Inspection on 27/07/05 for Dovedale Court Nursing and Residential Home

This inspection was carried out on 27th July 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.

Other inspections for this house

Dovedale Court Nursing and... 06/11/07

Dovedale Court Nursing and... 04/10/06

Dovedale Court Nursing and... 12/12/05

Dovedale Court Nursing and... 01/11/04

Dovedale Court Nursing and... 24/05/04

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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 Dovedale Court Nursing And Residential Home Holyhead Road Wednesbury West Midlands WS10 7PZ Lead Inspector Richard Eaves Announced 27 July 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dovedale Court Nursing And Residential Home Address Holyhead Road, Wednesbury, West Midlands, WS10 7PZ 0121 502 6444 0121 502 0655 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Healthcare (Services) Ltd Care Home 76 Category(ies) of Dementia - over 65 years of age (42) registration, with number Mental 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 E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That staffing levels do no fall below the following minimum numbers set out in Notice of Registration document (March 2003) 2. That service users accommodated who have Dementia DE(E) require personal care only and must not exceed 42 in number. 3. That service users accommodated requiring nursing care are aged 65 years and over (OP) and must not exceed 42 in number. 4. That 1 service user (male) MD(E) requires personal care only. 5. That 1 service user (male) MD requires nursing care 6. That the service user catogories 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).. Date of last inspection 1st November 2004 Brief Description of the Service: Dovedale Court is a purpose built two-storey building, registered to accommodate thirty-two elderly people requiring nursing care on the ground floor, and forty-two elderly people requiring personal care who have dementia, on the first floor. 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 E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an announced inspection undertaken by one inspector over one day during the summer of 2005. The focus of the inspection was on the delivery of care and included case tracking records of service users on both units. The home was found to be functioning calmly and efficiently and in conversation with the service users, those that were able confirmed that they were content with life at the home. Other information was gathered by observations during a tour of the building, meeting with staff and an inspection of records. The inspector had opportunity to speak with a number of visitors and their comments were overall positive regarding all aspects of the home and the provision of care. The Standards not inspected on this occasion will be included in the next inspection. What the service does well: What has improved since the last inspection? Since the previous inspection action has been taken to ensure bed or room bound service users are attended frequently to prevent isolation as well as to attend to more practical needs and these visits are documented. Formal responses to complaints by the home now include reference to and details of the Commission should the complainant remain dissatisfied with the outcomes. Good progress has been made in implementing the homes decoration and refurbishment programme with the entrance and reception areas completed. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 6 What they could do better: 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 E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 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 standard(s) 1 - 5 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering 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. EVIDENCE: The statement of purpose and service user guide are kept under review and updated and meet the requirements listed in the regulations and schedule 1 to Regulations. Copies of both documents were available in the reception area and include the results of recent quality assurance surveys and the previous inspection report All residents files include a contract and a letter of confirmation that service users needs can be met by the service. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 9 Pre-admission assessments are undertaken by senior nursing staff for the nursing unit and experienced senior carers for the residential unit. Case files include a range of assessments including; social, activities of daily living, cognition, mental capacity and behaviour rating. The file also contains a comprehensive checklist of completion of these assessments. A range of service user specific risk assessments are undertaken of clinical needs including those for falls, nutritional status, pressure areas and continence. All assessments are subject to regular reviews and updating and there is good evidence of family involvement in the assessment, care planning and review processes with care plans signed by them. Trial visits are arranged for prospective service users and one lady was spending a half day visit during the day. Standard 6 is not applicable to the home as intermediate care is not provided at this time. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 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 standard(s) 7, 8 & 9 In general the health care needs of service uses are fully met and care planning in the home is overall of a good standard adequately guiding staff in the delivery of care needs, there remains scope to improve if service users are not to be at risk of potential needs not being fully met. Medications are well managed at the home, facilitating the promotion of service users health. 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 seen to be 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. In a small number of cases there were notable omissions from the plans, examples include a lack of contingency plan in the care plan for a diabetic or identification of the normal range of blood sugar levels and actions to be taken if monitoring shows the levels to be outside this range. A contingency plan was required for seizures although it is accepted that the service users condition was very well controlled with no seizures since admission. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 11 Care plans for wound care overall were good but the progress reviews were recorded inconsistently, sometimes in the daily report and other times in the care plans giving an impression of incompleteness. The files examined show that the service users are registered with a General Practitioner and other allied medical practitioners provide services, including ophthalmic, Dental, Chiropody and other therapeutic services as required such as audiometry. Nursing staff undertake assessments for tissue viability, nutrition, continence and falls routinely and involve specialist advisors as required. The incidence of pressure sores is recorded and the care plans identify the actions required for the promotion of healthy intact skin. The home has a plentiful supply of equipment and aids to assist them in pressure sore prevention. 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. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 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 standard(s) 12, 13 & 15 The home provides well-organised and varied social and recreational activities that provide interest and pleasure for the residents. An open visiting policy assists service users to maintain contact with their family and friends. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. 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 were observed to be engaged in a beetle drive game and appeared to be having fun. The home has an open visiting policy, which was observed in action with visitors arriving and leaving during the inspection. One family member specifically asked to speak with the inspector about the arrangements for care being aware that senior staff were absent due to illness. The issues raised were brought to the attention of staff and were addressed. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 13 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 lunch observed being served during the visit appeared very appetising. Portions served were individual to service users from small to large. The kitchens were clean and all aspects of hazard analysis and critical control points were in place to provide a safe food production area. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 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 standard(s) 16 The home has a satisfactory complaints policy and service users and their supporters can be confident that their views will be listened to and acted upon. EVIDENCE: The home’s complaints policy and procedure is included in the service users guide and notices are located around the home. 8 complaints have been received, 5 from relatives, and these have been responded to their satisfaction. Issues among staff continue to be the subject of management actions. A relative met during the inspection expressed concern that families were not kept informed of current management changes or who to speak with while they are ongoing. Staff, while individually very good, do not keep such notices as who the key worker is up to date. This gap means that no one person takes responsibility to look after personal items such as electric razors or find lost clothing. One other concern that generally applies to residents is that staff do not facilitate or encourage service users to wash their hands after the toilet. These matters were brought to the attention of the acting manager who undertook to address them within the local complaints procedure. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 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 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 reception and corridors have been completed recently and the lounges and dining rooms due to commence and including extensive refurnishing. 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. On the day of inspection a fan was seen in place to control the Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 16 heat, this is not good practice and if control of heat is required then a conditioning unit may be required. Each bedroom is furnished, decorated and equipped to individual service user wishes and personalised with possessions such as pictures and ornaments. Requirements for double sockets, low surface temperature radiators and window restrictors are met, approved door locks and lockable facility, smoke detectors and a staff call system are provided. A number of height adjustable beds are available and a further 10 profiling beds are on order for the nursing unit. During the inspection it was observed that incontinence products were being stored on the floor of the en-suite and at risk of contamination. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 Service users need are met by number and still mix of staff. The continuing low number of staff trained to NVQ level 2 or equivalent means that there is no certainty that service users are in safe hands at all times Service users are protected by good recruitment and selection practices that adhere to policy and are implemented thoroughly. 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, an increase of 4 hours a day has been provided for the laundry. Each unit, ground and first floors, are staffed separately, the nursing unit having 30 service users currently have a nurse in charge and 5 carers during the day and at night a nurse and 4 carers. 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 7 of carers. The training matrix which identifies good progress in achieving mandatory targets for moving and handling, fire safety food hygiene, adult protection and health and safety does not include any details of NVQ training. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 18 A sample of staff files were inspected including 2 new starters, a nurse and a domestic, these show that the recruitment and selection procedures are implemented thoroughly with all necessary checks undertaken. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 & 38 Staff benefit from regular supervision, which prepares them to safeguard the rights of service users. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. EVIDENCE: During the inspection it was notified that the registered manager who was absent, had tendered her resignation and would not be returning. The temporary arrangement of cover by the company project manager would continue until an appointment is made. 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. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 20 The Home was found to be functioning safely with clear passageways, free from fire loads and staff were observed to be undertaking their work in a safe manner. An inspection of monitoring records of fire alarms testing and emergency lighting were complete and up to date. A full range of certificates of annual and more frequent servicing such as lifts and hoists were made available. Staff receive training in all aspects of health and safety in the work place and have written guidance on safe working practices. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 1 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x 3 x 3 Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard op7 Regulation 15 Requirement The registered person must ensure that care plans take account of contingency planning for specific conditions. The registered person must provide the Commission with the programme for decoration and refurbishment of the communal rooms including timescales and any precautionary measures to be taken. The registered person must make arrangements for the storage of incontinence pads that will offer protection from contamination. The home has a minimum ration of 50 trained members of care staff(NVQ level 2 or equivalent achieved by 31.12.2005. The responsible person will arrange for an application to withdraw registration on behalf of the manager who has resign from post. Timescale for action 30.9.2005 2. op19 23(2)(a) & (d) 30.9.2005 3. op23 23(2)(l) 30.9.2005 4. op28 18 31.12.2005 5. op31 8 30.9.2005 Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 23 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 op26 op7 Good Practice Recommendations The responsible person should make suitable arrangements for for controlling the ambient temperature of the laundry to a comfortable working level. The responsible person will ensure that care plan evaluations (wounds) are recorded in a consistent way. Dovedale Court Nursing And Residential Home E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 24 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Hill Halesowen 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 E55 S4846 Dovedale V232022 270705 Stg4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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