Inspection on 29/01/07 for Dovecott Care Home

This inspection was carried out on 29th January 2007.

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 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

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Hawkhills

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

CARE HOMES FOR OLDER PEOPLE Dovecott Care Home 83 Weelsby Road Grimsby North East Lincs DN32 0PY Lead Inspector Theresa Bryson Unannounced Inspection 29th January 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dovecott Care Home DS0000002852.V329415.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 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.V329415.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. 11th May 2006 Date of last inspection Brief Description of the Service: Dovecott provides care for 20 people in the category of old age and dementia. The accommodation is set over two floors. The home has completed a first floor extension providing a further 7 single ensuite rooms and reconfiguration of an existing double bedroom into a single ensuite bedroom. The extension l also provides an assisted shower and a separate Jacuzzi bath. The home is set close to the centre of Grimsby and local parks and other amenities. There is parking to the rear of the building and in side streets next to the home. The owners are developing the garden area and courtyard for service user use. The home has 3 communal areas including a dining room and service users can smoke in a designated area. There are ample toilet and bathroom facilities. Domestic and kitchen staff and a handyman support the care staff. The weekly fees range from £329 to £367, extras include hairdressing, chiropody and toiletries charges, which are based per item. The home will accept local authority funded persons and privately paying individuals. 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.V329415.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in January 2007. Prior to the site visit the inspector interviewed 8 district nurses,1 team leader from the local social services department (who had surveyed her team), 1 local fire officer, 1 environmental health officer and 1 community mental health nurse. On the day of the visit 4 relatives who were visiting the home were spoken to and 6 staff members as well as the manager and second owner. The event history of the home was also checked. This showed that there had been no regulatory activity prior to this visit and the Statutory Enforcement notices had been served and checked on a random inspection visit in September 2006. During the site visit there were no people resident in the home who could make informed decision and answer questions. What the service does well: What has improved since the last inspection? The recording of care by staff has greatly improved since the last inspection. The inspector was able to track events which had taken place and staff appeared more competent in writing the needs of each individual and planning the care to be delivered. This runs from the time of assessment through to a person’s final days in the home. The drug administration records were more clearly written and along with the care plans are being audited on a regular basis by the manager to ensure staff are aware of current needs and problems of individual residents in the home. Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 6 This ensures that the staff keep up to date with everyone’s needs and people living in the home are having their needs met at all times. More effort had been made in providing different types of activities to ensure peoples social and cultural needs and expectations are being met and events have been better recorded. Visitors to the home had commented to the inspector on the improved attitude to health professionals, using them more as a resource and helpers in the care of each individual. This was supported by the comments also received by relatives who stated such as “staff always contact me if mother is unwell” and “I’ve never met a friendlier bunch of people, always smiling and concerned about my home life too”. The management team at the home had worked hard since the September visit and corrected all areas that needed some work around the home. Such as special signs on the bathroom and toilet doors. These are in the form of words and pictures for those whose memory is not as it should be and they can then identify those rooms with ease. Other parts of the home such as bedrooms needing new carpets, buying of new bed linen and towels, making flooring safe and planning further work both inside and outside the home. This is making for a warm and comfortable environment for people to live. Staff training has improved ensuring that they are kept up to date on all aspects of caring for the people living in the home. Staff themselves commented on how they felt this had helped them understand more the needs of the people they are looking after. The manager’s supervision sessions with the staff have also ensured that every one is keeping themselves up dated, that care is being monitored and any issues with staff addressed immediately so they are safe to work with the people living in the home. What they could do better: Some areas still need to be improved upon at the home including the following aspects of care for individuals. The meals provided appeared nutritious and portion sizes were adequate. Some aspects of the cleanliness in the kitchen needed to be improved to ensure that meals are prepared in a clean environment. To ensure that the home is a safe place to live in the manager has been asked to send copies of the boiler maintenance contract. Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 7 The home also has to produce evidence that it has consulted with people living in the home and other visitors. This will help the people living there to feel part of the home and that they are contributing to their care. The management team at the home is also not using a tool to monitor all quality aspects in the home. With out this it is difficult for the team to ensure that the staff are doing their job, the care is being delivered and the home is safe to live in. Part of last year’s statutory enforcement action was to check the recruitment of new staff. This still has not been tested as no new staff have been recruited. The outstanding requirements are to remain on the report until such time as new staff are recruited. This will then be tested to ensure that staff are safe to work with people living there. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dovecott Care Home DS0000002852.V329415.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.V329415.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that they gather comprehensive information on each prospective service user prior to admission to prepare staff and make the person feel welcome. EVIDENCE: During the course of this inspection Standards 3 and 6 were checked. The manager is now using new documentation to assess prospective service users prior to admission. This is a comprehensive document and looks at each person’s needs in an holistic way. The document is in 9 sections and also includes the person’s name, date of birth and signature of the assessor, who is usually the manager. The assessor Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 10 also uses a waterlow risk assessment tool to assess pressure sore risk at the same time. Documentation was seen on the day of the last admission to the home and also a file on a prospective new admission planned for the following day, which all had the new documentation duly completed. This enables staff to prepare for that admission and make the service user feel welcome to the home. The home does not admit service users with intermediate needs and therefore Standard 6 is not applicable. Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Documentation is used in the home to ensure that service users needs are monitored on a regular basis and accurate recording of events ensures the delivery of care can be tracked. EVIDENCE: During the course of this inspection Standards 7,8,9 and 10 were checked. Prior to the inspection 4 different sets of district nursing services staff were interviewed, (involving in total 8 individual district nurses); a community mental health nurse; a Team leader from the local Social Services department, (who had surveyed her team of assessment officers); a local fire officer and local environmental health officer. Any issues raised were checked during the course of the visit and comments asked for from the manager. These issues had been resolved, which had concerned heating in the home and menus, prior to the visit. Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 12 There were no service users resident in the home who could make informed decision, but 4 sets of relatives were spoken to who were visiting on the inspection day and all gave very positive comments about the care delivered to their loved ones and the attitude and friendliness of the staff. 4 care plans were tracked in depth, including that of a new person to the home and documentation also on a positive admission for the following day. All sections had been completed. The care plans showed a marked improvement from the last inspection and most staff spoken to state they had a better understanding of the need to keep up dated records on each service user. The content of the problems identifies recorded actual needs, what the aims for that person would be and how they staff were to meet those needs. The care plan audit by the manager and/or the second owner were also better. There was also more follow through documented on the visits by other health care professionals and visits to such events as out patient hospital appointments and accidents. The manager needs to ensure that all staff are aware of the importance of maintaining accurate records to ensure that service users needs are being met. The systems in place have only just begun and the CSCI would like to see the systems in place being maintained over a longer period to ensure that the management team and staff have grasped the concept of recording delivery of care. Some concerns had been raised by some people interviewed about the knowledge base of staff over certain conditions service users were presenting with in the home and whether staff fully understand actions which need to be taken regarding emergency situations. The supervision records of staff have only just begun to be recorded in depth and therefore could not be fully tested by the inspector. Staff spoken to on the day appeared to have a basic working knowledge of service users conditions, but may need to expand their knowledge base and this to be tested during supervision and follow up training. (This will be addressed under Standards 30 and 36). All medication records were checked and 4 tracked in depth. The senior carer going over the drugs with the inspector appeared to have a good understanding of why certain drugs were being given and any failures on behalf of the supplying chemist. No lancets for testing blood sugar levels of service users were in use by the home, the visiting district nurses are testing the one person this affects. Insulin is kept in a food fridge, but in a plastic container, named for that person. The staff and visiting district nurses must ensure this is replaced in the correct place after each use to ensure items are not soiled or lost. Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 13 During the course of the day the inspector observed staff assisting service users in a variety of tasks. This included toileting needs, meal times and activities during the afternoon time. Their approach was very calm and relaxed and they tried to encourage each person with each activity. There were many positive comments received from service users relatives on the day about how caring and friendly staff were to them. Each person knew their key worker for their loved one and said how helpful each person was in passing on information about their relative. Other professionals interviewed also said there had been a marked improvement to the attitude of the care staff to them and staff were using them more as a resource. Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some varied activities are offered in the home so that service users social need and expectations can be met, but better contact needs to be made with the local community. The varied diet planned needs to be adhered to to ensure service users receive a nutritional diet. EVIDENCE: During the course of the inspection Standards 12,13,14 and 15 were checked. Prior to the inspection the local environmental health offer was contacted and confirmed that the last major visit had been in September 2006 and all action had been taken by the home. He also completed a spot check two days prior to the site visit and no action was needed by the home regarding working practises taking place in the kitchen area. Comments had been received that at times the menu on offer did not reflect the meals offered. The menu submitted prior to the inspection appeared to be Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 15 balanced and the change of menu on the day was reflected in the diary for the kitchen. The inspector observed snacks and the main lunch menu being served to service users and there appeared to be adequate portion sizes and ample food being offered. The staff assisted service users with special needs in a relaxed and calm manner, encouraging them to finish their meals. Relatives spoken to stated they did not feel their loved ones had lost any weight and one person said how their loved one, in some lucid moments states how “tasty” the meals are to eat. Other professionals stated they are offered beverages when in the home. The kitchen was of an acceptable standard of cleanliness, but the manager needs to ensure that the cleaning schedules are kept up to date, as the gaps in the signature required appeared to be from a senior member of staff. Two sets of items needed a thorough clean these were the condiment, used by service users and the outer casing of the deep fat fryer. Food must be prepared in a clean and safe environment for the safety of service users. Records were seen to show that service users appeared to be offered more activities sessions to meet their needs. The care plans tracked showed that each person had a social needs assessment completed, which is up dated monthly. A range of activities material was seen to be in place, which is an improvement from the last inspection. Some scraps had been commenced for some service users, which record their artwork and photos of events they have participated in. The records need to be expanded upon, as they only give very basic information. There was very little evidence to show what contacts had been sought in the local community, but the manager assured the inspector she is still making enquiries as to suitable events for service users in this category to attend and also for resources to come to the home. Relatives spoken to felt their loved ones were given choice within their capabilities. Such as meals, what to have in their rooms, when to rise and go to bed, when to see relatives and when to be taken out by relatives and staff members. The care plans have improved and showed that more care was being taken to ensure specific needs such as blindness of a person, diabetics and those who still want to smoke are taken into consideration when planning the person’s daily care. This all ensures that individual needs are being met and unmet needs recorded and addressed as they occur. Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that there is a robust system in place to protect service users from abuse and that complaints are dealt with in a timely manner. EVIDENCE: During the course of this inspection Standards 16 and 18 were checked. Since the last inspection the on going protection of vulnerable adults case has been closed down by the local authority, the block on admissions to the home has been lifted by them and the inspector was assured that there were no outstanding issues with the main local authority placing service users in the home. Neither had there been any complaints received directly to CSCI or to the home. The complaints log was seen and no entries had been made. A niggles book had been commenced and three entries had been recorded. These had been addressed by the manager within 48hours and all had positive outcomes recorded. The complaints procedure is now on display near the visitors signing in book and now has the correct information. Relatives and other visitors to the home stated they were aware of the process and felt that the management team Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 17 would address any issues raised. Staff also said that the manager’s way of dealing with issues had changed and felt this was a positive way forward and would prevent issues being left for a long time before they were dealt with by the team. Since the beginning of last year the staff records showed that all staff have now received an up date course in the protection of vulnerable adults. All policies have been updated and the local authority guidelines are now in place. Dovecott Care Home DS0000002852.V329415.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was safe and clean for service users and staff to live and work in. EVIDENCE: During the course of this inspection Standards 19 and 26 were checked. The management team had been working very hard since the last inspection to upgrade certain areas of the home. This included; - carpets being replaced in some areas previously identified, other carpets being repaired, some areas being repainted and some rooms having a complete refurbishment programme. Signing had also been completed on bathroom and toilet doors in the form of words and pictures to enable service users to identify these areas when Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 19 required. Some new towels had been purchased and a full linen audit had taken place. The management team had also cleared some storages areas in the home making a staff room, which is also now used for staff training and has toilet facilities near by for staff use. The Company had also now received the retrospective planning permission for the local council to enable them to reinstate the fencing around a garden area, which is being made secure for service users use. There are plans being set out for the gardens to be redesigned in the warmer months of they year. Certificates were seen to ensure that all maintenance is kept up to date for equipment in use and the manager completes a workplace audit monthly, which also includes the environment. The boiler was to be serviced on 7th February 2007 and the manager asked to send the certificate to the inspector. A brief tour of the outside of the building took place by the inspector, accompanied by the manager. This was free of hazards and looked tidier and cleaner especially around the outside fire exit staircase. The inspector was assured by the manager that the laundry area was under consideration as to the walk way to it, as it can be hazardous is icy weather and the Company hopes to provide a covered walk way to the main house. All equipment was in working order and there was a new dryer in use. The environmental health officer and fire officer spoken to prior to the site visit did not have any outstanding issues with the home. On a tour of the main facility, where the inspector was accompanied by the manager, all communal areas were seen, all bathrooms and toilets and most bedrooms. The home was clean and tidy and appeared safe for service users to live in and staff to work. Dovecott Care Home DS0000002852.V329415.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had been made in the training of staff to ensure they are trained to do their jobs and look after service users safely, but recruitment could not be tested as no new staff had been employed. New policies are in place for when staff are recruited. EVIDENCE: During the course of the inspection Standards 27,28,29 and 30 were checked. The requirements outstanding from the statutory enforcement notices issued last year had been included on the list of outstanding requirements from the random inspection in September 2006, as no new staff had been recruited. These will remain in place until such time as they can be tested by the inspector to ensure the recruitment policy now in place is robust and service users are protected from unsafe staff being employed. 4 staff personal files were tracked in depth and found to have the correct information on file to ensure they have been checked as being safe to work with service users. The inspector saw the records to show that a training audit of staff needs and a plan had been put into place, since the last inspection. This has enabled the Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 21 manager to plan specific topics for training and keep abreast of statutory requirement training and individual staff needs. This topic was also seen to be recorded as discussed when the supervision records of staff were seen. The sessions which have taken place have covered topics which service users were currently experiencing. How much of this knowledge has been consumed by the staff still needs to be tested by the manager and recorded. Records showed that at the time of the inspection 5 staff had completed their NVQ level 2 in care, 3 were currently finishing, 2 were wanting to go on the course and 1 staff member had had her level 3 in care award material sent away to be verified. The manager hopes that by the summer over 50 will have completed their level 2 awards, which is a significant improvement from last year. Staff spoken to felt this and other training has helped them advance the care they now give to service users and has given them a better understanding of the service users needs. The rotas of staff were seen and copies given to the inspector at the time of the site visit. No changes had been made and there were no staff vacancies. Staff stated they felt there were enough staff on duty to complete tasks allocated to them. 6 staff were spoken to on the day and all made very positive comments about working at the home. They felt moral had improved and that the different style of management structures now in place, as one staff member stated “keeps us on our toes, which is right”. Dovecott Care Home DS0000002852.V329415.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management structures are more sound and effort is being made to consult service users and their loved ones on the running of the building, the home and individual needs. EVIDENCE: During the course of the inspection Standards 31,32,33,35,36 and 38 were checked. The management team have had to come to terms with some very serious concerns raised by CSCI and the local authority in the last year. They have taken the issues one by one and have completed almost all the requirements set for them. Due to the volume of the requirements and detail required some Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 23 items remain outstanding in this section, which has partly been to restraints on time by the management team and fact finding from outside resources. The manger was able to show the inspector her training record which showed she has kept her own statutory training up to date, but had still not produced the evidence to show that the Registered manager’s award she is studying on is the correct one. The manager offered to obtain a letter to be sent to the inspector to prove this. The manager stated she now feels “in control of the home” and has learnt some new skills in handling staff. This will ensure the service users that some one is in charge of all matters relating to them and ensuring the environment is safe to live in, with properly trained staff to look after them. During the course of the day the second owner arrived on site and the inspector was able to discuss with that person the running of the home, which was felt to be in a positive atmosphere. It has been recognised by the management team that they have to work towards gathering evidence to support a good quality assurance programme. Some work has been completed for example care plan and drug auditing. Letters were seen and questionnaires which had been sent to service users relatives, but no evidence could be produced that these had yet been returned. Supervision records were now in place for staff and these showed a significant improvement. Although the target of 6 per year would not be reached, the content was much improved. These showed that discussions had taken place and also observational sessions, (some which included photographs of staff performing tasks such as music and movement activities and crafts). Staff were able to inform the inspector when their last supervision sessions had taken place and this was helping them plan training in any short comings identified to them. Records and documentation were checked to ensure that all equipment had been checked and all certificates were valid at the time of the inspection. This has made for a safe environment in which service users can live. Dovecott Care Home DS0000002852.V329415.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 X 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 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 3 3 X 3 Dovecott Care Home DS0000002852.V329415.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 OP13 Regulation 16.2.m.n. and 16.3. Requirement Timescale for action 30/04/07 2. OP15 16.2.j. 3. OP19 23.2.b. 4. OP29 19.1.a c. The registered person must ensure that all service users have access to community services and activities and this can be evidenced. (Previous time scale of 25/08/06 and 20/01/07 not met). The registered person must 30/04/07 ensure that all cleaning schedules in the kitchen area are maintained and all items especially condiments and the deep fat fryer are cleaned thoroughly. The registered person must 08/02/07 ensure that the maintenance of the boiler is kept up to date and the latest certificate sent to the inspector on completion of service on 07/02/07. The review and revision of the 30/04/07 care home’s recruitment policies and procedures must ensure that the following issues are adequately addressed: No prospective member of staff should commence work until all recruitment checks have been DS0000002852.V329415.R01.S.doc Version 5.2 Dovecott Care Home Page 26 5. OP30 18.1.c.i. 6. OP31 9.2.b.i. 7. OP32 21.1. completed and the registered manager is satisfied as to the applicant’s suitability. The assessment of applicants’ suitability must include close scrutiny of the document’s authenticity and it’s factual accuracy. Where inconsistencies in an applicant’s employment history are identified a record of the action taken to address these inconsistencies must be made and maintained for inspection by the Commission. Where a positive CRB disclosure is received a full record of the assessment of the applicant’s suitability to work in the care home should be maintained and an action plan put in place to ensure that vulnerable people are not placed at risk. The Registered Person’s action plan for monitoring suitability must be kept up to date with at all times. (Previous time scales of 14/09/06 and 20/01/07 not met as no new staff had been recruited.) All new staff must be provided 30/04/07 with structured induction training and the content of the induction training must be recorded and made available for inspection. (Previous time scales of 14/09/06 and 20/01/07 not met, as new staff had been recruited.) The registered person must 01/03/07 ensure that the manager has registered on the correct Registered manager’s award and this verification is sent for checking to the inspector. The registered person must 30/04/07 provide evidence of the DS0000002852.V329415.R01.S.doc Version 5.2 Page 27 Dovecott Care Home 8 OP33 24.1.a.b. consultations with the service users and staff on development of the home and the services provided. (Previous time scales of 01/05/05,30/03/06,08/09/ 06 and 20/01/07 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 scales of 01/05/05,30/03/05,08/09/ 06 and 20/01/07 not met). 30/04/07 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. Refer to Standard OP28 OP38 Good Practice Recommendations The manager must pursue NVQ level 2 training for care staff. The management team needs to be mindful that as the service develops they will have to expand their policy and procedure manual. Dovecott Care Home DS0000002852.V329415.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dovecott Care Home DS0000002852.V329415.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. 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