Inspection on 02/12/08 for Dovecott Care Home

This inspection was carried out on 2nd December 2008.

CSCI found this care home to be providing an Poor service.

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

Other inspections for this house

Dovecott Care Home 28/05/09

Dovecott Care Home 12/03/08

Dovecott Care Home 29/01/07

Dovecott Care Home 11/05/06

Dovecott Care Home 20/01/06

Dovecott Care Home 23/06/05

Dovecott Care Home 27/01/05

Dovecott Care Home 28/06/04

Dovecott Care Home 11/02/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

CARE HOMES FOR OLDER PEOPLE Dovecott Care Home 83 Weelsby Road Grimsby North East Lincs DN32 0PY Lead Inspector Theresa Bryson Key Unannounced Inspection 2nd December 2008 10:00 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.V373419.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.V373419.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.V373419.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. 12th March 2008 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.V373419.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use the service experience poor quality outcomes. This key inspection was brought forward and therefore no surveys were able to be sent out prior to the inspection taking place. People living in the home who had capacity to make decisions to speak to us were spoken to on the day of the site visit. For all other people living in the home attempts were made to contact relatives and a number were spoken to by telephone. Some other health and social care staff who have visited the home recently were also spoken to either by telephone or as part of a separate meeting. 5 staff were also spoken to during the course of the site visit. It was also not possible to send out the CSCI Annual Quality Assessment Audit tool for the home to complete prior to the site visit, but the CSCI database was checked prior to the visit. On the day a number of files of people using the home, staff records and other records were checked. The Registered Manager was present through out the visit and the second owner and Responsible Individual was spoken to by telephone at the beginning of the visit. We have reviewed our practise when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Staff are very friendly and open when spoken to and appeared to have an adequate knowledge of the needs of the people they look after. People told us, who live in the home, as well as relatives that the majority of staff are “kind” and “caring”. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 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 Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Standards 3 and 6 were checked. Adequate information is available to help people make informed choices about using the home. EVIDENCE: Due to the current safe guarding adults’ investigation being under taken by the Local Authority the home is closed to admissions. We checked the booklet used daily by staff to record how many people are in the home and this showed it had not been completed since November 28th 2008. We were informed by staff this is used to show how many people are resident in the home on each day but was not at the time of the visit accurate. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 9 We also checked the discharges and deaths book but the Manager was completing this during the course of the inspection. It was seen by us that the manger had failed to keep this record up to date and was entering an event, which had taken place in September 2008. It is an offence to not keep accurate records, of all types, which should always be open for inspection. The home does not give intermediate care and therefore Standard 6 is not applicable. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is poor. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 7,8,9 and 10 were checked. Poor record keeping is putting people at risk from unmet needs not being evaluated correctly on a regular basis. EVIDENCE: As this inspection was brought forward it was not possible to send surveys out prior to the inspection but we were given a list of telephone numbers by the manager to enable us to contact relatives. Of the 18 people currently resident in the home we were informed that 5 did not have relatives to speak on their behalf. Of the others we were able to contact 10 relatives who many gave us positive feed back on how they feel their loved ones are looked after. Making such comments as “care good as far as I can see” and “the staff are excellent and keep us up to date” and “staff very good”. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 11 Some stated that due to those wandering in the home small items had gone missing, but the general comment was “we know the home cannot do anything” Some also stated they do not see the manager very often but when contact was made the manager was “pleasant”. 3 people were able to discuss their care needs with us and each person stated they felt care staff were “excellent” and “good”. One person stating, “Nothing is too much trouble”. During the course of our observation in the home on one occasion no care staff were present in the downstairs area of the home for over 20minutes, during this time the manager also left her office for 10 minutes and did not check care staff were available. Staff would not have been aware if people needed any assistance as no one had a call bell to hand and the majority could not make informed decision to inform any one of their needs. This could have put people at risk of harm and injury. 5 care plans were tracked in depth, of these 3 showed significant errors on the documentation seen which potentially could put people at risk of harm. For example one person showed a significant weight loss over a three-month period yet there was no record to show that a GP or dieticians had been called for this. There was no action plan for staff to follow identifying the nutritional risk for this person. On another care plan the accident records showed where a person had had an accident but the dates differed. The dates on the accident form and daily report sheet were different on the evaluation form for this person’s needs assessment around falling. There was also no follow up recorded in the notes even though the person had sustained an injury. Also on this file the review in August 2008 remarked that the care plan needed updating from July and should be monthly. This had not been completed correctly as the last up date was September 2008. The care plan review undertaken at the end of September stated, “Seems up to date”, despite there being errors on the records. On a third care plan accident reports were seen for two accidents where injuries had occurred to the person. Neither had entries in the daily report sheets and again there was no follow through mentioned. Also in this folder our inspection took place on 1st December 2008 yet the care plan review was dates 8th December 2008. This is not only a failure by the service to maintain accurate records but could potentially put people at risk if other health professionals are not called and/or injuries are not followed through and care plans maintained regularly to ensure current needs are being met. The requirement for accident policy to be followed through has been an outstanding requirement from the last inspection. There was no evidence on the training files that staff had received up dated training in dignity and respect, which has been a requirement from the last Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 12 inspection. Relatives spoken to stated that staff appeared caring and a person spoken to said “staff will do anything for you, nothing is too much trouble”. During our observations in the home one member of staff spoke to people in a very brisk manner and one person, dispensing beverages did not speak to any of the people they came into contact with. This training will still need to be actioned to ensure all staff know how to approach people with these special needs. A selection of drug administration sheets were checked, which showed some gaps in signature boxes, which could not be accounted for. Also one person’s record showed changes but no record of who authorised this change. There was also no record of when fridge temperatures and room temperatures were completed to ensure medication is stored at the correct temperature. The drug audit had now been completed. Staff were using a very out of date reference book and the management team were not aware this could be purchased. During the course of our visit staff had to be reminded to fix the drug’s trolley securely to the wall, as this had been free standing on our arrival. This will prevent the trolley from going missing and ensure medication is safe. Staff must follow a sound drug administration policy to ensure they are safe practioners and people are given medication safely. Poor record keeping and a failure to ensure there is recorded follow through where care needs are to be adjusted is potentially putting people at risk of harm. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Standards 12,13,14 and 15 were checked. People using the service had a minimum amount of choices in social activities and there needs to be some tightening up of record keeping in the kitchen area to ensure food is prepared in a safe environment. EVIDENCE: During the course of the site visit there were some individual quality time sessions taking place with some people living in the home and during the afternoon an arts and craft session was taking place. People seemed to be enjoying this and most people contributed well to the event. A separate booklet was in place in which staff record social events, which have taken place. These were very repetitive for example many sessions of bingo, dominoes, and games and some entertainers. A few sessions were taken by a motivation therapist for reminiscence and some arts and craft sessions based around themes such as Halloween and Christmas. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 14 The booklet also detailed who had taken part in events and this was mainly with 8 people, out of 18. (Having between 4 to 9 sessions each). 5 other people only took part in 1 to 2 sessions. This was for a period of just over 3 weeks. The staff have included as social activities sessions when the hairdresser attends and when nail care occurs, instead of considering that this is part of personal care of individuals. There was very limited evidence to suggest that those with special needs such as dementia or those one or two people who like to access events in the community are being encouraged to do so. One person spoken to told us how much they enjoy going out to visit friends and visit the pub, yet there were no details of this in the activities information. People should be continually assessed to ensure their expectations regarding social, religious and cultural needs are being met. A brief tour of the kitchen took place as the home had received a pop in visit by the Environmental Health Officer (EHO) in September. This had been a follow up to a main visit in January 2008. We were informed that the manager had been reminded that to ensure food safety accurate records must be kept, which were not so at that visit and on our inspection visit was also not so. There were still some gaps in the HACCP records, but the broken thermometer had been replaced. We were also informed by the EHO that this level of visits to a care home is “exceptional” as a further visit was planned in the New Year. At the feedback session the management team were again reminded how important it was to keep accurate records to ensure safety standards are maintained in the home. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Standards 16 and 18 were checked. Training has taken place to ensure staff are aware how to make concerns known and how to refer safe guarding issues should the need arise. EVIDENCE: Since the last inspection there were no recorded concerns raised according to the complaints log seen and the management team information given to us during the site visit. The home has completed the training of all staff in safe guarding protocols to ensure people are safe and staff know how to make referrals should the need arise. The home is still currently the subject of a safe guarding adults’ referral, which the local authority is the lead agency and this investigation is still on going. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Standards 19 and 26 were checked. The environment was clean, but there needs to be more attention to detail to ensure that all areas are comfortable, safe and a well maintained place to live. EVIDENCE: During the site visit we were able to tour the home unaccompanied. There was evidence that some individual bedrooms had been redecorated. And we were assured by the manager that more refurbishment work is to continue in the near future. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 17 We looked at all communal areas, toilets, bathrooms, sitting rooms and dining rooms and some individual bedrooms. Some communal areas appeared very cluttered with lots of furniture in place and little thought to detail. For example in the main front lounge an unused television had been placed behind some seats obscuring the view from the window. In a second middle lounge the door was closed through out the visit so people could not see out into the main corridor and no one in that lounge appeared to have access to a call bell. In the sitting room/dining room a number of people were sitting but articles were stored in one corner and the drugs trolley, which is kept in this area had not been fixed to the wall on our arrival. Some toilet and bathroom areas needed to be tidier and there was evidence of communal toiletries being used and in one bathroom a jar of emulsifying cream prescribed for a person living in the home had been left in the sink. In one toilet a hand towel was in general use not paper towels, which was one inspectors used on the day and both had to seek other methods of drying hands. The laundry area pathway was still uneven and the area appeared cold, but we were assured by a staff member that a heater is provided on very cold days. During the site visit the laundry assistant was wearing their coat to iron. We were also notified on the day of an untoward incident, which had occurred before our visit, where an act of vandalism had occurred to a dryer in the laundry. We had not been informed of this incident. A temporary solution had been put in place. The pathway from the back entrance to the garage area is still uneven, which could cause a trip hazard. The service must ensure that all areas are safe and secure to live in and the environment is safe and comfortable. More attention to detail such as valances around the bed bases, curtains hung correctly and toiletries put away will hence the environment for people living in the home. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is poor. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 27,28,29 and 30 were checked. There is no robust system in place to ensure safety checks are completed on staff prior to commencement of employment and that they are then trained to do their jobs. EVIDENCE: 5 staff personal files were tracked during the course of the site visit and some inconstancies seen. For example on one file a person’s full Criminal Records Bureau (CRB) check had not been returned until 9th September 2008 but the person had been working with just one other staff member for 3 shifts prior to this coming in. There was no indication on the “live” working rota that this person had been supervised during that time. On another file there was no evidence that another person had been supervised during the period between the POVA 1st check being received and the full CRB being received. The manager informed us that staff are supervised until the CRB is returned and this was on the duty rota. In these instances this was not the case. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 19 We were informed by the manager at the beginning of the site visit that no new staff had been recruited since the last inspection. During the visit a staff member was spoken to who had commenced duty since the last inspection and on checking the person’s record they had no current CRB or POVA 1st or recent job application or references. It was recommended to the manager that action should be taken to ensure people are safe guarded until the situation could be rectified. Another person’s file showed that references had been obtained after the person had commenced employment and although employed for 2 months had only received 1 supervision. Failures to ensure a robust system of recruitment is in place has been the subject of outstanding requirements for the last 2 inspections and has also been subject to previous Statutory Enforcement Notices in this service. A failure to ensure people are correctly vetted prior to commencement of employment and are then supervised correctly could put people living in the home at risk if they are then unsuitable. There was a lack of evidence to support that induction training is followed through by the management team. One staff member spoken to stated they had been given a Skills for Care Booklet to complete but that no one had asked about it since and they had commenced work in October. Another person stated they had nearly finished their booklet “ don’t know what to do about the booklet, I have nearly finished but no one has looked at it”. The matrix seen showed that some training had taken place but the management team must be aware that this is an on going process and when peoples needs change there may also need to be a time where new skills have to be learnt to prevent people living in the home being put at risk. As well as all statutory training being reviewed. There was a lack of evidence of fire training and the manager was not aware, she stated “ of current practise”. Some staff had not had any fire training and some not for two years. In the event of an emergency this could put peoples lives at risk. The “live” working rota was seen as well as some previous rotas. Staff spoken to stated that more staff are now on duty to enable them to complete their work. One staff member stated this has meant, “the home seems a lot calmer and staffing levels better”. No one living in the home indicated that his or her needs are not being adequately met. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 20 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): 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. Standards 31,32,33,35,35,36 and 38 were checked. More attention to detail in the recording of evidence is required to ensure people are living in a safe environment suited to their needs and expectations. EVIDENCE: There was no evidence to support that the manager has updated herself in current practise and that she is working towards a management qualification. Supporting evidence should be produced to ensure The Commission could test the Registered Manager’s fitness to practise. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 21 Records were seen to show whether the home is a safe place to live and all certificates appeared to be in place. The policy and procedure manual needs to be reviewed to ensure that information is current and valid. Some policies had not been reviewed since April 2007. This will assist staff in ensuring they have the correct tools to make a comfortable and safe place in which people can live and work. Supervision is now being recorded with staff, but in a very brief format. This now needs to be expanded upon to ensure previous action points have been reviewed and future action recorded. This will ensure staff are aware of their failings and people can be safe guarded against poor practises. Some progress has also been made to take into consideration the views of people using the service. One relative told us “I am asked to fill in a questionnaire each year and have been invited to meetings as well”. Another one told us “I’ve been invited to the Christmas party”. A third person stated, “We are always asked if we are happy with everything and we definitely are”. Statements and conversations people have told us they have with staff needs to be recorded and documented to ensure we can see that suffiecnt consultation takes place with all parties for the benefit of people living in the home. Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 17 Requirement Timescale for action 30/01/09 2 OP7 17 3 OP7 15.2.b. The registered person must ensure that accurate records are kept throughout the home and are all open for inspection. This is includes all records of people living there, all staff employed and all records to ensure it is a safe place to live and work. The registered person must 30/01/09 ensure that all accidents are accurately recorded and action taken where required ensuring people are free from harm. (Previous time scale of 11/08/08 and 11/10/08 not met). The registered person must 30/01/09 ensure that any changes to a person’s care is accurately recorded and updated when required. To ensure their current needs are being met. Particular attention must be given to those with challenging behaviour, a history of falls and more complex care needs, as a lack of evidence was in care plans tracked. (Previous timescale of 11/10/08 not met). DS0000002852.V373419.R01.S.doc Version 5.2 Dovecott Care Home Page 24 4 OP7 15.2.b. The registered person must ensure that the home’s own audit tool is used accurately when looking at care plans and any failures recorded so staff understand what they have to do and to prevent people from being harmed from unmet needs. (Previous timescale of 11/10/08 not met). The registered person must ensure that when necessary health care professionals advice is sought to ensure people remain fit and well and this action is accurately recorded. The registered person must ensure that the policy on medication is adhered to by staff administering medication to ensure safe practises are in place. The registered person must ensure that all staff receive training in dignity and respect and respect the privacy and dignity of people at all times. (Previous timescale of 11/08/08 and 11/11/08 not met). All staff must have safety checks prior to commencement of employment and any challenges made to references and/or Criminal Records bureau checks be documented. (Previous timescale of 14/05/08 and 11/11/08 not met). 30/01/09 5 OP8 13.1.b. 30/01/09 6 OP9 13.2. 30/01/09 7 OP10 18.1.c. 30/01/09 8 OP29 19 30/01/09 Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 25 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 OP9 Good Practice Recommendations It is recommended that the Registered Person use a suitable reference tool as guidance for the administration of medicines in the care home. The Registered Person should ensure it follows the guidance set out by the Environmental Health officer to ensure safe practises are adhered to in the kitchen area. The Registered Person should ensure that it follows health and safety guidance to ensure that the home is a safe and clean place to live. The Registered Person should ensure that the home follows its own training matrix to ensure staff keep themselves up to date and be safe practioners. The Registered Person should ensure that the quality auditing checks undertaken in the home include consultation with people using the service, staff and other stakeholders. And that all records are open for inspection. The Registered Person should ensure that the supervision records of all staff are open for inspection and reflect the type of session undertaken whether discussion or observation and any action recorded. The Registered Person should ensure that all documentation relating to the safety of the building and equipment in use is kept up to date and open for inspection and kept on the premises. 2. 3. 4. 5. OP15 OP19 OP30 OP33 6. OP36 7. OP38 Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 26 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 © 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 Dovecott Care Home DS0000002852.V373419.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!