Inspection on 28/05/09 for Dovecott Care Home

This inspection was carried out on 28th May 2009.

CQC found this care home to be providing an Adequate 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 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 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 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Dovecott Care Home 83 Weelsby Road Grimsby North East Lincs DN32 0PY Lead Inspector Theresa Bryson Key Unannounced Inspection 28th May 2009 09:30 DS0000002852.V375939.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Dovecott Care Home DS0000002852.V375939.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.V375939.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. 2nd December 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 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. Extras to fees 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.V375939.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 1 star. This means that the people who use this service experience adequate quality outcomes. This site visit took place over one day in May 2009. Prior to the visit we sent out surveys to people who live in the home and staff. Six were returned by people who live there and four by staff. We also looked at information the home had sent us since the last inspection and talked to people who have visited the home. The home sent us their Annual Quality Assurance Assessment which gave us information about what the home has put in place and is planning to do. It also gave us a lot of statistical information. We looked at a number of records and documents during the site visit and spoke to some people living there and staff. The link inspector for this home was accompanied on this occasion by a member of CQC enforcement team. The registered manager was present throughout the site visit and the second owner was there for the feedback session. What the service does well: Staff are always pleasant and friendly and give every cooperation to the inspector during any visit. People living in the home spoke highly of the “caring staff” and how they were “always there for them”. Meals are provided in a clean and safe environment and there are choices to suit people’s needs and tastes. Staff assist those who have difficulty maintaining a good diet with encouragement and patience. Some people are more closely monitored to ensure they have a sufficient diet to maintain their health and well being. People living in the home can personalise their own bedroom areas to suit their tastes and needs. They are able to bring in with them furniture, ornaments and pictures, which they said had helped them settle in. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 6 There are adequate numbers of staff on duty to meet people’s needs at all times and the dependency levels of each person are maintained in case the staffing numbers need adjusting. Certificates are in place to ensure the building is a safe place in which to live and work. What has improved since the last inspection? What they could do better: The responsible individual for the home must ensure that every one living there falls with in their category of registration. This will ensure all people living there are safe and staff have been trained to look after them and can adequately meet their needs. Staff working at the home must be trained to do their jobs. This must include manual handling training to ensure people are not being harmed when moving about the home. There must be at least one person who has an updated certificate in first aid on duty at all times to be able to respond quickly and effectively in the event of an emergency. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 7 To be able to monitor whether the home is being run for the benefit of people living there and to help plan for the future the responsible individual must put an annual development plan in place. This will ensure that they know whether it is a safe place to live and meets people’s expectations and needs. Closer monitoring must take place to ensure the personal allowance money of people in the home is more controlled. At all times there should be sufficient funds in place to enable people to have what they need to maintain a good quality of life, such as regular hairdressing visits and to be able to buy newspapers or treats. These records must show accurate recording and money balances must be correct. This will ensure that any fraudulent use of funds can be picked up as soon as possible and referrals made to the correct statutory body. A number of recommendations have also been made at this key inspection concerning record keeping, staff training, more creative activities, better use of the premises, monitoring of use of equipment and policy changes. This will ensure that the home is being monitored to ensure peoples needs and expectations are being met at all times. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Dovecott Care Home DS0000002852.V375939.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.V375939.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 1,3 and 6 were checked. Information is available to ensure people can make informed choices about using the home to meet their needs. EVIDENCE: Since the last key inspection and random inspection there have been no new admissions to the home due to the Local Authority stopping admissions. The owners had decided not to market the home in other areas or to privately funded people during this time. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and Service users Guide remains the same and will be offered to any one new approaching the home to enquiry whether it can meet their needs. During the course of the care plan tracking of people living in the home there appeared to be two people whose needs did not currently totally meet the categories of registration of this home. The care of these two people, according to staff, “was difficult at times” and not all staff appeared confident in how to manage these indivudals. The people themselves were interviewed and only one expressed any wish to remain in the home. The documentation for these people was poor at times and in one case the follow through when accidents occurred did not follow the procedures the owners had set down for accurate recording. This could cause this person to be at risk if details were not correct for staff to follow to enable them to prevent this person from being harmed. The names of these individuals were later that day passed by us to the local care management team for further assessment of their current needs to ensure the owners of this home were not breaching their registration categories. The home does not provide intermediate care and therefore Standard 6 is not applicable. Dovecott Care Home DS0000002852.V375939.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 7, 8, 9 and 10 were checked. Care plan documentation is in place and efforts made to ensure they are kept up to date and people are involved in the planning of their current needs. EVIDENCE: Prior to the site visit surveys were sent by us to people living in the home and staff, four staff were also spoken to on the day and four people who live in the home. Six surveys were returned by people living there and four by staff. Staff comments included that they felt there could be better communication amongst themselves and the management team to ensure the needs of people are always met and current needs identified. This was also reiterated by care management staff who were spoken to, who stated that messages “did not Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 12 always get passed on and we don’t always get feedback when we have asked for a task to be completed”. This could result in peoples current needs not being met and there being a disjointed approach to their needs and expectations. When checking the admissions and discharges register, three people had passed away since the last site visit. The responsible individual should send us this information in the form of a Regulation 37 notice. None had been received by us, until the time of this visit and the home is to send us copies and proof of posting, so we had no way to ascertain whether these notifications had been sent and been lost. This was a requirement from a previous inspection and will remain on this report. A more robust system must be in place to ensure we receive this information and can make a valued judgment as to whether the home has taken appropriate action. The management team had sent us a notification about a serious incident and there was enough detail to ensure we could make a judgement as to whether all action had been taken to prevent the two individuals from being harmed. We also case tracked four peoples care plans in depth. These are now audited on a more regular basis by two senior members of staff and there was written evidence to support when this takes place and any action which may be necessary for the key workers to undertake. This will ensure that people’s expectations and current needs are passed on for all staff to see. The manager has also put in place a new observations folder which included monitoring sheets such as what is eaten at meal times (for those whose weight needs monitoring) and observations charts for behaviour (to ensure other people living there are not put at risk). A new manual handling risk assessment had also been put in place to ensure staff are aware of peoples current mobility needs and not put them at risk from incorrect lifting methods. The care plans had much improved and when discussed with staff they appeared to better understand the reasons for accurate care plan recording and described them as “so much easier to work with”. The recordings were legible, with only a couple of pieces of information not following the Company policy. For example on one day one person had four falls recorded in the accident records, but not recorded on the daily reporting sheet, which we were informed was the first place staff would look for an update on a person’s recent activity. This could have meant that if this person had suffered after effects from the falls staff could not respond appropriately or be looking for any problems. In another care plan someone with weight loss had a meal monitoring chart in place, yet another person did not, who had also experienced weight loss. We were also informed that the scales in use were not calibrated regularly and staff did not appear to be using any other type of weight monitoring device Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 13 such as a height and length chart to ascertain a person’s base line weight. This measures the height of a person and is calcuted agsisnt the length of this person to give an approximate weight. This could put them at risk if the correct information is not available to enable staff to help those individuals to maintain their health and well being. The drug administration records were checked and also the storage facilities for all medication. The recording had much improved but there were a few gaps in the signature boxes for a couple of people. So we were only able to ascertain by speaking to staff as to whether these people had correctly received their prescribed medication. Medication is stored in a couple of places in the home – a trolley, a cupboard and a drug’s fridge. Temperatures were not being taken in these areas and it is recommended that some records be kept to make sure all medication is stored safely and follows Royal Pharmaceutical Guidance for storage of medication to ensure it is safe to use. People living in the home made positive comments about the way staff look after them. Saying such as “I do somethings for my self but know the staff are there for me” and “staff are pretty good to me”. Dovecott Care Home DS0000002852.V375939.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 12, 13, 14 and 15 were checked. A programme of activities is on offer to enable people’s social, cultural and religious expectations can be met. EVIDENCE: The activities records of people living in the home showed that attempts are made to involve indivudals in the events which take place. This involves one to one events such as chats and card games. Sometimes people are taken out in wheelchairs (but this was described by people using the home as “rare”). A specialist company dealing with reminiscence therapy attends the home once a week for those with memory loss. We were also informed by the management team that attempts had been made with other agencies to access specialist help for those with symptoms of dementia. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 15 People described to us that they like to read, watch the television or knit, which staff sometimes were able to join them with. Which was described “like having my family around me”. The choices for activities were very limited and staff need to be more creative in what is on offer to ensure people have the opportunity to lead as full a life as they are able, both inside and outside the home. The list of entertainers visiting the home was varied and included groups of singers and individual acts, which people described as “fun to watch”. Another person said they had the “choice to watch, which I do sometimes, but I like my TV”. Others stated that they would like different choices of activities, but were unsure what these might consist of. When touring the home there was ample evidence that people had been allowed to personalise their own living space with ornaments, pictures and furniture. The garden area is still in the process of being developed and needs further work to ensure it is a safe and welcoming area in which people can relax. Some parts had been poorly attended to and looked unkempt and untidy, especially the front entrance garden. As the environmental health department had recently visited the home only a brief inspection of the kitchen area took place. Food appeared to be prepared in a clean environment and choices were available to ensure people maintained a healthy diet. People living there described the meals as “adequate” and “felt there was enough to eat and only had to ask for more”. Staff were observed over a lunch time period assisting people with their meals, which they did in a dignified and calm manner. Dovecott Care Home DS0000002852.V375939.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 16 and 18 were checked. A system is in place to ensure people know how to make concerns known to the staff but some staff still require updated training in how to recognise abuse and refer concerns to the appropriate statutory body. EVIDENCE: Since the last random inspection a safe guarding adults referral was made, which has now been concluded by the local team. Strategies have been put in place to ensure the home is aware of how to meet the needs of this person at all times and protect others. We looked at the complaints book and niggles book which had nothing recorded. People spoken to appear to understand who to go to if they had any concerns whilst being resident. Staff spoken to were clear about reporting any abusive situations and could describe what constitutes abuse. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 17 The adult protection policy was unclear and did not give clear direction about who to report incidents to. The Annual Quality Assurance Assessment (AQAA) completed by the home prior to this site visit stated that polices had been reviewed in April 2009. This particular one should be reviewed again to ensure it gives accurate instructions from guidance which is available about reporting situations to protect people from abuse. Not all staff have completed up date training in adult protection, but written evidence was seen that some staff had been booked on a course locally. If all staff are to respond appropriately to incidents which may occur they need to have attended a course to enable them to have the knowledge base to prevent people from being harmed. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 19 and 26 were checked. People were living in a clean and tidy environment. EVIDENCE: We were able to tour the whole building and outside areas during the site visit. All areas were clean and tidy and there was evidence that people could personalise their rooms with furniture, ornaments and pictures from their own personal homes. There was no supporting written evidence of how these choices had been made and whether people could choice colours and bed linen Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 19 and towels for themselves. This could take away peoples independence and choices if they could normally make these types of decisions. During the feed back session to the management team certain areas of the home were highlighted to them which could cause a hazard to those living there. For example there were loose wires coming out of the walls in two areas of the home, both with bare cooper wire being exposed which if live could cause serious harm to any one who touched them. On the first floor a fire escape door had been wedged open which could cause serious injury to people in that part of the building if a fire was to spread. Also near the main entrance to the home the carpet was uneven and could cause a trip hazard. Staff need to ensure they give attention to detail in the home as some bedroom and bathroom areas had equipment in, which we were informed was not in use. For example a set of bed rails were underneath a bed resting on the carpet and dusty and could not be placed on anyone’s bed as they would be a health hazard. In one bath room there was soap and shampoo still resting in a bath which staff had failed to ensure was taken back to the person’s room that had last used this room. This could have been used by someone else. The garden areas were accessible to wheelchair users and we were informed this was an on going project and would receive more attention in the summer months. It looked unkempt and not a relaxing place to sit and enjoy the weather. The front garden leading to the main front door was particularly untidy. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards27, 28, 29 and 30 were checked. A more robust system is in place to ensure staff are safe to work with people prior to their commencement of employment. More attention should be given regarding renewal of staff training to ensure they have the skills to do their jobs. EVIDENCE: Four staff returned surveys sent to them by us and four staff were interviewed during the site visit. Staff were requesting more manual handling training and some more specific training to enable them to look after those with special needs such as dementia and substance abuse. There was no written evidence to support that staff’s training in manual handling had been updated recently. This could put people at risk if staff are unaware of how to move people safely. Part of the training policy seen in the home also states that staff should receive health and safety training but there was no evidence to support when this had last occurred. The Responsible Individual has told us that four staff, including Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 21 the manager had completed a train the trainer course, but there was no written evidence to support this at the time of the site visit. The home was also awaiting certificates from the Care Trust Plus who had provided training in cross infection. The Responsible Individual was also going to send to CQC a copy of the manual handling training course they had completed. We were very concerned that the first aid training of staff had been allowed to have elapsed. Those with certificates had all elapsed in February 2009. The homes’ policy states “the home will ensure that adequate provision is made for first aid provision”. We recommended to the management team that until such time as staff could receive training that other measures be put in place to ensure people were safe in the event of a first aid emergency occurring. There must be at least one person trained in first aid on each shift to ensure when an emergency arises that action can be taken quickly to prevent people being harmed. The training of staff was from a variety of sources. Certificates seen showed this was from outside agencies, some from the free local authority training and some in house. We were informed that those giving in house training had completed a train the trainer’s course but no written evidence could be produced on the day. All training must be from sources which can give clear guidance to staff from reliable sources. Three staff personal files were tracked in depth and there was sufficient evidence to show that adequate checks had been made prior to their commencement of employment. We were informed by staff and the management team that induction took place in the first few weeks and was a “hands on experience”. There should be some written evidence to support what has been covered to ensure staff are safe to work in the home. More care is now being taken to ensure the dependency levels of people living in the home are checked regularly and where necessary the staffing levels are adjusted to ensure everyone’s needs can be met. There is now an on call rota of senior management staff over 24hours seven day a week period. This ensures that staff have someone to relate to should they need advice. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 31,33,35,36 and 38 were checked. The management team are aware of the areas in which they need to improve and are putting strategies in place to ensure any necessary action is monitored regularly to ensure people in the home are free from risk and harm. EVIDENCE: After checking the supervision records of staff there appeared to be some confusion by the management team of what supervision should comprise of Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 23 and they were referred back to the National Minimum Standards for Older People for written confirmation of what should be covered and open for inspection. Supervision sessions had been spasmodically completed and were a combination of discussion and observation in the work place. Staff could tell us when they had received supervision but were unaware of how frequent these sessions should be. There should be a policy change to ensure staff are aware of what needs to be covered and how often, according to their roles with in the home. They may then feel more empowered to contribute positively to the process. The management team have commenced a quality assurance auditing process which is still in early stages of development. We were informed that when their questionnaires come back from people using the home, visitors and other stakeholders there is no collating of evidence gathered and this is not feedback to people living there. The management team are aware of person centred planning and thinking but find it difficult to translate this theory into practise to make a difference to the staff team and outcomes for people using the service. The AQAA gave us some limited information of where the home feels it needs to improve. The team do not produce an annual development plan or business plan which may help them set goals for the establishment and be able to be fed back to people using the service and other stakeholders. When checking the personal finance files and money of several people living in the home some discrepancies were found. Two out of three checked had insufficient funds to support entries on the logs seen. Eight other files had credit balances and there was no specific structure in place to ensure how this could be paid back to the home and by whom. It was unclear as to who was supplying the money to support these people with every day purchases such as toiletries and hairdressing. In the event of this money source drying up there was no plan in place to ensure people’s financial safety is protected. All safety certificates were checked and found to be valid. This ensures the building is a safe place in which to live and work. The registered person and registered manager are aware of the need to plan the business activity of the home but have difficulty transferring this into practical application for monitoring the running of the home. And ensuring that written evidence can be produced to support actions that are taken to safe guard people living there. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 24 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 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 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 3 Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation 14.1. Requirement Timescale for action 01/07/09 2 OP7 37 The responsible individual must ensure that each person resident in the home has been correctly assessed to ensure they fall with in the home’s category of registration. This will ensure they can be looked after correctly in an environment suited to their needs. 01/07/09 The registered person must ensure that any untoward incident, accident or death which occurs in the home is reported to CQC so we can determine whether the correct action has been taken to protect people from harm. (Previous timescale of 20/05/09 not met). The responsible individual should 01/07/09 ensure that all areas of the home are safe to live in and that there are no bare electric cables which could harm someone if they were touched. The responsible individual must 30/08/09 ensure that staff have received DS0000002852.V375939.R01.S.doc Version 5.2 3 OP19 23 4 OP30 18.1. C.i and ii. Dovecott Care Home Page 26 5 OP33 24 6 OP35 25 adequate training to look after people who are living in the home to prevent them from being harmed. This must include manual handling training and first aid. The responsible individual must ensure that an annual development plan is produced to ensure that the quality of care provided in the home is being monitored. This will ensure people are living in a suitable environment suited to their needs and their views are taken into consideration. The responsible individual must ensure all financial transactions made with peoples personal allowance money is accurate and systems are put into place to ensure adequate financial control and monitoring takes place. And there is no risk of fraudulent use of funds. 30/08/09 30/08/09 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 2 3 4 Refer to Standard OP1 OP7 OP9 OP12 Good Practice Recommendations Accurate records should be kept at all times to ensure peoples current needs are being met and records can be kept about events in the home. There should be accurate recording of accidents to ensure people are not put at risk at any time. Temperatures should be kept in the medication storage areas of the home to ensure drugs are kept at the correct recommended temperatures and are safe to give. There should be more variety of activities in place to ensure everyone’s social, religious and cultural expectations are being met. DS0000002852.V375939.R01.S.doc Version 5.2 Page 27 Dovecott Care Home 5 6 OP13 OP18 There should be better use made of the garden area and it must be hazard free at all times for people to use. All staff should have received up dated training in safe guarding adults so they can recognise abusive situations and respond quickly when necessary. The policy for safe guarding people in the home should be reviewed to ensure staff have clear directions’ on how to respond to any given situations to prevent people from being harmed. All equipment in use at the home should be correctly calibrated to ensure it is fit for use. This should include the weighing scales. People living in the home should be allowed to contribute to the redecoration programme and evidence written of how this has been achieved. 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. There should be evidence available to show how staff have received induction in the home and when they have been considered suitable to work on their own, once all the safety checks have been completed. Staff should receive training in specific topics to ensure they can meet the needs of people in the home. A system should be put in place to ensure staff can respond to a first aid emergency until such time as staff have received training in this topic. 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 individual should ensure that when information is collated about the running of the home that this is fed back to all parties concerned. The policy for supervision should be reviewed to ensure all staff members and the management team fully understand the reasoning behind why sessions need to take place. 7 OP18 8 9 10 OP19 OP19 OP30 11 OP30 12 13 14 OP30 OP30 OP33 15 16 OP33 OP36 Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 28 Care Quality Commission North Eastern Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Dovecott Care Home DS0000002852.V375939.R01.S.doc Version 5.2 Page 29 - 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!