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Inspection on 12/12/05 for Dovedale Court Nursing and Residential Home

Also see our care home review for Dovedale Court Nursing and Residential Home for more information

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The sources of information about the home to prospective service users is of a high standard showing the range of services the home is able to provide. Service users receive good standards of care and support delivered in an individual way and in the way the resident wishes by experienced staff in a safe well-maintained environment. The meals provided give good choices and a balanced diet. The recreational activities are delivered in appropriate ways for each of the units. The home has satisfactory procedures for handling complaints and any expressed views can reliably be expected to be acted upon in a positive way. The home is very well presented to prospective clients both in general appearance and the welcoming by staff.

What has improved since the last inspection?

Care planning has improved with better contingency planning and a consistent approach to recording evaluations. The decoration programme has involved service users providing choice. Arrangements for the storage personal issue of incontinence products has been addressed to avoid possible contamination. The home has achieved and passed the staff training target of 50% of care staff holding NVQ at level 2.

What the care home could do better:

Hot water supplies to staff hand wash out lets should be subject to control to promote good hand washing practice.Staff would find training in care of the dying helpful as this unit is rarely taken up as a unit during the NVQ training as the appropriate opportunities are not available generally. The manager should make application for registration.

CARE HOMES FOR OLDER PEOPLE Dovedale Court Nursing And Residential Home Holyhead Road Wednesbury West Midlands WS10 7PZ Lead Inspector Richard Eaves Unannounced Inspection 12th December 2005 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 Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 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. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dovedale Court Nursing And Residential Home Address Holyhead Road Wednesbury West Midlands WS10 7PZ 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) 0121 502 6444 0121 502 0655 Southern Cross Healthcare Services Limited Judith Webster Care Home 76 Category(ies) of Dementia - over 65 years of age (42), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (1), Old age, not falling within any other category (32) Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. That service users accommodated requiring nursing care are aged 65 years and over (OP) and must not exceed 32 in number That service users accommodated who have Dementia DE(E) require personal care only and must not exceed 42 in number That staffing levels do not fall below the following minimum numbers set out in the Notice of Registration document (March 2003) That 1 service user (male) MD(E) requires personal care only That 1 service user (male) MD requires nursing care That the service user categories of MD and MD(E) remain subject to current service users residing at the home. At such time that their placement is terminated, the service user category will revert back to OP and DE(E). 27th July 2005 Date of last inspection Brief Description of the Service: Dovedale Court is a purpose built two-storey building, registered to accommodate thirty-three elderly people requiring nursing care on the ground floor, and forty-three elderly people requiring personal care who have dementia, on the first floor all in single en-suite bedrooms. The first floor is accessed by two passenger shaft lifts. There is a spacious reception area at the front of the building where the Manager, administration offices and visitors room are situated. All bedrooms are single with én-suite facilities. Lounges and separate dining rooms and all facilities are provided on both floors to meet the needs of service users. The home is situated in close proximity to Wednesbury town centre and has easy access to public transport. The home also has good parking provision to the front of the premises with enclosed gardens to the rear and side of the building. Ancillary services of catering, cleaning, laundry and maintenance are provided in-house. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by one inspector over one day. The focus of the inspection was on the delivery of care and included case tracking. The inspector had opportunity to speak with many of the service users and those able to communicate were positive regarding life at the home and they all appeared content. There was a relaxed atmosphere among service users and staff. The inspection also included a tour of the building, meeting with service users and inspection of records. What the service does well: What has improved since the last inspection? What they could do better: Hot water supplies to staff hand wash out lets should be subject to control to promote good hand washing practice. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 6 Staff would find training in care of the dying helpful as this unit is rarely taken up as a unit during the NVQ training as the appropriate opportunities are not available generally. The manager should make application for registration. 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. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–5 The homes statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home and further confirmed by contract at the time of admission. Service users are invited to visit and trial the home before committing themselves to staying at the home. EVIDENCE: The statement of purpose and service users guide have recently been reviewed and amendments made to include details of the new in post manager and both documents re-issued. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 9 An inspection of a sample of case files on both floors show these to include a contract of terms and conditions, a copy letter of confirmation that assessed needs can be met and inviting trial visits. The manager jointly with the manager of the residential unit undertakes pre-admission assessments. Case files include a range of assessments including social, activities of daily living, cognition, mental capacity and behaviour rating, and a range of individual risk assessments. The file also contains a comprehensive checklist of completion of these assessments. The home does not currently provide an intermediate care service. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 11 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. Staff have been developed to provide care at the time of service users dying with sensitivity and respect. EVIDENCE: A sample of case files were selected at random in each area of the home to be inspected and case tracked. The care plans were drawn from the assessed needs process and were relevant and maintained to a good standard. The care plans reflect actual care requirements and the service users preferences of how it is to be given. All service users are registered with a GP and the district nursing service visits on the residential unit on request. Other allied medical and chiropodist visits regularly. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 11 The home uses the Venalink monitored dosage system for the administration of most frequently prescribed medicines. Each of the two units of the home have their own medicine room, these were found to be clean and tidy and appropriate for storage of medication. Records examined show them to be completed thoroughly. A contract is in place for the disposal of pharmaceutical waste. The induction programme includes a section on treating service users with respect and their privacy is upheld with locks fitted to bedroom doors, in addition staff were observed to knock before entering and interact in a friendly and open way using the service users choice of name. A limited programme of training is included in the NVQ units and the Nursing staff have extensive experience in care of the dying. A recommendation is made that this be formalised with a standardised approach for all staff. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The home provides well-organised and varied social and recreational activities that provide interest and pleasure for the residents. Visitors are welcome and help to keep service users informed about the wider community Many aspects of care evidences that service users exercise choice and control over their lives. The meals at Dovedale care home are good, offering both choice and variety and catering well for special dietary needs. EVIDENCE: The home continues to provide a programme of activities both within and outside of the home led by an activities coordinator. During the morning of inspection a group on the first floor were observed to be engaged in a game of bingo and appeared to be having fun. The activities co-ordinator provides a service to both floors over 5 days a week organising in-house activities such as crafts, quizzes, bingo and games and co-ordinates events such as clothing and toiletry parties, exercise to music and entertainments. Arrangements have bee Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 13 made for Christmas events and include parties, carols by school children and a pantomime. The home has an open visiting policy, which was observed in action with visitors arriving and leaving during the inspection. The new manager has introduced evening surgeries for visitors and will recommence regular relative meetings The case files include a section that identifies personal likes and wishes such as rising and settling time and their ability to make their own choices of clothes to wear. In conversation with service users they were content that these wishes are fully taken into account by care staff in the assistance they provide. The 4-week rolling menus provide for a balanced and nutritious diet that is well received by the residents, many able to recall the choices offered at each of the meals and that the three main meals offered a cooked option. The menus have been assessed as nutritionally sound and are put together using a high proportion of fresh produce. The menus include details of the evening snack to be provided. The lunch observed being served during the visit appeared very appetising. Portions served were individual to service users wishes from small to large. The home won the company wide menu award and has recently achieved a gold award from Sandwell EHO for kitchen hygiene. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 18 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights are protected and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse. EVIDENCE: The home has a detailed complaints procedure which is well promoted by way of notices and the service users guide. No complaints have been received in recent times. Advocacy service are promoted with notices, leaflets and telephone numbers of Care Aware advocacy service available in reception. The manager identifies that the electoral roll procedure has been completed for the forthcoming year. All staff have attended adult protection training provided by the local social services and also through NVQ training which all staff have either completed or are currently undertaken. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home provides a good standard of décor, furnishings and managed services providing a safe environment and an attractive, comfortable and homely place to live. The home is clean, free from odours and hygienic. EVIDENCE: Dovedale Court is a purpose built two-storey building close to the town centre and public transport. Accommodation is all single bedrooms with én-suite with a range of communal rooms, the first floor being serviced by two passenger lifts. The premises are generally well maintained and in good decorative order overall and subject to a programme of redecoration and refurbishment, the ground floor being completed this year and the first floor is underway. The home was found to be clean, hygienic and free from odours, each floor has sluice disinfection facilities and the modern laundry is fitted with washing machines with sluicing and disinfection programmes and all surfaces are washable. The hot water supply to staff hand wash sinks is very hot and not compatible with good hand washing practice. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: An inspection of the current staff rotas show that sufficient care and nursing staff with the necessary experience are allocated to cover the full 24-hour day with appropriate support of ancillary staff. Each of the units, ground and first floor, are staffed separately, the nursing unit has a nurse in charge and 5 carers during the day and at night a nurse and 3 carers occasionally increased to 4 to meet dependency needs. The first floor is covered by 2 senior carers and 5 carers by day and 4 carers at night. At the time of this inspection the numbers of staff holding an NVQ was identified as 52 of carers. The training matrix identifies good progress in achieving mandatory targets for moving and handling, fire safety food hygiene, adult protection and health and safety. Other training includes challenging behaviour, pressure care, care planning, administration of medicines, effective Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 17 communications, infection control, dementia awareness and continence management. Recruitment and selection are completed to a good standard and includes all necessary checks such as CRB, POVA and nursing registration. The sample of staff files inspected also show that two references are obtained and a record kept of the interview. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 –32 & 35 – 37 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receive supervision and direction to ensure that the service users receive consistent quality care. The best interests of service users are safeguarded by the homes record keeping, policies and procedures. EVIDENCE: The manager is new in post and requires to complete the registration process. Morale at the home appears good and staff welcome the arrival of the manager and the managerial impact she is making to the working environment. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 19 The home does not act as appointee for service users but have in place good accounting practice to assist service users in keeping their personal allowance safe. Supervision notes seen by the inspector demonstrate an effective formal supervision process for staff of at least six times per year. Annual appraisals have also been undertaken. Policies and procedures are available for staff to read. Records required by regulation and the schedules are maintained and kept up to date. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 20 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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 3 X Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP26 Regulation 13(4)(a) Requirement The registered person must provide safe supply of hot water at staff hanwash points of sluice, kitchen and laundry to promote good hand-washing practice. The manager must make application and complete the registration process Timescale for action 31/03/06 2 OP31 9 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP11 Good Practice Recommendations The responsible person should source and introduce a short training course in the care of the dying for all staff. Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dovedale Court Nursing And Residential Home DS0000004846.V270786.R01.S.doc Version 5.0 Page 23 - 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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