Inspection on 23/06/05 for Dovecott Care Home

This inspection was carried out on 23rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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 02/12/08

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 27/01/05

Dovecott Care Home 28/06/04

Dovecott Care Home 11/02/04

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

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Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dovecott 83 Weelsby Road Grimsby DN32 0PY Lead Inspector Theresa Bryson Unannounced 23 June 2005 9:30 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 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 J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dovecott Address 83 Weelsby Road, Grimsby, DN32 0PY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01482 878133 Mr Stuart Peter Farmery Mrs Rita Ethel Farmery CRH 20 OP 20 Category(ies) of DE(E) 20 registration, with number of places Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Shaft lift must be completed to the first floor extension within two months of the date of this notice. 2. A safe and secure garden area accessible and suitable for the number and category of service users accommodated must be provided within 3 months of registration. 3. 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. Date of last inspection 27/01/05 Brief Description of the Service: Dovecott is currently registered to provide care for up to 14 service users with mental disorder in old age. The proprietors have applied for a major variation to their registration to 20 service users and 3 day care place, this is subject to conditions listed above. The accomodation 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 will also provide 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 court yard for service user use. The home has 3 communal areas including a dining room and service users can smoke in a designated area. there is ample toilet and bathroom facilities. Staff training is undertaken by the owners and other agencies and some staff have worked very hard to obtain their NVQ care awards at different levels. The care staff are supported by domestic and kitchen staff and a handyman. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in June 2005. The inspector asked the local fire brigade officer and environmental health officer to attend the home at the same time. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke to the manager and the staff working in the home at the time of the inspection. The inspector also spoke to 2 people who live in the home and 2 visiting relatives. Paper work kept in the home was also seen to make sure that the checks were made on staff, to make sure they were safe before working in the home. Paper work was looked at to make sure that the home and the things used in it were safe and were checked often. The manager of the home, Mrs.Rita Farmery had been in charge for a number of years and is the co owner of the home with her husband Stuart. What the service does well: People living in the home said how kind and caring the staff were to them at all times. They would do any thing for them and relatives said they were made to feel welcome and always made drinks when visiting their loved ones. The staff were friendly and knew about the care of the people who lived there The people in the home and staff said that meals were good and there was always plenty to eat. They said there was a choice for every one and if they did not like something they would be given something else. The home had enough staff in the home at any one time to make sure everyone could be cared for and people living in the home said that the staff came when they rang their call bell. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The records kept by the staff on people living in the home had not been kept up to date. Not all the details of their needs had been written. This could mean that needs could be missed and current needs of people in the home were not being looked at on a regular basis. The manager did not audit the care plans. All visits by GPs’ and others who attend to the people in the home were asked to be put on the care plans and records to show what happens each day and how people living in the home spend their days. This should be in place to see what each person likes to do each day and how other people, not working in the home are helping with those needs. The home has to make a garden that people who wander and live in the home can use. This is to enable them to have fresh air and enjoy the garden area. On checking the medication in the store trolley some did not match the dates on the paperwork in use. The manager was asked to look at this and make sure all items were in date to prevent mistakes being made. Paperwork to tell new people coming into the home, about the home could not be found and the manager was asked to send a copy to the inspector. If new people do not know what the home does this may prevent new people from coming to the home. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 7 The care plans kept on people who live in the home must show that those people have signed to say they know about the care plan. Recruitment procedures were not robust and the records were not up to date. Not all staff had completed their yearly training or special training in the home, to make them aware of needs of people currently living in the home. The home did not have a plan for the rest of the year. This means that the staff might not be able to do things for people safely. Caring staff have to be supervised at least 6 times each year. There was not enough paperwork for the inspector to see that the manager was checking that they could look after the people in the home and that they had all their needs fulfilled. The manager could not produce enough paper work so the inspector could see that all parts of health and safety guidelines had been followed. The inspector was helped with this by visits of the local fire officer and the environmental health officer. The manager and owner had not completed a number of needs from the last inspection and some new ones were added. The manager must make sure all water outlets have temperatures recorded to prevent too hot or too cold water being used and causing injury to a person. The fire safety was not good in the home and the fire officer and inspector gave the home only a short time to make sure all fire safety requirements were in place. Staff had not had all the training in the last year, which could make it unsafe if they did not know what to do. The home had a new extension and some decoration work was still to be completed for example a new carpet laid in the main dining room/sitting room. This will make the home more relaxing to live in for the people. The manager was told that all outstanding needs for health and safety purposes must be made quickly. This would make sure the home was safe to live in for the people. Some repairs were needed in the kitchen area. This would protect staff from injury. Some records checked were not correct of the people’s personal money and the inspector could see that some columns had not been added up correctly. The manager was asked to look at the way she completes those sheets and the inspector would check again soon. She has to keep accurate records to show what money people have in their accounts. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 8 The manager needed to have some method in place to show that she is checking all of the home for health and safety reasons and the well being of the staff and people living in the home. There was no such system in place, if there had been a track could have been kept of outstanding problems and needs and reduced the number of items needed to be looked at after this inspection. 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. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 9 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 Standards Statutory Requirements Identified During the Inspection Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 10 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 standard(s) 1,2,4 and 6. There was no evidence to support that a preassessment tool is used prior to admission to the home, but each service user now has a written contract of terms and conditions. The service users guide and statement of purpose, which the manager stated had been sent to CSCI, was not on file and could not be thoroughly checked. The home does not provide intermediate care and therefore Standard 6 is not applicable. EVIDENCE: The manager stated that the service user guide and statement of purpose had been sent previously to the CSCI, but this could not be found in the main file of the CSCI and therefore will have to be reviewed on another visit. No written documentation could be produced to support that a full assessment had taken place for each service user, which would not enable the home to prepare for new admissions. There was also limited evidence that staff had undergone training in service specific topics recently, especially around the Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 11 mental health care needs seen within the home, by reading of the care plans and in discussion with staff. Each service user had a written contract of terms and conditions, which followed and included current guidelines. The home does not provide intermediate care and therefore Standard 6 is not applicable. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 12 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 standard(s) 7,8,9,10 and11. Although care plans were in place for all service users these were not adequately evaluated and risk assessments were missing from some files. There was insufficient evidence to support that all health care needs of service users had been identified. Staff were knowledgeable of service users individual needs and carried out tasks in a manner, which respected their dignity and privacy. Service users were unaware that records are kept on them. Medication supplies in use did not correspond with the amounts given on the administration sheets, this could put service users at risk from being given out of date medication. The procedures in place for looking after the dying person in the home were adequate for this home’s category of service user. EVIDENCE: 5 care plans were tracked in depth during the visit and varied in the content enclosed in each document and the standard of assessment. This included examination of care records and discussion with service users and staff. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 13 The care plans were well organised in sections and clearly written by care staff. There were inconsistencies in the basic documentation used and not all care plans showed written evidence that all paperwork was in use. The problems identified on the care plans seen were written very simply and only gave basic instructions to staff. There was written evidence that these are evaluated on a monthly basis. There was evidence that where risks had been identified these had not been developed fully, for example a service user with specific sexual needs explored practical coping mechanisms, but not any physiological needs of that person. Failure to identify risks could leave the service user with unidentified health problems in early stages, which could be supported at an initial assessment. Some of the content read on the daily report sheets was also very basic and after talking to staff, did not show a true reflection of all events, which the service users partake in each day. Recording of visits by other health care professionals was spasmodic and did not reflect actual events, which had occurred. This was supported by the discussion with a visiting health care professional and then checking that service user’s written daily report sheet. 4 immediate requirements notices were issued on the day of inspection for the home to address deficiencies in the care plan documentation. 1 0f those for a named person. 3 of those immediate requirements concerned matters of serious concern, which had not been addressed since the last inspection. There are also 4 other requirements concerning care plans, which need to be identified in the time scales given at the end of the report. The care plan documentation showed some attention had been given to addressing nutritional needs of service users, but only if a risk had been identified. A screening tool was not in use. There was evidence in the daily report sheets that other health care professionals had been called, for example GPs’ and district nurses, but this was spasmodically recorded. There was no written evidence that service users or their families had been consulted over health care needs. Relatives spoken to state they are informed of day-to-day problems, but where not aware they could see care notes if service users gave permission. Staff were aware, but no one had offered these notes at review meetings. There still remains an outstanding requirement to address this issue. The recordings of notifiable incidents to the CSCI has much improved since the last inspection and are now sent as they occur. The inspector was able to read the policy for the death procedure for service users and the guidelines for staff, which showed a good understanding of how to care for the dying person. Staff stated that some had attended courses, in previous years on funeral awareness and some had researched this as part of Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 14 their NVQ training. There is now a telephone in use on all floors for service users, but no one had a personal telephone line. Medication records were checked. The administration sheets were signed in the correct manner and codes used when for example service users refused medication. There was some medication on the trolley which needed to be returned to the local chemist and this practise appears not to have changed from the last inspection. No valid explanation could be given why some medication was still in use from several months previously. The manager was asked to audit the medication against that ordered recently, for which an immediate requirements notice was issued. There still remains an outstanding requirement from the last inspection, which the home has failed to address, concerning stock control of medication. Staff have completed courses on drug administration as recorded in their training files. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 15 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 standard(s) 12,14 and 15. The service users daily routines and social activities were only spasmodically recorded and it was difficult for the inspector to make a judgement on how they are able to exercise choice. Staff were polite and pleasant and made visitors feel welcome. The meals provided in the home were of good quality offering choice and variety. Attention to detail was required regarding maintenance in the kitchen area, of equipment. EVIDENCE: Staff were able to describe a variety of activities on offer to service users, such as games, videos and sing songs, plus outings, depending on the weather. There was very little evidence to support when events take place, but most service users had a completed assessment of social needs in their care plans. During the course of the two-day visit the service users were observed playing board games with staff and watching the television. 3 service users also received visitors, who were made very welcome by the staff. Relatives spoken to stated how kind staff are to their loved ones and very knowledgeable about their condition. Each visitor was always offered drinks on entering the home. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 16 The 2 service users and 2 relatives spoken to during the visit felt that all their needs were being currently addressed by staff. Staff spoken to stated a variety of ways in which they assist service users to make individual choices. This ranged from helping to choice clothes, to times of getting up and going to bed and meals. Policies were read which indicate that staff have been given guidelines on service users rights, choices and independence. The cook showed the inspector around the kitchen area and storerooms. Areas such as broken cupboard handles and poor recording of cleaning schedules were identified to the cook and passed to the manager to address. The standards of hygiene were very basic in the kitchen area and these standards were reflected in the poor way in which cleaning schedules were kept, attention to detail on the cleanliness of the kitchen floor and poor cleaning regime of the deep fat fryer. The menu plan was on display in the office, but there was no indication that this was displayed to service users. Staff were observed offering teatime choices to service users on both days of the inspection. The main lunch meals seen on both days looked adequate proportions and was well presented. There appeared to be very little wastage. The cook had a table plan so she could identify where service users generally liked to sit and so address their individual needs such as a diabetic or soft diet. There were some errors in the recording of fridge and freezers temperatures and the way temperature control was recorded needed improvement, as it was difficult to follow the records to pick up errors in equipment, which was not beneficial to the company. An immediate requirement notice was issued on the day to ensure that cupboard handles are replaced and cleaning schedules were in place and accurate records kept. 1 requirement remains outstanding from the last inspection regarding the provision of fly screens, which are still not in place. The inspector found it necessary to contact the environmental health officer, who arrived to inspect the kitchen area on the second day and his report was to follow to the home. During the feedback session, attended by the inspector the environmental health officer gave the manager a selection of leaflets, which will aid the kitchen in providing a quality service to the service users. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 17 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 standard(s) 16 and 18. The relationships between the manager, staff and service users enabled the service users to feel confident in making a complaint if it was necessary. This was supported by the policy and procedure in place. Notifiable incidents are now sent to enable the CSCI to make a judgement as to their risk for the service users. There was a lack of evidence of up to date staff training in the protection of vulnerable adults, so potentially putting service users at risk. EVIDENCE: The complaints procedure was on display in the home and contained all the relevant information and up to date addresses of all parties, should service users or visitors feel the need to complain. The service users, relatives and staff spoken to all felt confident in the senior management team to address and deal with any concerns raised, should the need arise. The complaints log was seen and there had been no complaints logged since the last inspection. The staff files showed that all criminal investigation bureau checks were up to date for all staff. A variety of policies were read in the policy manual, to show that there was an awareness of protection of vulnerable adults issues by the management team, which would be cascaded to all staff members. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 18 The whistle blowing policy had been revised in March 2005. Aggression towards staff policy revised in May 2005 and Restraint policy revised in April 2005. Staff, when questioned gave very accurate answers to a scenario of a protection issue with service users. The staff training records showed little recent up date training in protection of vulnerable adults for most staff and in some cases no training had occurred. The manager was unaware of the referral flowchart issued by the local authority protection team and parts of the policy for this topic needed to be revised to include latest guidelines. Training is completed in house on this topic by the owner, but there was no evidence of the content of this course. To ensure that all service users are protected and all staff have an up to date knowledge base the manager was issued with an immediate requirements notice. This was to include a training plan, the content of the training and to have commenced training by a certain date. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 19 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 standard(s) 19,20,21,22,24,25 and 26. The home was clean, but extensive refurbishment work has still to be completed making it difficult for domestic staff to keep on top of cleaning schedules. Major work still needs to be completed in the garden area and main dining room. All new areas were clean and bright. There was sufficient circulation space for service users and adequate storage for staff. The laundry area needed some attention to detail with refurbishment and cleaning of the floor area. EVIDENCE: The home has recently completed an extension to the main building giving ensuite bedroom facilities, shower and bathroom areas. This has also included an installation of a lift. The staff stated that the service users had minimal disruption to their daily routines and were pleased with their new environment. The clerk of building works, who has now given completion certificates to the Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 20 home for all new buildling work, made a visit during the course of the inspection. During the tour of the home it was noted that there were still 9 outstanding requirements for the home concerning the environment. These included; -work to be completed in the garden area, replacing lounge/dining carpet and various items under fire safety regulations. The inspector asked the environmental health officer and fire officer to make a visit, which they both completed on the second day of the inspection. The environmental health officer identified issues outstanding from the previous CSCI inspection, such as a repair to a toilet basin and his report was to follow. He gave the manager a number of leaflets at the feedback session, which would enable her to complete accurate records to identify risks in the home and concerning water regulations. The manager produced a document, which stated should be completed monthly, which was a health and safety checklist. There was a lack of continuity in the completed ones seen regarding dates of completion. This paperwork did state that water outlets had been checked, but did not describe how and temperatures were not recorded. Outlet water temperatures were some times recorded when a service user had a bath, as were seen in the care plan notes. The manager was advised that water temperatures were required to be recorded regularly on all outlets affecting service users and a record of adjustments made, where necessary. This has remained outstanding since the last inspection and could pose a risk to service users if temperatures are not checked before use and at random other times. Some work had been completed since the last inspection. Rusty commodes had been replaced. Double sockets were available in individual bedrooms. A bedroom door had been repaired. A blind had been fitted in a bathroom. A radiator guard had been secured to a wall. The manager stated that the lounge/dining room carpet was to be laid at the beginning of July 2005. The garden and car parking area was in the process of being renovated at the time of the inspection. The path to the laundry was still proving hazardous for staff to use. The laundry it self was in need of repair. The floor had still not been attended to and part of the panelling was coming away from the wall, with the danger it may fall on staff and also cause dust on clean items of laundry. 2 immediate requirement notices were issued on the day concerning these outstanding items in the laundry area. The linen cupboards showed adequate stocks of good linen and staff stated they were never short of supplies. Each bedroom area showed good attention to detail by staff in trying to colour co-ordinate linen and towels. The linen Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 21 cupboards still require to be locked as a fire preventive measure. The fire officer stated his requirements under fire prevention legislation and his report was to follow. Most urgent ones have been detailed in the management and administration section of this report. A door was found to be in an unsafe state of repair between the dining room and extension corridor. The manager was issued an immediate requirement notice to correct this within 7 days. An outstanding requirement concerning the locking of the electrical cupboard door had still not been completed and the fire officer made a suggestion as to the type of lock suitable for use. Generally in the home there was adequate circulation space for 20 service users and the rooms were airy and had a homely touch with the type of furniture in use. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 22 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. The staffing levels were appropriate for the current dependency of the service users accommodated. Whilst there was some evidence to indicate a staff training programme the manager was not able to produce evidence of training planned or training in some statutory areas or service specific topics for all staff. The recruitment practises in the home had not been adequately implemented in all cases to ensure sufficient protection for the service users. EVIDENCE: 3 requirements remained outstanding from the last inspection report, which covered areas of concern with staff personal files and training. An immediate requirement notice was issued on the inspection visit to ensure that the manager audits all staff files and all items listed under Schedules 2 and 4 of the Regulations had been included in these files. 4 staff files were tracked in detail and there was a lack of evidence in some to show that these had been audited and all correct checks made on staff members prior to employment. This is in place to protect service users from staff who should not be working with vulnerable people. Staff stated to the inspector that they felt able to fulfil all service users needs with the current staffing levels in the home. The only difficult times were when sickness and holidays occurred, but the manager stated that cover could be found if the need arose. The rota was seen and identified senior staff and other Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 23 grades on the care rota and cooks and other staff on a corresponding rota. Service users and relatives spoke highly of the level of care provided by staff and of their caring and kind manner. Staff interviewed were very experienced carers and able to give a good account of individual service users needs and their own needs regarding training. Several staff files recorded showed they had completed NVQ training at various levels in the Care Awards. Certificates were in place for some staff training and individual sheets kept as records of when staff had completed sessions in any one year. There were gaps in these records for statutory training; service specific training and any special needs of individual staff. The manager had no training programme. Some staff records showed training had taken place in the protection of vulnerable adults, this was not consistent for all staff and there were gaps in the training records. The fire officer reminded the manager that in a care setting fire training should take place twice a year and there was no evidence this had taken place. An immediate requirement notice was issued for the manager to produce a programme of training within 7 days. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 24 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34, 35,36,37 and 38. The manager had not been proactive in keeping health and safety checks in the home and there was a lack of evidence to support that policies are renewed and checks completed on a regular basis. To ensure staff and service users are not put at risk all outstanding requirements need to have been completed, plus the requirements of the environmental health officer and fire officer. Checks on service users records need to be maintained and evidence produced to support this has taken place. All employment records need to be audited and evidence produced to support this has been completed and an adequate training programme put in place. There was no sufficient written evidence to support any of the above items and discussions with staff were inconclusive. EVIDENCE: Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 25 The manager stated that she had not completed her NVQ level 4 in management due to difficulties with her training provider. She did produce written evidence that some up date training had taken place. A questionnaire was given to the inspector that the home intends should go out to all service users. The care plan documentation tracked and in discussion with relatives and some service users confirmed that the manager does not produce any written evidence to support any consultation with service users and their families. Some staff stated that they were aware that this should be documented and others were not aware. There was not sufficient evidence available to support that the home uses a verifiable tool for their quality assurance control or that an annual development plan was in place. The personal allowance money was checked by the inspector and some accounting discrepancies were found. It was necessary to issue an immediate requirements notice on the second day of the inspection. The manager was unsure of why this had occurred and was reminded that accurate accounting records must be kept at all times. Some records were seen in the staff files that appraisals had taken place in the last year. Care staff spoken to were unaware that this should be 6 times a year and the manager was asked to produce evidence that sessions had taken place with staff signatures and mentors signatures. The inspector had felt it necessary during the first day of the visit to ask the local fire officer and environmental officer to inspect the home as it was felt Regulations, which those departments oversee, had been breached. Both visited on the second day of the visit. The CSCI inspector toured the building with the fire officer and listened to the feed back to the manager. The environmental health officer made two visits on the same day – a morning visit for a kitchen inspection and an afternoon visit for a health and safety inspection. The CSCI inspector also sat in on this feedback session and permission to do so on both occasions had been granted by the manager. As both departments decided to issue requirements and recommendation letters to the home, the timescales with breaches of the Care Standards Act 2000, which dovetailed into other legislation were agreed by all inspectors present. It was necessary on the second day of the visit to issue immediate requirements notices for several breaches of the Care Standards Act 2000. These surrounded; - adequate staff supervision being in place, all fire risk assessments being reviewed, accident documentation being audited and reviewed and all records of service users personal allowance money being accurate. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 26 Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 27 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 3 x 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 2 COMPLAINTS AND PROTECTION 1 2 3 2 x 3 2 1 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 2 1 1 2 2 2 1 1 Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 28 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 5.2. Requirement The registered person must develop a service users guide and provide a copy to the CSCI. (Previous time scale of 01/04/05 not met). The registered person must further develop the statement of purpose to include all information in Schudule 1 of the Care Standards Regulations 2001. (Previous time scale of 01/04/05 not met). The registered person must develop risk assessments with particular attention to challenging behaviour. (Previous time scale of 01/04/05 not met). The registered person must ensure that care plans are kept up to date. (Previous time scale of immediate effect not met). The registered person must ensure that service users or their representatives are involved in the planning of their care plans. (Previous time scale of immedaite effect not met). The registered person must Timescale for action 30/09/05 2. 1 5.1a. 30/09/05 3. 7 15.2c. 22/07/05 4. 7 15.2b. 22/07/05 5. 7 15.2c. 22/07/05 6. Dovecott 8 15.1. 22/07/05 Page 29 J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 7. 8 15.1. 8. 8 13.4c. 9. 8 16.2i. 10. 9 13.2. 11. 9 13.2. 12. 12 16.2.m. further develop the assessment to include all areas as listed in standard 3 and include assessment of mental state and cognition and associasted risks. (Previous time scale of 01/04/05 not met). The registered person must ensure that the care plan of a named individual has been fully assessed and all parties, including external agencies are aware of the outcome of the care plan. The registered person must develop risk assessments to identify those at risk of developing pressure sores. (Previous time scale of 01/04/05 not met). The registered person must ensure that nutritional screening is completed on admission and then regularly reviwed to ensure problems were identified. (Previous time scale of 01/04/05 not met). The registered person must ensure that medication no longer prescribed or left from previous months monitored dosage system are returned to the pharmacist. (Previous time scale of immediate effect not met). The registered person must ensure that an audit is completed of medication recieved against all medication in stock. The registered person must consult service users about their social interests and programme of activities in the home, and make arrangements to enable servicie users to engage in local social and community activities. Provide assessments of need, 08/07/05 30/08/05 30/08/05 01/07/05 01/07/05 30/08/05 Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 30 13. 15 23.2b. 14. 15 23.2d. 15. 15 23.2d. 16. 17. 15 18 23.2b. 13.6. 18. 19 23.4a. 19. 19 23.2o. 20. 19 23.2b. care plans and activity plans. (Previous time scale of 01/04/05 not met). The registered person must ensure that the fly screen is correctly and securely fitted. (Previous time scale of 01/04/05 not met). The registered person must ensure that the standards of cleanliness and hygiene in the kitchen are improved and adequate and appropriate food storage is provided. (Previous time scale of immediate effect not met). The registered person must ensure the kitchen cleaning schedule records are maintained. (Previous time scale of immediate effect not met). The registered person must ensure that all door handles in the kitchen have been repaired. The registered person must ensure that;- 1. a plan of training is in place for all staff on the protection of vulnerable adults, 2. that the in house training prograame content has been submitted to the CSCI and 3. that training has commenced. The registered person must ensure that the fire door from the dining room to the ground floor extension closes fully. (Previous time scale of immediate effect not met). The registered person must provide a secure garden area to meet the needs of the service users who have a tendency to wander. (Previous time scale of 01/5/05 not met). The registered person must ensure that the path to the laundry is repaired and made 22/07/05 22/07/05 01/07/05 01/07/05 1. 01/07/05 and 2. 08/07/05 and 3.22/07/05 01/07/05 30/09/05 30/09/05 Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 31 21. 20 23.2d. 22. 21 23.2b. 23. 21 23.2b. 24. 25 13.4. 25. 26 23.4a. 26. 26 23.2b. 27. 29 19.1a,b,c. 28. 30 18.1c,i. safe. (Previous time scale of 01/04/05 not met). The registered person must ensure that the lounge carpet is replaced. (Previous time scale if 01/04/05 not met). The registered person must ensure that the ground floor toilet is renovated.. (Previous time scale of 01/07/05 outstanding). The registered person must ensure that the cupboard containing electrical systems is kept locked. (Previous time scale of immedaite effect not met). The registered person must ensure that hot water accessible to service users are maintained close to and not exceeding 43 degs C. (Previous time scale of immediate effect not met). The registered person must ensure that linen cupboards are kept locked. (Previous time scale of immediate effect not met). The registered person must provide laundry facilities with impermeable floors. (Previous time scale of 01/04/05 not met). The registered person must ensure that staff files are maintained to meet Schedules 2 and 4 of the Care Standards Act 2001. (Previous time scale of immediate effect not met). The registered person must provide a staff training and development programme which meets National Training Organisation workforce targets 30/09/05 22/07/05 30/08/05 30/08/05 22/07/05 08/07/05 22/07/05 01/07/05 Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 32 29. 30 18.1c,i. 30. 31 10.3. 31. 32 21.1. 32. 33 24.1a, b. 33. 34 25.1. 34. 35 16.2l. which includes induction and foundation training as set out in this standard. (Previous time scale of 01/05/05 not met). The registered person must provide a training plan that sets out how training is to be kept up to date and specific training such as dementia is to be provided. Training must also set out NVQ targets. (Previous time scale of 01/04/05 not met). The registered person must ensure that the manager has commenced training to achieve NVQ level 4 in management and care in 2005. (Previous time scale of 01/04/05 not met). The registered person must provide evidence of the consultations with the service users and staff on the development of the home and the services provided. (Previous time scale of 01/05/05 not met). The registered person must develop a system to monitor the quality of care provided and provide a report to service users and the CSCI. (Previous time scale of 01/05/07 not met). The registered person must maintain financial accounts in respect of the care home that are open and avaliable for inspection and provide to the CSCI a completed business and financial plan for the home. (Previous time scale of 01/05/05 not met). The registered person must ensure that accurate records are kept of all service users personal 22/07/05 30/09/05 30/09/05 30/12/05 30/09/05 01/07/05 Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 33 finances. 35. 36 18.2. The registered person must ensure that care staff have at least 6 formal supervision sessions per year and that there is evidence to show that all aspects of practise, philosophy of the care home and career development have been covered. (Previous time scale of immediate effect not met). The registered person must maintain all records as stated in the Care Standards Act 2001. (Previous time scale of immediate effect not met). The registered person must develop and review all policies and procedures relating to safe working practises in line with relevant legislation particularly food hygiene. (Previous time scale of 01/04/05 not met). The registered person must ensure that all staff have been provided with fire training at least twice in a 12 month period. (Previous time scale of immediate effect not met). The registered person must ensure that the fire risk assessment identifies all risks and an action plan to minimize the risks is completed, including smoking in the home. (Previous time scale of immediate effect not met). The registered person must ensure that all accidents in the home are fully recorded. (Previous time scale of immediate effect not met). 01/07/05 36. 37 171a,b and 2 and 3 and 4. 121a,b. 30/12/05 37. 38 30/12/05 38. 38 23.4d. 22/09/05 39. 38 23.4a. 22/07/05 40. 38 17.1a. 08/07/05 Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 34 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 22 Good Practice Recommendations The registered person should ensure that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. Dovecott J54 2852 Dovecott V234627 23 June 05 Stage 4.doc Version 1.30 Page 35 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 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. 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