessment Audit (AQAA), completed by the home. This included repair to a broken cupboard and better cleaning schedules. Both items had not been completed at the time of the site visit. Evidence of poor hygiene standards in the kitchen were also seen on the day and brought to the manager’s attention. This included cleaning schedules not completed, a dirty microwave, and condiments for the tables were dirty and some food items were in unsealed packets on tops of freezers. To allow food to be prepared in an unclean environment could put people at significant risk and needs to be prioritised by the management team. Food choices appeared to be adequate and notes had been made when alternatives were offered. Food seen on the day was well presented and staff were seen to assist people with their meals in a calm and dignified manner. Comments received stated that food presented was “variable” to “enough to eat”. Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18 were checked. Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints process allows people to raise concerns if the need arises. EVIDENCE: No complaints had been received to us about the home since the last inspection. The complaints log was seen and showed that the home had dealt with what they had termed “niggles” by people in the home. These all had recorded outcomes and any action taken. Surveys and people spoken to felt staff were approachable, but that the management team could be more evident to them and more involved in the day to day running of the home. This would ensure that if problems were occurring they could be dealt with promptly and all evidence recorded. Staff have now undertaken training in safe guarding adults and appeared to be aware of the process to follow if the need should arise, when questioned. The policy was in place, which will help protect people living in the home from abuse.
Dovecott Care Home DS0000002852.V360638.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were checked. Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements had been made to ensure people are living in a more comfortable environment suited to their specific needs. EVIDENCE: We were able to tour the home alone and also with the owner and owner/manager. A number of projects in the home had been completed since the last inspection.
Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 18 This included the development of a ramp access to the front door, with handrails, a patio area and new fencing in part of the garden area and an aviary outside one of the sitting room windows. Inside the building some redecoration had taken place including a bathroom, some bedrooms and some corridors. New dining chairs had been purchased which were sturdier and some easy chairs in the sitting rooms. Evidence was also seen that the boiler has now been maintained through the year and all certificates for hoists, including new ones were in place. These improvements have made for a more comfortable environment in which people can live. It had been recommended previously by the local fire officer that an electrical cupboard must be locked at all times but this was not so at the site visit, so contravening guidance given to the manager. The wheelchairs stored for peoples use were also in an unclean state and no adequate explanation given as to why this was the case. This could cause peoples health to be put at risk. A system of cleaning needs to be put in place and checked regularly to also preserve peoples dignity. Some comments received about the home included negative feedback about the back of the building. This was reasonably free from hazards at the site visit, but needed tidying up and was in only an adequate state of repair. The laundry was very untidy and we were told the main washer had broken down the week before and there was a very large build up of soiled linen and clothes in the room. The management team had failed to notify us of this on a Regulation 37 notice, in spite of there being a risk of infection and the system being out of control. Some contingency plans were in place, but appeared not to be working and alternatives were suggested at the time of the site visit. The laundry room was also in a poor state of repair and requires attention on the maintenance plan urgently, to ensure it is a safe place to work and there is some clearer system in place to prevent cross infection and people being at risk. Dovecott Care Home DS0000002852.V360638.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were checked. Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff recruitment was more organised and staff had received update training in most mandatory subjects but need to expand their knowledge base in more topics to cover needs of people currently in the home, to enable them to care fully for them. EVIDENCE: 3 personal files were tracked in depth and appeared to have sufficient documentation to ensure staff were safe to work with people in the home. Interview guidance had been completed and induction training books were seen for two new staff to show how their first weeks training had gone. Surveys returned and people spoken to stated that some issues had not been dealt with by the management team but were not at this stage able to tell us more detail. The way the current Registered Manager deals with staff issues was spoken of at the feedback session. There were mixed views on the skill mix available in the home, but the pattern of rotas appeared to work for the staff employed and there were no concerns raised that care was not being
Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 20 delivered to people. Rotas for all departments were seen from as far back as January 2008. It is essential that all matters are dealt with promptly with staff to ensure they are still capable of looking after the people in the home. And this is recorded and kept on their files. The recording of training had improved since the last inspection and most staff had attended mandatory courses. Nearly half the staff group were working towards their NVQ awards at different levels, which they stated was helping them understand the people they look after. There was a lack of recent training to cover the specific needs of people living in the home, for example diabetes care and mobility around loss of limbs. The home must ensure the staff group are fully trained to enable them to look after the people in the home; otherwise their care could be compromised. Dovecott Care Home DS0000002852.V360638.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36 and 38 were checked. Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There needs to be a more organised management structure in the home to ensure the views of everyone are taken into consideration in the running of the home and it is a safe environment in which to live and work. EVIDENCE: The management structure is very open and friendly but there is very little structure to the way the home is managed. Evidence for this was found in the
Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 22 lack of Regulation 37 notices being sent to us for deaths and untoward incidents, which we were informed is a management responsibility. No evidence could be produced of staff meetings, relatives meetings or contact with other stakeholders. Questionnaires had been sent out concerning the delivery of care, staffing, meals, cleanliness and atmosphere but only a few examples could be found. There was also a lack of documented evidence of issues which had been raised by staff and some auditing tools, such as that mentioned in the section for drug administration had missed some vital information and also those for auditing care plans. Care must be taken to ensure all events are accurately recorded, outcomes and any action noted and any untoward incident and/or death is sent to us for tracking purposes. A failure to do so could result in people being put at risk from harm and having needs unmet. There has been a small improvement in some staff supervision records, but they are very brief and do not cover all aspects of the Standards set by us. Of the records seen there was a need for more observational supervision to ensure staff can do their jobs and are safe to work with people living in the home. This could put people at significant risk if not actioned immediately. Views of staff and management on supervision, received by us, differ on this aspect of their employment and do not correspond with Standards and Regulations set by us and need to be addressed as a mater of urgency. This was fed back to the manager at the end of the site visit. The safety certificates for the home were seen and appeared to be valid and adequate safety checks had been made in most of the home. More robust methods should be put in place to ensure the water temperatures meet the standards required and also the fire checks should be more through. The audit tool used does not address theses issues and failures in the system would not be picked up unless more robust methods were in place. For example there is no record of what water outlet temperatures actually are. All aspects of the home, regarding safety should be checked regularly to ensure it is a safe place to live and work and people are free from harm and their views taken in to consideration. Dovecott Care Home DS0000002852.V360638.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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 2 2 2 Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15.2.b. Requirement All care plans must be audited regularly by the management team and details of actions recorded. This is to ensure staff are adequately doing their job and each person’s needs are met. All care plans must have regular reviews and all action recorded to ensure people’s current needs are being met and people are happy with the care being delivered. All records for the administration of medicines must be accurate and people should have their medication when prescribed to stop them from becoming ill. The registered person must ensure that all cleaning schedules in the kitchen area are maintained and all items especially condiments and the deep fat fryer is cleaned thoroughly. (Previous time scale of 30/04/07 not met). Timescale for action 14/06/08 2 OP7 15.2.b, c. 14/06/08 3 OP9 13.2. 14/05/08 4 OP15 16.2.j. 14/05/08 Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 25 5 OP15 16.2.j. 6 OP19 23.2.c. 7 OP26 16.2.e. 8 OP29 18.1.a. 9 OP30 18.1.c. 10 OP31 24.1.a, b. 11 OP32 21.1. All packaging in the kitchen area must be secure and food stored in a clean environment, to prevent people from being harmed. All wheelchairs used by people in the home must be of a good standard of repair and clean to enable them to be used properly. The laundry facilities must be reviewed to ensure there is no build up of soiled linen and no risk of cross infection. Records kept on staff must be maintained accurately, especially when there have been disputes, to ensure they are safe to work with the people in the home. Staff must have adequate training to ensure they can look after the needs of people currently living in the home. Management audits must be accurate to ensure the Registered persons are monitoring the running of the home and it is safe to live and work in. The registered person must provide evidence of the consultations with the service users and staff on development of the home and the services provided. (Previous time scales of 01/05/05,30/03/06,08/09/ 06 and 20/01/07 and 30/04/07 not met). 14/05/08 14/05/08 14/06/08 14/05/08 14/06/08 14/06/08 14/06/08 12 OP33 24.1.a, b. The management team must ensure that all quality assurance audits are open for inspection, use a verifiable tool to make decisions and record any action taken over the last year. To ensure the home is being run for the people living there.
DS0000002852.V360638.R01.S.doc 14/06/08 Dovecott Care Home Version 5.2 Page 26 13 OP36 18.2. 14 OP37 37.1.a to g. Supervision records must reflect 14/06/08 the actual session that has taken place and be a balance between discussion and observation. This will ensure staff are safe to do their jobs. The management team must 14/05/08 ensure that all relevant instances under this Regulation are notified to us, so we can track that appropriate action has been taken and people are safe. 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 OP38 Good Practice Recommendations It is recommended that the audit tools for water safety checks and fire checks be reviewed to ensure more accurate auditing can takes place. Dovecott Care Home DS0000002852.V360638.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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
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