Inspection on 06/11/07 for Dovedale Court Nursing and Residential Home

This inspection was carried out on 6th November 2007.

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... 04/10/06

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

Dovedale Court Nursing and... 27/07/05

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

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

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

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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 Mrs Mandy Beck Key Unannounced Inspection 6th November 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 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 www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Mrs Terri Brindley 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.V347743.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. That staffing levels do not fall below the following minimum numbers set out in the Notice of Registration document (March 2003) That service users accommodated who have Dementia DE(E) require personal care only and must not exceed 42 in number That service users accommodated requiring nursing care are aged 65 years and over (OP) and must not exceed 32 in number 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). One service user (female) identified in the variation report dated 27.1.06 who is 61 years and over may be accommodated at the home in the category OP 4th October 2006 7. Date of last inspection Brief Description of the Service: Dovedale Court is a purpose built two-storey building, registered to accommodate thirty-three people requiring nursing care on the ground floor, and forty-three people requiring personal care who have dementia, on the first floor. The first floor is now separated and provides two units for people with dementia. 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 en-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 close 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. Fees for this home range from £492 - £580 per week. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection to the home. It was undertaken by two inspectors and lasted from 08:30 to 18:00 hours. We used various methods of information gathering to help us make the judgements in this report. The home has given us information about the service they provide in their Annual Quality Assurance Assessment (AQAA) we have used this information in the body of this report. We have also used information from the Thematic inspection the home was involved in with the Commission for Social Care Inspection (CSCI). The Thematic inspection looked specifically at how the home upholds the rights of privacy and dignity for people with dementia and how they support them in their daily lives. We spent time talking to staff and the people who use this service to find out what life is like at Dovedale Court. We looked in depth at the care records of some of the people who use this service. This forms part of our case tracking process and enables us to make decisions about whether the home is meeting the needs of the people who live in the home. We also walked around the home to make sure that it is still a pleasant and welcoming place for service users to live. What the service does well: People who live in this home said that they were happy and enjoyed living there. They told us “the staff will do anything for you”, “I get help with whatever I need I feel very supported by the home”. The home provides a relaxing environment for people to live in, it is well maintained and pleasantly decorated. People told us that the food was very nice, “there’s always plenty to eat and we get a choice” There are plenty of activities to keep people active throughout the day. One person said that they had particularly enjoyed the day trip to Weston Super Mare and was waiting for another. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 6 People felt confident that if they needed to make a complaint that it would be listened to and taken seriously by the staff. “I tell them things aren’t right and they always help me sort it out”. What has improved since the last inspection? What they could do better: The Statement of Purpose should be reviewed in order to show people how the home can meet the specialist needs of the people who live there. For example those people with dementia. There are improvements to be made to enhance the care planning and assessment processes in the home. We found evidence that showed us not all needs are being recorded and at time some information can be contradictory. The manager is aware of this and is already arranging further training for staff to address this problem. The home has good systems in place to record complaints when they happen. The home could improve further upon this by recording the outcome of the complaint and if the complainant was satisfied with the outcome. We also found that despite care needs being recorded in most cases there was not much evidence of an person centred approach to care planning. This was also discussed with the manager during the inspection. The home needs to develop this approach if they are to provide individualised care to the people who live there. Record keeping and accident recording could be better, although the home records most falls and accidents we found evidence that showed us this was not always the case. Consistent and accurate record keeping is essential and will not only make sure that people receive the care and attention they require but will help the home’s quality assurance system and the action planning following the manager’s audits. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. People who choose to use this service can feel confident their needs will be assessed in full prior to their admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: New service users are only admitted to the home once a full assessment of their needs has taken place. The manager or nurse in charge will visit people at home or in hospital prior to admission to complete an assessment and to satisfy them that the home can meet people’s needs. The home uses a model of assessment based around daily living skills. As part of our case tracking process we looked at the assessments and care plans of 5 people. It was pleasing to see that each had an assessment of needs but some did vary in the amount of information that was contained within them. One person’s “Pre Admission Assessment” form was blank. In this case the person or the home cannot feel sure that their needs would be met because Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 10 they were not identified prior to admission. Other people’s assessments had been completed although the home could improve upon their content by making them more person centred in their approach and demonstrating people’s involvement in this process. Once the home has completed an assessment the information they have gathered is then transferred into a care plan that shows how staff will work with the person in meeting their needs. This home does not offer intermediate care services. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. People who use this service can feel confident their health care needs will be met but improvements are needed to the home’s record keeping. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people living at the home has their own individual plan of care. This plan details how the nursing and care staff will meet their needs. In all five of the care files seen there were risk assessments in place that looked at the risk of malnutrition, falls, moving and handling and pressure sore development. The nursing staff also assess service users for the use of bed rails and their associated risks. In most cases where a risk had been identified a management or care plan had been drawn up showing how the risk was to be managed. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 12 However, there must be improvements to the record keeping to ensure that where an area of risk has been identified and a care plan drawn up, the content reflects the care that is being given. For instance some of the information was contradictory and did not give a clear picture of some people’s needs. One person’s pressure sore risk assessment indicated that they were doubly incontinent but their dependency assessment indicated that they have a “catheter or urostomy”. The manager confirmed that this person did not have a catheter. Other examples included staff recording that one person had a stiff right leg but when we spoke to the person we noticed it was a stiff left leg. Another person’s assessment clearly stated that they have their own teeth but there was no oral care plan and on observation, when chatting to the person the teeth were discoloured and looked coated with tartar and food residue. This was discussed with the manager during the inspection and has been acknowledged as an area for action and improvement. Staff must take care when reviewing care plans and risk assessments to make sure that they relate to any changes to the persons wellbeing. For example we looked at one care plan that addressed a person’s problems with mobility. It had been reviewed regularly but had made no mention of the recent falls that they had been experiencing. Staff had just written “continues to mobilise well around the unit”. Relatives told us “We are very satisfied with the care my aunt is receiving, they could do with more carers.”, “They treat everyone as individuals and pleasant and courteous”, Someone always telephones me if my relative is unwell in anyway. I am always consulted.” Someone always telephones me if my relative is unwell in anyway. I am always consulted”. The home must also be able to demonstrate how they have involved people or their representatives in the care planning process; none of the care plans viewed had been signed by the people who live there. All service users have regular contact with their own Doctors and are able to access other specialist community health services such as chiropody, dentists and the opticians. The home keeps records of all hearing and sight tests and ensures that service users have the appropriate aids such as glasses and hearing aids. Medication practices within the home are generally good and with some improvements will be even better for service users. The home has good systems in place for the ordering, receipt, storage and administration of medication. Staff do receive appropriate training and supervision when administering medication. We found that there were areas for improvement such as staff being aware of the way in which some medicines should be administered so that people get the full benefit of the medication prescribed to them. Staff record the temperature of the fridge and the treatment room this Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 13 make sure that all medication will be stored in line with manufacturers guidance. One of the medication fridges needs to be replaced as it appeared to be faulty during the inspection. The manager said that one is on order to replace it already. Throughout the inspection staff were observed talking to service users politely and clearly had a positive relationship with them. All staff were seen to be knocking doors to toilets before they entered to assist service users. When talking to staff they were able to give examples of how they would make sure that service users privacy and dignity were maintained such as “make sure that the curtains and the doors are closed when helping them to get washed”, “close the toilet door when people are using it”, “its about helping them to be dressed how they want to be and feeling comfortable”. A recommendation made during the last inspection was for staff to receive further training in meeting the needs of people when needing end of life care. Staff confirmed that they had not had this training but would welcome it. Records also show that in most cases people’s end of life care had not been comprehensively documented this is something the home must address if they are to feel confident about meeting the individual wishes of the people who live there. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. People who use this service can enjoy activities and will be encouraged to maintain contact with their families and friends. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were very pleased with the activities that are organised in the home. The home continues to provide a programme of activities for all service users to enjoy. The activity coordinator has been a positive introduction to the staff team. Service users said “she is very good and it really breaks up the day for us”, “we go to Mecca bingo now they have arranged a special wheelchair taxi for me, its very good”. “I like the day trips especially Western Super Mare”. Other activities include fish and chip suppers, crafts, quizzes and exercises to music. Recently the home was chosen to be part of a thematic inspection conducted by the CSCI. This thematic inspection specifically looked at service provision for people with dementia and how their needs are being met. It was pleasing to see that the home plans suitable activity for people with dementia and has given serious consideration to the environment in which they live. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 15 An activity board in the corridor displayed photographs of residents engaged in indoor gardening, in a karaoke session, helping at a car boot sale, and examples of pictures hand made by residents. A Magician and singer are booked to visit the home during the week of the inspection visit. Groups of service users also go to the local Mecca bingo every two weeks. This is very popular and a taxi accommodating wheelchairs is jointly funded by the home and the bingo company. Relatives told us that they are regularly consulted about service users care and felt included in their care. The home has an open visiting arrangement but visitors are asked to be considerate to service users needs when visiting late at night or early in the morning. Discussions also took place with the manager about the new Mental Capacity Act 2005 and how staff should be aware of their roles and responsibilities under the provision of this Act in making sure that people rights are upheld. She told us that training is being arranged with the Local Authority in the very near future and all staff will be attending. Mealtimes have recently been reviewed. Following the last Thematic report it was observed that mealtimes on the Dementia care unit was hectic and disorganised. This has been addressed by the home. they have now separated the large unit into two and staff have more time to assist and observe service users because there are smaller numbers. The manager was very pleased to show us the Nutmeg system for nutrition that has recently been introduced. This involves menu planning and making sure the meals are nutritious and do not exceed recommended levels of salt, fat or sugar. The manager is able to put the details of a planned meal into the computer that works out if the meal planned is good enough for service users to eat and enables her to make changes where needed. The home is able to cater for specialised diets. People told us “the food is always nice, they do give us a choice”, “I like soup, I can stomach it so I always ask for it”. One inspector had lunch with some of the service users, the meal was tasty and hot. Service users said “the meals are always this good but there is a lot of waste because they do too much, it’s a shame to see it wasted”. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. People can feel assured that their complaints will be listened to and acted upon and that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an easy to understand complaints procedure, which is in the service user guide, in large print. The service user guide is available in each bedroom, reception and framed and displayed throughout the home. The registered manager states that staff read and explain the complaints procedure to residents who may not be able to read or understand, for example people with dementia. The home does not currently have audio or pictorial versions. Staff are expected to attend Southern Cross customer care training and this also forms part of the induction for all new staff. Most of the existing staff group have now attended this training. All of the people we spoke to were clear about how they would make a complaint should they need to do so. The home has received 4 complaints since that last inspection and views complaints as a positive process. The manager audits complaints on a monthly basis in order to identify trends that may be occurring and to enable them to take action to avoid further problems. Actions taken by the manager to reduce problems or complaints occurring includes the manager surgeries held at the home once a week where service Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 17 users and their families can discuss concerns before they become complaints. It is recommended that the home begin to keep records of the complaints investigation and their outcome. It would be helpful to know if people were happy with the complaints process and whether they felt their views had been listened to and acted upon. Most of the staff at Dovedale Court have now completed their vulnerable adult training, this means that staff are now equipped with the skills and knowledge to spot potential signs of abuse and deal with allegations when they arise. There are policies within the home that protect service users and staff alike. All staff files seen contained relevant checks regarding Protection of Vulnerable Adults (PoVA) and Criminal Records Bureau (CRB) disclosures. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. People who use this service live in a well maintained and pleasant home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has continued to maintain it’s programme of redecoration and refurbishment. The biggest improvement to the home has been the introduction of two new dementia care units on the first floor. Previously this has been a large unit and has been a little chaotic for people to live in. The decision to make two smaller units is welcomed. The refurbishment and redecoration of Newbury unit is almost complete. Each resident has been encouraged to use their favourite colour for their own bedroom door, which also has a number, their name and a false letterbox and doorknocker. There are a wide variety of vivid colours. The bathroom doors are painted blue are and toilet doors are painted yellow, with pictorial signage Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 19 to aid orientation for the residents. The reception area, the office and the corridors have been redecorated to represent an indoor garden, with trees, plants, flowers, birds, butterflies, all of which have been fireproofed and the home has obtained approval from the West Midlands Fire service. One corridor also has a picture of a canal barge, which the manager states has been chosen because one of the residents formerly lived on a narrow boat. One person said “its amazing the work they have done, the paintings are lovely”. The manager also told us that the residents are going to be involved in choosing names for the corridors, for example Pine Street, so that the residents will have an address to relate to, such as F5, Pine Street. Oakwood unit has yet to be refurbished and decorated, there are plans to do this once Newbury unit it complete. We saw some people’s bedrooms as part of our inspection, all of which were decorated to individual tastes. The manager also told us that when rooms are due for redecoration service users are involved in colour choices and carpet choosing for their rooms. Random sample of bathrooms and toilets has been seen, these are being themed with paintings, such as dolphins. It is recommended that pictorial hand washing signs are put in all bathing, toilets and en-suites reminder to residents to wash their hands. In three toilets a toilet roll holders were broken, this apparently has not been reported to a manager who states she will rectify during this inspection visit. All staff have access to gloves and aprons in order to help them minimise the risk of cross infection to other service users. the majority of staff have had training in infection control practices and it was recommended that the manager obtain a copy of the department of Health publication Essential Steps. This will guide staff and make sure that they are continuing to practise within best practice guidance. The home has some pets, managers dog, Alfie visits, there are fish in a tank on Newbury in lounge and a budgie, Joey. The rabbit, Gizmo, lives in a large hutch in the garden and is often brought into the home for the residents to stroke and pet. They told us “I love the little dog he is so happy”, “the rabbit is a big one I can see him in the garden when I eat my dinner, it’s like company” There are extensive garden areas that are kept in order by the maintenance worker and the gardener who is funded by money raised by home. The manager has successfully bid for Government grant, which is to provide an extended patio, with large jardinières of plants and new garden furniture for people to enjoy. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. People who use this service live in a home that provides staff in sufficient numbers to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager gave us copies of staff rotas, from this we were able to see that there are sufficient staff on duty to meet the need of the people who live there. However we also saw that some staff are working excessive hours and this must be addressed by the manager. One member of care staff had worked 19 days with out having a day off. All of these 19 days were double shifts this means they worked both the early and late shift each day. In our questionnaires we asked people “do the care staff listen and act on what you say?” Service users responded “they are always here for us if we need them,” and “they always help and listen to me”. The home is continuing it’s programme of training staff to NVQ Level 2 they are still under target of 50 of care staff having achieved this. The manager has a further 17 care staff undertaking this training at present once completed the home should exceed 50 of care staff trained to NVQ level 2 competence. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 21 Staff files were seen and examined to assess whether the home is continuing to safeguard service users through robust recruitment practices, with the exception of a few minor shortfalls it was pleasing to see that all of the required checks were in place including the PoVA and CRB disclosures. The homes administrator was in the process of updating all staff files on the day of inspection. New workers do have a structured induction programme that meets the Skills for Care Standards and new workers are supported during their first few months of employment although the training records for one new employee were blank. The manager explained that they are waiting for training days so that the new worker can attend. The home also employs “in house” trainers who are responsible for delivering all of the mandatory training that staff require. This means that the trainer is able to readily identify those staff who need to take part in training to ensure that their skills and knowledge are kept up to date. At present the home has nurses who specialise in tissue viability and moving and handling. They have received training to enable them to train other staff. We also observed nursing students on placement at the home. The home has had good reports back from the University of Wolverhampton who supply to students to the home. The student we spoke to said that the placement had been enjoyable and that he had learnt a lot whilst he had been there. We also spoke to the university tutor who praised the home and the support they give to students on placement there. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. The people who use this service live in a home that is managed well and run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been no change in the management of the home since the last inspection. The manager runs the home in the best interests of the people who live here and has obtained the necessary qualifications to do so. In order to maintain standards at Dovedale Court, the manager completes monthly audits, these include medication, complaints, falls and the environment. Service users are included in this process and are asked to complete a questionnaire on yearly basis, this questionnaire gives each service Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 23 user a chance to tell the home what it is they are doing well and what it is that they could do better. The home has only recently sent out their annual questionnaires. The manager said once they have been returned she will complete an action plan to address any issues that may be identified. We also looked at the systems in place for dealing with service users monies. The company has a computerised system that keeps the individual expenditure of each service user up to date. The home obtains receipts for all purchases and records transactions appropriately. The health and safety management in the home is good and again there are systems in place that address the knowledge and skills training for each staff member. There is a computerised system that alerts the manager when each staff member is due for refresher training. Staff can expect to receive training in health and safety, moving and handling, fire safety, food hygiene and first aid. This will ensure that they are practicing safe working at all times and not placing people at risk. Southern Cross have systems in place for homes to accurately record, audit and analyse accidents, which they describe as an event resulting in an injury, and incidents, which are events not resulting in an injury. In addition the manager also completes a monthly audit of falls within the home. We looked at some of the more recent accident reports and found that there could be improvements made to the way staff complete the forms. We found that one person appeared to have had two falls in one day according to the dates on the accident forms but when we checked their care plan the falls had been recorded on different dates in the daily notes. The manager investigated this further and did confirm that this person had fallen on two different dates and that the accident forms had been dated wrongly on this occasion. Some of the home’s maintenance records were spot checked it was pleasing to see that they were all up to date. Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 2 Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 25 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 2 Standard OP7 OP7 Regulation 15 15 Requirement People’s care plans must include details of all their assessed needs. People’s risk assessments and health care screening must be kept up to date and amended as their needs change. People must have care plans for oral health care particularly where they have their own teeth That all accident records are accurately completed and indicate all other actions taken, such as reviews of medication, risk assessments, care plans Timescale for action 01/01/08 01/01/08 3 4 OP8 OP38 13 17 01/01/08 01/01/08 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 OP1 Good Practice Recommendations The Statement of Purpose should be provided in alternative formats, as standard and include the needs of DS0000004846.V347743.R01.S.doc Version 5.2 Page 26 Dovedale Court Nursing And Residential Home 2 3 4 OP7 OP9 OP9 people with dementia to inform and ensure no one is treated less favourably. Further work should be undertaken to ensure a person centred approach to care planning is undertaken based on individuals differing needs and involving the person. The specimen staff signatures for the administration of medication are kept up to date That all MAR sheets are maintained without gaps, and that medication is signed for the point of administration or an appropriate code entered for non-administration To purchase a new drugs fridge thermometer and commence daily recordings of minimum and maximum temperatures on the DE(E) units That all handwritten entries or changes on MAR sheets are signed and witnessed by two staff To ensure that Ibndronic Acid 150mg and Risedronate Sodium 35mg are administered strictly in accordance with written instructions with immediate effect; that is to be taken half an hour before food, drink or other medication with a full glass of water and that the resident remains sitting upright / standing for half an hour following administration To ensure any specialist instructions for the administration of medicines is clearly documented as part of the medication regime in each persons care plan The responsible person should source and introduce a short training course in the care of the dying for all staff. It is recommended that staff receive training around the Mental Capacity Act 2005 and their role, accountability and responsibility under the provision of this act. That the complaints register has an indication that an investigation has taken place, and whether upheld or whether complainant is satisfied with the outcome. That serious consideration is given to producing the complaints procedure in alternative formats, such as audio and pictorial / easy read versions That where staff have given residents verbal explanations of the complaints procedure, this is documented as part of their case file 5 6 7 OP9 OP9 OP9 8 9 10 OP9 OP11 OP14 11 OP16 12 13 OP16 OP16 Dovedale Court Nursing And Residential Home DS0000004846.V347743.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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