Inspection on 01/05/07 for Dovehaven

This inspection was carried out on 1st May 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

Dovehaven 31/07/06

Dovehaven 18/01/06

Dovehaven 04/07/05

Dovehaven 29/11/04

Dovehaven 22/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Dovehaven 22 Albert Road Southport Merseyside PR9 0LG Lead Inspector Daniel Hamilton Unannounced Inspection 1st May 2007 8:45 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 Dovehaven DS0000005399.V334908.R03.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. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dovehaven Address 22 Albert Road Southport Merseyside PR9 0LG 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) 01704 548880 Mr Mark J Gilbert Mrs Wendy J Gilbert Miss Laura Smith Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability over 65 years of age of places (10) Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 32 OP and up to 10 PD(E) Date of last inspection 31st July 2006 Brief Description of the Service: Dovehaven is a residential care home for older people providing 42 registered places, 32 of which are registered for older people and 10 for older people with a physical disability. The home is situated close to Southport town centre and all its amenities and is within easy reach of shops, parks and public transport. The home has 36 bedrooms, 6 of which are double rooms however these are currently used for single occupancy. The communal areas consist of a dining room and a large lounge to the front of the building with a conservatory attached. A smaller lounge is available for residents who wish to smoke. Toileting and bathing facilities are located throughout. The home has three levels with a passenger lift serving the main floors and chair lifts to the mezzanine floors giving residents access to all parts of the building. A call bell system is fitted in all areas of the home. There is a large garden to the rear of the home and parking facilities are available at the front of the property. The Care Home Fee is currently £370.00 per week. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 9.5 hours. 35 residents were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Owner, Registered Manager, Deputy Manager, two staff, two visitors and 8 residents were spoken to during the visit. Survey forms “Have Your Say About……” were also sent to all the residents or their representatives prior to the inspection, to obtain additional views / feedback about the home. All the key standards were assessed and action taken in response to previous requirements and / or recommendations issued at the last inspection in July 2006 was reviewed. What the service does well: Dovehaven presented as a caring and homely environment. The home was clean, decorated and furnished to a high standard. The people living in the home appeared relaxed and comfortable and staff were observed providing appropriate care and support to residents throughout the day. Feedback received from residents included; “The place is wonderful”; “Everybody is helpful and kind” and “I am happy and contented with the care I receive.” A relative said; “My mother is always spoken to nicely.” Daily life within the home was flexible and residents were able to receive visitors and exercise choice and control over their lives. One resident said; “It’s a nice home to live in and there are no set routines except mealtimes. I think it’s an easy going place to be.” A selection of activities were provided for residents to participate in and a number of residents spoken with reported that they had enjoyed a trip to Burbo Bank at Blundellsands on the day of the visit. Meals were well managed and a choice of nutritious and wholesome meals were provided each day. Residents complimented the quality of the catering. For example, comments received from two residents included; “Meals are excellent on the whole and beautifully laid out with lots of tea and biscuits in between” and “There is always good food at the home with a good variety of choices.” Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 6 Complaints / concerns had been acted upon by the manager and residents spoken with confirmed that they were confident that their views would be listened to and acted upon. The home’s complaints procedure was displayed around the home for people to view. Systems had been established to account for personal money handled on behalf of the people using the service and a quality assurance system had been developed, which included seeking the views of the people using the service and / or their representatives. What has improved since the last inspection? What they could do better: Some pre-admission assessments completed by the home were incomplete and lacked detail on equality and diversity issues, for example ethnicity. A full assessment of need should always be undertaken to confirm the service can meet the diverse needs of people accessing social care services. Risk assessments viewed lacked information on the preventative measures required to control risks / hazards. Risk assessments should be updated to Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 7 address this issue, to ensure the welfare of the people using the service is fully safeguarded. The home had changed its recording system for monitoring the outcome of health care appointments since the last visit and the outcome of some appointments had not been recorded. Arrangements should be made to address this issue, to provide evidence that all the health care needs of residents are monitored. The home had not achieved the target date of 31st December 2005 for 50 of the care staff to achieve a National Vocational Qualification in Care at level 2 or equivalent. Arrangements had been made to ensure the home was working towards the 50 target and this should be kept under regular review. Although induction records were available for the majority of new staff, records showed that staff had not been inducted in accordance with the new ‘Skills for Care’ – Common Induction Standards and some induction records were incomplete or could not be located. Action should be taken to ensure staff are inducted appropriately, before they are considered safe to work with vulnerable adults. Staff spoken with also reported that they had not received formal supervision from their line manager. The manager should review the practice and training and development needs of staff as part of a formal supervision process, to ensure staff are appropriately supported. Some staff spoken with reported that they had not completed all the necessary Safe Working Practice training and training records highlighted a number of staff required this important training. The home should continue to monitor the training needs of all staff and support them to complete statutory training in key health and safety subjects e.g. food hygiene, first aid, infection control, moving and handling and fire awareness, to safeguard the health and safety of the people using the service. A fire risk assessment could not be located and there was no evidence that the home’s lifting equipment was being serviced twice a year in accordance with the Lifting Operations and Lifting Equipment Regulations. These issues must be addressed to confirm the home complies with the relevant health and safety legislation. 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. Dovehaven DS0000005399.V334908.R03.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 Dovehaven DS0000005399.V334908.R03.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): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some assessment information completed by the home was incomplete. Unless a full assessment is undertaken before admission there is no assurance that care needs will be met. EVIDENCE: Since the last visit, the home’s Statement of Purpose and Service User Guide had been updated to include the contact details of the Commission for Social Care Inspection. The manager was advised to display a copy in the reception area of the home for visitors to view. Feedback received from residents through discussion and via Care Home Survey forms confirmed that residents had received a Contract and information on the home prior to admission. Signed copies of individual contracts had been stored within each resident’s personal file. The files of four residents who had moved into the home since the last visit were viewed (Case Tracked) during the visit. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 10 A copy of a pre-admission assessment been completed by the home for three of the four residents. Two of the assessments were incomplete as the third page was missing and key information on; social interests, hobbies, religious and cultural needs; personal safety and risk; mental state and cognition; carer and family involvement and social contacts / relationships had not been assessed. The manager was advised to update the assessment documentation to ensure a full assessment of needs is undertaken for all prospective residents, which considers equality and diversity issues. Copies of assessments completed by health or social services care managers had also been obtained for people referred through care management arrangements. Dovehaven DS0000005399.V334908.R03.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some records were in need of review, however the people living in the home confirmed they had received appropriate care and support, to ensure their health and personal care needs were met. EVIDENCE: The files of four residents who had moved into the home since the last inspection were viewed (case tracked). The manager reported that the care plans had been updated / improved since the last visit. Care plans viewed included key information on each person’s ‘level of functioning’; health, personal and social care ‘needs’; ‘actions to be taken’ and ‘aims’. Care plans had been kept under monthly review and signed by individual residents and / or their representatives. Supporting documentation including risk assessments and daily report sheets were also available for reference. Advice was given to the manager on how to develop risk assessments, as examples viewed had limited information on the preventative / control measures. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 12 Since the last visit, the home had stopped recording details of health care appointments and the outcomes of visits on ‘Additional Information Sheets.’ Visits from doctors and district nurses had been recorded on daily record sheets. The names of residents who had attended Chiropodist and Dentist visits had been recorded on a separate record however no details of the outcomes of appointments had been recorded. Weight records had been completed every 6 to 8 weeks. The manager was advised to establish individual records for all health care appointments to improve record keeping and to demonstrate the health care needs of all residents were being monitored. Feedback received from residents via Care Home Surveys and discussion confirmed residents had access to the medical support they needed. For example; a resident spoken with said; “I have seen a doctor since I moved in.” Likewise, another resident said; “A doctor, district nurse and chiropodist have visited me. The staff don’t hesitate in calling the doctor if someone is unwell.” Previous inspection records detail that the home had developed a medication policy and that staff responsible for the administration of medication had completed both in-house and training from the local pharmacist or an external training provider. Records of staff authorised to administer medication were in place and a system had been established to check the competency of staff and the identity of residents prior to administering medication. The deputy manager was advised to also review the competency of staff responsible for medication at regular intervals. Since the last visit, a copy of guidelines issued by the Royal Pharmaceutical Society of Great Britain had been obtained for staff to reference. Declaration forms had been completed by residents (where practicable) to confirm consent had been obtained for the administration of medication and a risk assessment had been completed for two residents who self-administered medication. Advice was given to the deputy manager on how to further develop the risk assessment for people who self-administered, to provide more detail of the assessment, monitoring and review processes. The home continued to use a monitored dosage system, which was dispensed by a local pharmacist. Medication Administration Records (MAR) viewed had been correctly completed to record the details of medication received and administered in the home. The deputy manager was advised to record the date medication boxes are opened to provide an audit trail. Suitable systems had been established to account for medication returned to the pharmacist. Feedback received from residents and / or their representatives confirmed the people living in the home were treated with privacy and dignity. Staff spoken with during the visit were able to give good examples of how they promoted the principles of respect, privacy and dignity in their day-to-day care practices. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 13 Comments received from the people living in the home included; “The place is wonderful”; “Everybody is helpful and kind” and “I am happy and contented with the care I receive.” A relative said; “My mother is always spoken to nicely.” Dovehaven DS0000005399.V334908.R03.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily life, activities and meals were flexible and varied to meet the preferred routines, expectations and preferences of the people living in the home. EVIDENCE: Discussion with the Manager and Residents confirmed that the home continued to provide activities for the people living in the home. The programme of activities remained the same as at the last visit, with the exception of hairdressing. The hairdressing day had moved from a Monday to Wednesday and Saturdays Other activities provided by the home included: a Trip to a choice of destinations in the home’s mini bus on a Tuesday afternoon; bingo on a Wednesday and Saturday and Musical Movement and Physical exercises with a physiotherapist on a Thursday afternoon. Records of activities showed that an outside entertainer had also visited the home and that representatives from the local Roman Catholic church visited residents on a weekly basis, subject to their religious beliefs. Some residents spoken with reported that representatives from the local Elam church had also attended the home, however record of activities and participants showed they had not visited since December 2006. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 15 Overall feedback received from residents and / or their representatives via Care Home Survey forms and discussion confirmed the people living in the home were generally satisfied with the activities provided and encouraged to participate, dependent upon their wishes and interest. Only one resident spoken with reported that they would like to see more activities. Residents reported that they especially enjoyed the weekly trips out. One resident said; “We’ve been to Burbo Bank at Blundellsands today in the minibus. It’s always nice to get out.” Residents spoken with confirmed that the lifestyle experienced in the home was relaxed and geared towards their needs and preferences. Residents also reported that they were encouraged to retain their independence and to exercise choice and control over their lives. One resident said; “It’s a nice home to live in and there are no set routines except mealtimes. I think it’s an easy going place to be.” Rooms viewed had been personalised with pictures and personal possessions and friends and relatives were observed to visit residents throughout the day in the communal areas of the home or in the privacy of resident’s rooms. Meals were served in the home’s dining room, which was pleasantly furnished with condiments, tablemats and flowers. The home had a four-week menu, which provided a choice of alternative meals for residents at each sitting. The manager reported that the menus had been amended during September 2006 in consultation with residents. Menus viewed offered residents a balanced, wholesome and nutritious diet. A copy of the daily menu was displayed on the home’s notice board and on each table for residents to view. On the day of the visit, residents were served mixed grill with boiled or chipped potatoes for dinner with peaches and custard for desert (unless they had chosen an alternative). Feedback received from residents via Care Home Surveys and discussion confirmed residents were very satisfied with the range and quality of meals provided. Comments received from residents and / or their representatives included; “A very good home. The meals are excellent and the staff are very caring”; “Meals are excellent on the whole and beautifully laid out with lots of tea and biscuits in between” and “There is always good food at the home with a good variety of choices.” Staff were available to offer support to residents at mealtimes and the manager reported that special and cultural dietary needs would be catered for, subject to individual needs. Dovehaven DS0000005399.V334908.R03.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems had been developed to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The home had a complaints policy, the details of which were included in the home’s Statement of Purpose and Service User Guide. A copy of the policy was displayed on notice boards throughout the home. Records showed that six complaints had been received by the home since the last inspection. The complaints (concerns) were made by residents regarding excessive noise from television sets (2) and the kitchen (1), missing articles of clothing (1), residents sitting in communal chairs (1) and plates and soup bowls being left on the table when desert was being served (1). Records showed that the manager had taken appropriate action to resolve the issues. No complaints had been referred to the Commission for Social Care Inspection since the last visit. Feedback received from residents via Care Home Survey forms and through discussion confirmed that the residents were aware of how to complain and that the staff listened and acted upon any issues raised. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 17 Comments included; “There is no need to be unhappy. Everything is fine”; “The manager is a very understanding person to speak to” and “I don’t have anything to complain about.” Since the last visit, the home had obtained an up-to-date copy of the City of Liverpool and Borough of Sefton Adult protection procedures. Policies and procedures were also in place to provide guidance to staff on the procedures to follow in response to suspicion or evidence of abuse. The manager reported that the home employed 27 staff in various capacities. Pre-inspection records detailed that ‘Abuse’ training had been organised during July 2006. Nine staff had not completed the training at the time of the visit. The manager reported that training would be arranged for the outstanding staff as a matter of priority Staff interviewed during the visit confirmed they had completed training in the protection of vulnerable adults. One person lacked awareness of how to recognise and respond to suspicion or evidence of abuse. This was discussed with the manager and immediate action was taken to clarify the issues raised. Dovehaven DS0000005399.V334908.R03.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was well maintained and clean. This provided residents with an attractive and comfortable home in which to live. EVIDENCE: The home continued to employ a handyperson who was responsible for maintaining the home. Contractors were hired for major and specialised work as and when required. A maintenance plan had not been developed for the renewal of the fabric and decoration of the home however areas viewed were maintained to a good standard. Records were available to confirm the manager and handyperson had undertaken a monthly health and safety audit / checklist, to monitor the condition of the home. Pre-inspection records detailed that since the last visit, six bedrooms had been decorated and re-carpeted, the ceiling in the ground floor toilet had been lowered and the area redecorated, a new washing machine had been installed Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 19 in the laundry and a new deep fat fryer had been fitted in the kitchen. A new de-luxe bath master seat (electronic lifting equipment) had also been purchased to assist residents with poor mobility. The front entrance of the home was accessed via steps however the rear entrance was accessible to wheelchair users. The home was equipped with a call bell system, stair lifts and a passenger lift and assisted bathing and toilet facilities were available for residents to use. Residents were observed to have access to personal mobility aids, subject to individual needs. (Please refer to the ‘Brief Description of the Service’ section for more information on the premises). Rotas showed that the home continued to employ four part-time domestics. Areas viewed during the visit were clean and free from offensive smells. Infection Control procedures were available for reference however training records showed that 13 of the home’s staff had not completed training in this subject. Residents spoken with confirmed that the home was always kept clean and fresh. Dovehaven DS0000005399.V334908.R03.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who are correctly recruited however some staff have not completed the necessary training, to confirm they are competent to undertake their roles effectively. EVIDENCE: The home’s staffing rotas detailed that staffing levels remained the same as at the last visit and this was confirmed through discussion with the manager and staff. Three care assistants and the manager or a senior member of staff were on duty during the day, with two waking night staff and an additional member of staff providing a sleep-in service throughout the night. The manager was allocated one day per week, to complete administrative duties. Residents spoken with during the inspection confirmed that staff were always available when required to assist them with personal care and day-to-day activities and this was discreetly observed in practice. The home had a recruitment policy in place, which had recently been updated. Since the last visit, four new staff had commenced employment at the home. Records required under the Care Home Regulations 2001 were in place for all the staff. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 21 Staff records viewed did not contain evidence of staff supervision and staff spoken with reported that they had not received formal supervision from the manager. Records of induction were available for all new staff with the exception of one employee. The staff member was spoken with during the inspection and reported that she had not received an induction. This was discussed with the manager during the visit. Some induction records viewed had not been signed by staff or were not dated. The home’s induction programme was based upon the Training Organisation for Personal Social Services (TOPSS) induction standards, which were withdrawn at the end of September 2006. The manager was advised to update the induction programme to ensure it complied with the ‘Skills for Care’ common induction standards. Eighteen care staff were employed in the home. The manager reported that seven staff (38.8 ) had completed a National Vocational Qualification (NVQ) at level 2 or above in Care however certificates were available for only six staff (33.33 ). A further three staff were working towards the award. One qualified member of staff had left the home since the last visit. Once the outstanding staff have completed the award and all staff have received their certificates, 10 of the staff (55.55 ) will have completed the qualification. Pre-inspection records detailed that some staff had received training in the protection of vulnerable adults (abuse), fire awareness, medication and moving and handling training since the last inspection. A record of staff training for the team had been written on a white board for reference. The dates of training had not been recorded. The matrix showed that a number of staff required training for; food hygiene (14), health and safety (11), fire awareness (9), moving and handling (4) and infection control training (13). Dovehaven DS0000005399.V334908.R03.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed effectively, and the views of residents and their relatives sought to ensure an ongoing quality service. EVIDENCE: The manager (Miss Laura Smith) was registered with the Commission for Social Care Inspection and had managed the home since 1997. Prior to her appointment, she had gained approximately 5 years experience as the deputy manager of the home. Records showed that the manager had completed a range of training that was relevant to her role. This included; the National Vocational Qualification (NVQ) level 4 in Management, the City and Guilds 325/3 Advanced Management for Care and the D32/D33 assessor’s award. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 23 The manager reported that she had completed medication and fire awareness training since the last visit. The manager had not enrolled to undertake a NVQ level 4 in Care and required refresher training in some safe working practice topics as previously noted. Residents and relatives spoken with during the visit confirmed the manager was approachable and supportive in her role. The home continued to commission an external consultant to undertake an annual quality assurance assessment. This was last completed during March 2007 and involved the distribution of survey forms to residents and / or their representatives. The results of the surveys had been displayed in the reception area of the home. Since the last visit, the manager had coordinated two Resident Meetings during August 2006 and March 2007. Minutes of the meetings were available for reference. Pre-inspection records detailed that the manager did not act as an appointee for any of the residents. The manager confirmed that all the residents looked after their financial affairs independently or with support from family members / solicitors. The organisations head office was responsible for invoicing and administering fees as noted at the last visit. The manager looked after the personal allowances for eight residents. Records checked were up-to-date, receipts had been obtained and balances were correct. Pre-inspection records detailed that equipment within the home was regularly inspected and serviced. Fire records were examined. Records confirmed that the fire alarm system was tested on a weekly basis and the emergency lighting and fire doors on a monthly basis. Records were also in place to confirm visual inspections had been undertaken on the fire extinguishers although some gaps were noted. A certificate was in place to confirm the emergency lights, fire extinguishers and fire alarm system had been serviced. Records were available to confirm that staff had received fire refresher training every six months. At the time of the visit, the home’s fire risk assessment could not be located. A selection of other service / maintenance and insurance certificates were viewed. No service contract was available to confirm that equipment for lifting persons was being serviced twice a year in accordance with the Lifting Operations and Lifting Equipment Regulations (L.O.L.E.R). Monthly records of Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 24 tests / servicing had been recorded by the handyperson, however there were no details of which equipment had been tested. Some staff had not completed all the necessary Safe Working Practice training as identified in Standard 30. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 25 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 3 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 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 26 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 OP38 Regulation 23 (2) (C) Requirement A certificate must be obtained to confirm lifting equipment used by the people in the home is safe and has been serviced in accordance with the Lifting Operations and Lifting Equipment Regulations. Timescale for action 15/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations A full assessment of needs should be undertaken by the home prior to prospective residents being admitted, to ensure the diverse needs of people accessing the service are assessed. The home’s pre-admission assessment should be updated to ensure equality and diversity issues are considered as part of the assessment process, to ensure best practice. Risk assessments should be updated to identify the hazard / issue, level of risk, preventative measures and contingency arrangements. This will provide better safeguards for the people using the service. DS0000005399.V334908.R03.S.doc Version 5.2 Page 27 2 3 OP3 OP7 Dovehaven 4 OP8 5 OP9 6 OP18 7 OP28 8 9 10 11 12 OP30 OP30 OP31 OP38 OP38 Individual records of all Health Care Appointments should be established and the outcomes recorded, to provide evidence that the home supports people to remain in good health. Risk assessments for people who self-administer medication should be reviewed to ensure they provide more information on the assessment, monitoring and review processes. All staff working in the home should completed training in the Protection of Vulnerable Adults from Abuse and refresher training should be organised when required. This will help staff to recognise and respond to abuse appropriately. 50 of the care staff should have completed a National Vocational Qualification in Care at level 2 or equivalent by 31st December 2005, to comply with National Training Targets. The home’s induction programme should be updated in accordance with the ‘Skills for Care’, to ensure staff are trained in accordance with Common Induction Standards. All staff should complete Induction training and records should be dated and signed to provide evidence of induction. The manager should complete a National Vocational Qualification in Care at Level 4, to ensure she has the necessary qualifications for her role. An up-to-date fire risk assessment should be available for inspection, to ensure compliance with fire safety laws. All staff should complete training in Safe Working Practice topics, to ensure safeguard health and safety practice. Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dovehaven DS0000005399.V334908.R03.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!