Inspection on 15/03/05 for Dovedale Court

Care Homes For Adults (18 ­ 65)Dovedale CourtQuantock Drive Ashford Kent TN24 8RRUnannounced Inspection15th March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Dovedale Court Address Quantock Drive, Ashford, Kent, TN24 8RR Email address Tel No: 01233 611 536 Fax No:Name of registered provider(s)/company (if applicable) United Response Name of registered manager (if applicable) Mr Warwick Burridge Type of registration Care Home No. of places registered (if applicable) 10Category(ies) of registration, with (number of places) Learning disability (10) Registration number H050000233 Date first registered 5th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 20th July 2004 Yes NO 01/2005 If Yes refer to Part CDovedale CourtPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 315th March 2005 09:30 am Elizabeth HendryID Code165188Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionLiesl Cooper, Deputy ManagerDovedale CourtPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementDovedale CourtPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Dovedale Court. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Dovedale CourtPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Dovedale court is registered to provide accommodation, support and personal care for up to 14 adults with learning disabilities between the ages of 18 and 65. Dovedale Court consists of three houses for two people, five self contained flats. Staff facilities are located on the first floor of one of the buildings. The complex overlooks a large fenced garden which is on two levels and contains a seating area, walk ways, landscaping and two sheds. There is an onsite activity centre where skill development programmes are attended. Dovedale Court is located in a quiet residential area within a short walk to Ashford town centre. The home is owned by United Response, a registered national charity. United Response and its directors are therefore wholly responsible for the adequacy of all aspects of the facilities, resources and services provided at Dovedale Court.Dovedale CourtPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an unannounced inspection undertaken by Elizabeth Hendry, Regulatory Inspector. On the day of the inspection there were nine service users residing within Dovedale Court. The inspector found the home to be well decorated and furnished to a good standard, service users appeared relaxed and comfortable within their surroundings. Staff spoken to by the inspector were knowledgeable about service users in their care and spoke of receiving comprehensive training and support on a regular basis. The inspector was pleased to find a wide range of activities available to all residents, service users spoken to confirmed that staff encourage development of personal interests and hobbies. Community involvement is evident within service user files and communication books. The registered manager was on leave during the unannounced inspection, and as a result, many of the standards were not inspected. Requirements have been issued with regards to medication storage and recording, and the repair to wall in House 4 as a result of water damage.Dovedale CourtPage 6 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Dovedale CourtPage 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action Management must cease the decanting of o prescription drugs into separate containers. All medication should be kept locked away at all times and keys for the medication cabinet within the staff kitchen should be securely stored and not on display within the room. External cream should be kept in a sealed container in line with the Royal Pharmaceutical Society of Great Britain guidelines. 2 16 (2,k), 23 YA24 Repair to the damp patch on the first floor stairwell of House 4. 31-05-05113 (2)YA2030-04-05RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. Dovedale Court Page 8 No.Refer to Standard *Good Practice Recommendations* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: YES YES NO YES YES NO YES NA YES NO YES NO YES YES NO NO NO YES NO YESDovedale CourtPage 9 Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)4 0 0 NO NO YES YES 22 0 15/3/05 10.00 4.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Dovedale CourtPage 10 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to `test drive the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence This standard was not inspected on this occasion.Standard met?0Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dovedale CourtPage 11 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dovedale CourtPage 12 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Of those individual care plans seen by the inspector, all were found to be easy to follow and showed evidence of ongoing review. Clear goals are set and any restrictions are identified and agreed. Although the individual plans are not written in a service user format, residents would be provided with the necessary level of support in order to understand the contents. Each service user is assigned a key worker who develops close working relationships with the resident in order to ensure that all needs are fully met. All plans viewed by the inspector contained signatures of agreement from both residents and the home manager. This standard was fully met. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The inspector noted that during the course of the inspection service users were enabled to make choices regarding their daily lives by staff, records viewed confirmed that daily choices are well recorded. Regular service user meetings are held and recorded. Residents spoken to by the inspector spoke of taking responsibility for their own homes and enjoyed being involved in household tasks. The deputy manager told the inspector that local advocacy groups would be accessed as required. All service users have their own named bank account, and support managing individual finances is provided. The inspector noted that choice boards were in place within a number of flats/ houses, which enables service users to make individual choices and decisions.Dovedale CourtPage 13 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? All risk assessments are held within the staff office. Of those viewed by the inspector clear guidelines were in place for staff to follow. Evidence of frequent and ongoing reviews could be seen within individual care plans. Personal boundaries and limitations were well documented and evidence of service user involvement could be seen. This standard was fully met.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dovedale CourtPage 14 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Service users are encouraged to develop interests and continue education and training where appropriate. Individual care plans identify personal choices with regards to courses and skills training. Dovedale Court has an activity centre within its grounds, a part time teacher provides support in numeracy and literacy for any residents who express an interest. The deputy manager told the inspector that some service users attend the Boccia Centre in Dover. Due to the level of needs none of the residents currently hold paid or voluntary employment.Dovedale CourtPage 15 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Dovedale Court is situated within a housing estate, the home does not in any way stand out from the surrounding homes. All service users are encouraged to participate in community life, and access local amenities and public transport. The home has access to three vehicles, which enable residents to access the wider community. All service users are registered to vote and staff would provide assistance if an interest was expressed.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? This standard was not inspected on this occasion.0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Care plans seen by the inspector clearly identified the level of family involvement and the preferred method in maintaining these links. Home visits are fully supported and visitors are welcome to the home at any time. Service users are able to use any of the communal rooms in addition to their bedroom to entertain guests. The deputy manager told the inspector that should any service users choose to develop personal relationships, staff would ensure that consensual issues were addressed and the individuals healthcare needs were fully met.Dovedale CourtPage 16 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Throughout the course of the inspection, the inspector observed staff enabling residents to make personal choices and encouraging independence. Service users privacy is fully respected and staff were observed to knock on bedroom doors and gain permission prior to entering. Service users are supported to open their own mail. The inspector noted that staff interact well with service users and a relaxed atmosphere was apparent. Rules on smoking, drugs and alcohol are fully understood. Service users have access to all areas within their home with exception being the COSHH cupboard, and medication cupboard. Each service user is given their own household responsibilities, such a laying the table, cleaning their room and laundry. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users are supported to plan, prepare and serve their own meals. Choices are recorded in individual care plans and staff provide assistance in maintaining a healthy, nutritious diet. Meal times are entirely flexible to suit individual preference. For those residents who require monitoring with regards to diet and weight, appropriate records were in place. Religious and cultural diets are fully catered for. Risk assessments are in place for service users who prepare meals and drinks independently. This standard was fully met.Dovedale CourtPage 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Personal care is provided in a manner that maintains an individuals independence and dignity. Individual care plans viewed by the inspector identified levels of support required. Times for getting up and going to bed are flexible dependent on the residents individual preferences. The inspector noted that each service user had created their own personal style with regards to dress and personality. The deputy manager confirmed that should any specialist adaptations be required, they would be provided upon approval from a qualified health professional. Regular advice and guidance is sought from occupational therapists, speech therapists and psychiatrists. Each individual has an assigned key worker who has been chosen based on individual interests and personalities. Key workers are responsible for developing strong relationships with residents to ensure that their personal aspirations are addressed and met. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? The deputy manager told the inspector that each service user is given a choice of a GP, due to the nature of individual disabilities and issues regarding communication full support is provided to all service users when attending appointments. The inspector noted that individual health needs are well documented and there was evidence of ongoing reviews. The inspector was told that should any health issues arise, they would be quickly addressed. This standard was fully met.Dovedale CourtPage 18 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 1 Key findings/Evidence Standard met? The inspector viewed medication storage and records in both homes and within the staff office. Records within the two homes were found to tally with drugs stored. The inspector highlighted concerns with regard to the storage of drugs within the staff office and kitchen area. A requirement has been issued to stop the decanting of one prescription drug into a separate container. Records for this were unable to be located on the day of inspection. All medication should be kept locked away at all times and keys for the medication cabinet within the staff kitchen should be securely stored and not on display within the room. All staff involved in the administration of medication have attended a safe handling of medication training course. Medication policies and procedures were viewed by the inspector and were found to be in order. Refer to Requirement 1. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dovedale CourtPage 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X Standard met? 0Key findings/Evidence This standard was not inspected on this occasion.Dovedale CourtPage 20 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The inspector viewed the homes adult protection and whistle blowing policy, which were easy to follow and fully complied with the Department of Healths no secrets guidance. All staff undertake adult protection and abuse awareness training on commencement of their post as part of the induction process. The deputy manager confirmed that all service users have their own named bank account. Support is provided in managing service user monies, monies held within the staff office were checked by the inspector and found to be in order. Staff on duty on the day of the inspection were fully aware of the importance of the protection of vulnerable adults, and had a clear understanding of the organisations policies and procedures. This standard was fully met.Dovedale CourtPage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service users live in a homely, comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The inspector was shown around two houses during the course of the inspection. House number 5 was found to be in a good decorative state with furnishings domestic in nature and of good quality. The inspector noted that in house 4, the stairwell to the first floor showed signs of damp, the deputy manager confirmed that this had been identified and there is planned works to repair it. A requirement has been issued to ensure completion of this work. The staff member on duty within house 4 told the inspector that a new bathroom had been installed to meet the changing needs of the resident. Both houses viewed were safe, secure and suitable for their intended purpose. Dovedale court has no availability for the provision of respite or short term placements. Refer to requirement 2.Dovedale CourtPage 22 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard was not inspected on this occasion. YES NO NO X X X X Standard met? 0 X XX X X XDovedale CourtPage 23 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This standard was not inspected on this occasion. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dovedale CourtPage 24 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? On the day of the inspection the home was clean, airy and free from any offensive odours. Laundry facilities are located within the kitchens of the individual flats/houses. Flooring to the kitchen are impermeable in nature and in a good state of repair. Dovedale court also benefits from a large industrial washing machine and tumble dryer which is situated within the complex. Liquid hand soap and paper towels where in situ in all bathrooms. All members of staff receive infection control training as part of the induction process.Dovedale CourtPage 25 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dovedale CourtPage 26 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXKey findings/Evidence This standard was not inspected on this occasion.Standard met?0Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dovedale CourtPage 27 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The deputy manager told the inspector that all new members of staff undertake the Learning Disability Award Framework. Staff files viewed by the inspector confirmed this and demonstrated that staff receive the minimum five paid days training per year. The inspector spoke with a new member of staff who praised the level of support and training received from both management and colleagues since commencement of employment. The ethos of the home encourages staff development and the achievement of National Vocational Qualifications. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This standard was not inspected on this occasion.0Dovedale CourtPage 28 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users rights and best interests are safeguarded by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence This standard was not inspected on this occasion. YES 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dovedale CourtPage 29 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not inspected on this occasion.Dovedale CourtPage 30 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The inspector viewed records evidencing regular fire safety checks and drills, all extinguishers viewed were found to be in date. Staff receive first aid, basic food hygiene, manual handling, infection control and health and safety training as part of the induction process. Fridge temperatures are recorded daily and all food stuffs found in the fridge were dated. Window restrictors were in situ in all bedrooms. The inspector queried the storage of the accident book with the staff on duty at the time of the inspection and later with the manager. The manager confirmed that records are not accessible to anyone other than the staff team, being stored in a staff only area. Accident/incidents are discussed and risk assessed at team meetings. Once information has been risk assessed and disseminated forms are filed within the managers office. Dovedale Court has an ongoing programme of maintenance. All electrical appliances are PAT tested annually and records seen by the inspector confirmed this. The management of the complex has a good ethos on risk assessment and clear evidence of review was documented.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not inspected on this occasion.Dovedale CourtPage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorElizabeth HendrySignature Elizabeth Hendry Signature SignatureRegulation Manager Suzannah Burden Date 4.4.05Dovedale CourtPage 32 Public reports It should be noted that all CSCI inspection reports are public documents.Dovedale CourtPage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 15th March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Dovedale Court Page 34 Amendments to the report were necessaryYESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 2nd May 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NODovedale CourtPage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Dovedale Court confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Dovedale Court am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Dovedale CourtPage 36 Dovedale Court / 15th March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000023722.V213666.R02© This report may only be used in its entirety. 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