CARE HOMES FOR OLDER PEOPLE
Dovehaven 22 Albert Road Southport Merseyside PR9 0LG Lead Inspector
Daniel Hamilton Unannounced Inspection 31st July 2006 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 Dovehaven DS0000005399.V295725.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. Dovehaven DS0000005399.V295725.R01.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.V295725.R01.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 18th January 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. The Care Home Fee is £361.50 per week. Dovehaven DS0000005399.V295725.R01.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 a total of 10 hours. 34 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 Registered Manager, three staff members, 2 relatives and 8 residents were spoken to during the visit. Furthermore, satisfaction survey forms “Have Your Say About….” were distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional views / feedback about the home. All the core standards were reviewed and previous requirements and recommendations from the last inspection in January 2006 were discussed. What the service does well:
Dovehaven presented as a warm, comfortable and well-maintained environment. The home was decorated and furnished to a very good standard and the people living in the home appeared relaxed and well cared for. Staff were observed to be attentive and respectful towards the individual needs of residents and residents spoke highly of the care provided. Comments from two residents included; I wasn’t sure about moving into this place but its turned out to be very nice. The staff are good people and appear to genuinely care for our welfare” and “The carers have a warm and friendly nature and make you feel comfortable at all times.” Information on the service was available for prospective residents and / or their representatives to view and the home had developed an assessment and care planning system. Assessments of need had been undertaken before residents had moved in to ensure the home was able to meet the needs of residents. Feedback from residents and examination of records confirmed the people living in the home had access to health care services as required. A resident spoken with said; “The staff would not hesitate in contacting my doctor if I was ill. They are all very attentive. In my opinion I am well cared for.” Residents confirmed they were satisfied with the lifestyle experienced in the home and that they had choice and control over their lives. The home had developed a programme of activities which residents enjoyed and meals were well managed.
Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 6 Comments from three residents included; “There is a choice of activities on offer and we also have entertainers from time-to-time”; “I have as much freedom as I need and I’m happy living here” and “I get a varied menu and receive good food which is well cooked”. Residents reported that friends and family members were encouraged to visit at any reasonable time. A complaints procedure had been developed and feedback received from residents confirmed that they were aware of who to talk to if they had a concern and that they felt listened to. One resident spoken with said; “I have no complaints about the home. I am well looked after.” The complaints record book confirmed that the manager had acted upon complaints received from residents. Procedures were in place to protect residents from abuse and staff spoken with demonstrated a good understanding of their duty of care to protect vulnerable people. What has improved since the last inspection? What they could do better:
The home’s Statement of Purpose and Service User Guide should be updated to ensure residents and their representatives have the correct details of the Commission for Social Care Inspection. Some risk assessments had not been kept under regular review and did not clearly identify the risks, hazards and control measures. Action should be taken by the home to address this matter in order to fully safeguard the welfare of residents.
Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 7 Variable doses of medication had not always been recorded on Medication Administration Records. This practice is not safe and must stop. Furthermore, the balance of some medication checked was not the same as the balance recorded on Medication Administration Records. Regular checks should be undertaken to monitor and control this issue. Although the home had developed guidance to ensure the protection of vulnerable adults, a copy of the new local authority adult protection procedures was not in place. Likewise, a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain had not been obtained, as recommended at the last visit. The home should obtain a copy of both the documents for reference. Examination of recruitment records showed that only one reference was on file for an existing member of staff. The home should obtain a second reference in accordance with the Care Home Regulations 2001 and ensure all existing staff records are up-to-date. Training records showed that only 22.2 of the home’s staff had a National Vocational Qualification (NVQ) in Care at Level 2. A further four staff were working towards the award however action should be taken to ensure a minimum of 50 of the staff complete this award. The manager should also complete an award equivalent to the NVQ level 4 in Care and ensure all safe working practice training is up-to-date. As highlighted at the last inspection, the results of quality assurance questionnaires should be collated and published in order to improve consultation process and to provide useful information for current and prospective residents and other interested parties. 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. Dovehaven DS0000005399.V295725.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 Dovehaven DS0000005399.V295725.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of need had been undertaken prior to admission, to ensure the needs of prospective residents were identified. Prospective residents had access to a range of information on the home to enable them to make an informed decision about the service provided. EVIDENCE: The home had developed a Statement of Purpose and Service User Guide to provide information to prospective residents on the service provided. The manager reported that a copy of the document was given to residents or their representatives prior to admission. At the time of the inspection the document was in need of review, as it did not include details of the Commission for Social Care Inspection. Examination of records and 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 were available for inspection on files viewed. Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 10 Four files were viewed during the visit. Three files were for residents who had recently moved into the home and one was for a resident who had lived in the home for approximately ten years. Each file contained a copy of an assessment completed by a social worker and / or a health care professional. The assessments had been completed before each resident had moved into the home. Only one file contained a pre-admission assessment completed by the home as two residents had been admitted on an emergency basis. Dovehaven DS0000005399.V295725.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place that outlined how the care needs of residents were to be met. Some medication administration records were not being appropriately maintained to account for medication administered and stocks. Residents had access to health care services and care was provided in accordance with the needs and expectations of residents. EVIDENCE: Four files were examined during the visit. Three files were for residents who had recently moved into the home and one was for a resident who had lived in the home for approximately ten years. Each file contained a ‘Service User Plan’ which provided basic information on individual ‘Needs / Problems’, ‘Actions to be Taken’ by staff and the ‘Aims’ of each plan. Since the last visit, the home had taken action to ensure all the needs of residents and the support required by staff were identified and planned for. Care Plans viewed had been signed by residents or their representatives and kept under monthly review.
Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 12 Additional supporting documentation including; person centred risk assessments; handling load assessments; lifestyle profiles and health care, weight, accident / incident and daily report records were also in place. Some risk assessments had not been kept under regular review and the risk assessment for “Radiators and hot water” required more information in order to ensure the risk, hazards and preventative measures were identified and planned for. Health Care Records showed that residents had access to a range of health care services / professionals, subject to individual need. These included; hospital appointments; audiologists; general practitioners; chiropodists; district nurses and opticians. Feedback received from residents via Care Home Surveys and discussion confirmed residents had access to the medical support they needed. One resident reported; The care is excellent. I can’t praise the staff enough.” Likewise, another resident said; “The staff would not hesitate in contacting my doctor if I was ill. They are all very attentive. In my opinion I am well cared for.” The home had developed a medication policy to provide guidance to staff. A copy of guidelines issued by the Royal Pharmaceutical Society of Great Britain had not been obtained as recommended at the last visit. The deputy manager reported that staff responsible for the administration of medication had completed in-house training and received additional training from the local pharmacist. Systems had been developed to ensure the competency of staff responsible for the administration of medication was checked, prior to being authorised to administer medication. A record of staff authorised to administer medication together with sample signatures was in place. Likewise, a system had been established to check the identity of residents prior to administering medication. Declaration forms had been completed by service users (where practicable) to confirm consent had been obtained for the administration of medication and a risk assessment had been completed for a resident who self-administered medication. The home used a monitored dosage system, which was dispensed by a local pharmacist. Medication Administration Records (MAR) had been completed to record the administration of medication. Records were checked for four residents. Records viewed were generally well maintained however the balance of medication for one resident did not correspond with the number of tablets in stock and variable doses of medication had not been recorded for another resident. Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 13 Since the last inspection, arrangements had been made to stop secondary dispensing practice and the date and quantity of all medication entering the home had been recorded on Medication Administration Records. Suitable records were in place to account for medication returned to the pharmacist and to account for the administration of controlled drugs. Residents spoken with complimented the care provided and confirmed they were treated with privacy and dignity. Staff were observed to be respectful and sensitive towards the needs of residents during the visit and staff interviewed demonstrated a good awareness of how to promote social care values in their day-to-day practice. Comments from two residents included; “I wasn’t sure about moving in but its turned out to be very nice. The staff are good people and appear to genuinely care for our welfare” and “The carers have a warm and friendly nature and make you feel comfortable at all times.” Dovehaven DS0000005399.V295725.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 at least once during a 12 month period. 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 and activities within the home were flexible and varied to meet the preferred routines and recreational needs and interests of residents. Meals were well managed and residents received a wholesome and balanced diet. EVIDENCE: Feedback received from residents via Care Home Survey forms and through discussion confirmed that the home provided a range of recreational activities. The home’s record of activities and participants was viewed. This confirmed that activities were provided on a regular basis and that the home’s activities programme remained the same as at the last visit. Activities provided by the home included: Hairdressing on a Monday; a Trip to a choice of destinations in the home’s mini bus on a Tuesday afternoon; Bingo on a Wednesday afternoon; Musical Movement and Physical Exercises with a physiotherapist on a Thursday afternoon and an additional Bingo session on a Saturday afternoon. Representatives from three local churches also visited the home to meet with residents, subject to individual religious beliefs / preferences. Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 15 Residents spoken with expressed different views about their interest in activities but all were satisfied with the activities provided by the home. Feedback received from residents included; I’m not particularly interested in activities. I prefer my own company and like to read”; “Every Tuesday we have trips out. They are very good. We have visited the Wirral and other interesting places” and “There is a choice of activities on offer and we also have entertainers from time-to-time.” Residents spoken with confirmed they were able to exercise choice and control over their lives and that they were able to receive visitors of their choice at any reasonable time. Comments received from residents included: “I can come and go as I please. There are no restrictions”; “I have as much freedom as I need and I’m happy living here” and “I can visit my family whenever I wish and they can visit me whenever they want.” Residents were observed to receive visitors during the visit and were able to meet family and friends in the privacy of their own 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 were due to be changed in the near future, subject to 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. Feedback received from residents via Care Home Surveys and discussion confirmed residents were very satisfied with the range and quality of meals provided. Comments included; “I get a varied menu and receive good food which is well cooked”; “I’m not a big eater but the food is lovely and well presented” and “I have no complaints about the food. It is of good quality, well prepared and wholesome.” Additional drinks were served throughout the day and residents were able to eat their meals in their room if they wished. Care staff were available to provide assistance with meals as required. Special diets were catered for subject to individual need. Dovehaven DS0000005399.V295725.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 inspected at least once during a 12 month period. 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. Complaints received by the home had been handled appropriately and residents were confident that any complaints would be listened to and acted upon. Safeguards were in place to ensure a proper response to any suspicion or evidence of 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 was also displayed on the notice board in the reception area of the home. Records showed that three complaints had been received by the home since the last inspection and that the manager had taken appropriate action to resolve the issues. No complaints had been referred to the Commission for Social Care Inspection. 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 what they said. None of the residents spoken with during the visit had any complaints about the service. Comments included; “The home is lovely and I’m very happy living here”; “I have no complaints about the home. I am well looked after” and “The staff are excellent and will do anything they can to help you.” Policies and procedures were in place to provide guidance to staff on the procedures to follow in response to suspicion or evidence of abuse. At the time of the visit, the home did not have an up-to-date copy of the City of Liverpool
Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 17 and Borough of Sefton Adult protection procedures. The manager was advised to obtain a copy for reference. Good progress had been made on providing staff with training on the Protection of Vulnerable Adults from Abuse. Staff spoken with demonstrated a good awareness of the different types of abuse and how to recognise and respond to suspicion or evidence of abuse. Dovehaven DS0000005399.V295725.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 at least once during a 12 month period. 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 suitable for the needs of the residents and was accessible, well maintained and clean. EVIDENCE: The home was equipped with a call bell system, stair lifts and a passenger lift. Grab rails were fitted in some communal toilets and residents had access to mobility aids, subject to individual needs. The home had steps to the front entrance but was accessible via the rear entrance. The home did not have a maintenance plan for the maintenance and renewal of the fabric and decoration of the home as the home received ongoing investment and maintenance as required. Pre-inspection records detailed that seven rooms had been redecorated since the last visit. A partial tour of the premises was undertaken. Areas viewed were clean, hygienic and free from obvious hazards. The fabric, fittings and decoration remained in good condition and the grounds were well maintained.
Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 19 The home employed a handyperson and four part-time domestics, to ensure maintenance and domestic duties were undertaken. Health and Safety Audits were completed by the handperson and the manager on a monthly basis, to monitor the condition of the home and staff recorded details of work in need of attention / completed in a separate maintenance book. The home’s laundry was equipped with one drier, two washers, individual baskets and a stainless sink. The home had a sluice facility on the second floor. Infection Control procedures were in place and training records showed that staff received training in Infection Control, to ensure safe working practices. Residents spoken with confirmed that the home was always kept clean and fresh. One resident reported; “The home is well furnished, always warm and spotlessly clean.” Dovehaven DS0000005399.V295725.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff were deployed to meet the needs of the people living in the home. Recruitment practice had improved and safeguards were in place to protect the welfare of the people living in the home. Good progress was being made in supporting staff to undertake training and to develop competence. EVIDENCE: Inspection of the staffing rota, direct observation and discussion with the manager confirmed that staffing levels had not changed since the last visit. 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. Feedback received from residents during the visit confirmed the people living in the home received the care and support they required and that staff were available when needed. Staff were observed to be attentive to the needs of residents and were seen to spend time talking to residents and providing care and support as required. Residents and their representatives complimented the staff team and the care provided in the home. Comments included; “The staff are very good” and “The care is excellent. I can’t praise the staff enough.” Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 21 The manager reported that the home employed 18 care staff and that 4 staff (22.2 ) had completed a National Vocational Qualification at level 2 or above in Care. At the time of the visit, certificates were available for only 2 staff (11.1 ). A further four staff were working towards the award. Once the outstanding staff have completed the award and all staff have received their certificates, 8 of the staff (44.4 ) will have completed the qualification. The home had a recruitment and an equal opportunities policy in place. The manager was advised to review the home’s policies and procedures as the recruitment policy had not been reviewed since February 2003. Only one new care staff had commenced employment at the home since the last visit. Recruitment records were examined for the new starter and three existing staff. Records confirmed that the home had undertaken a Protection of Vulnerable Adult check and received two written references prior to starting the new member of staff. An application form, health declaration, proof of identity (but no photograph), contract of employment and induction and training record were also on file. The recruitment records for the existing members of staff were generally in order with the exception of one employee, who only had one written reference on file. The manager was advised to review recruitment information to ensure all the necessary records are in place in accordance with Regulation 19 (4). Examination of training records and discussion with staff confirmed staff had access to induction, safe working practice and ongoing training that was relevant to their role. The home’s training matrix identified that some staff had not completed training in all safe working practice training topics. Records showed that the manager had developed systems to monitor outstanding training needs for staff and was in the process of nominating staff for additional training. Dovehaven DS0000005399.V295725.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their representatives were consulted periodically about the quality of the service provided, however the results of service user surveys had not been published and made available to current and prospective users. Systems had been developed to protect the financial interests of residents and to safeguard health and safety. 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.V295725.R01.S.doc Version 5.2 Page 23 The manager did not have a NVQ level 4 in Care and required refresher training for some Safe Working Practice topics as noted at the last inspection. Residents, staff and visitors spoken with during the inspection reported that the manager was friendly, approachable and supportive in her role. The manager was observed to spend time chatting, supporting and listening to residents throughout the day and demonstrated a commitment to creating a warm and inclusive atmosphere. The home continued to commission an external consultant to undertake an annual quality assurance assessment. The manager reported that Quality Assurance Questionnaires had been distributed to residents by the home during October 2005, however copies were not available for inspection. The results of the surveys had not been published for current and prospective residents, their representatives and other interested parties to view, as recommended at the last visit. Discussion with the manager and residents confirmed that one residents’ meeting had taken place on the 24th July 2006. Minutes were not available to view at the time of the visit. Records showed that the manager did not act as an appointee for any of the residents. 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 reported that she looked after the personal allowances for five residents. Two records were checked. Records of financial transactions were up-to-date and balances were correct. Pre-inspection records detailed that equipment within the home was regularly inspected and serviced. Since the last inspection the home had arranged to have the gas installation checked and a gas safety certificate dated 27/01/06 was viewed. Training in Safe Working Practices was provided to staff. Inspection of fire records confirmed that the fire alarm system was tested on a weekly basis and that a monthly visual inspection of the emergency lighting was undertaken. There was no record of the fire extinguishers being visually inspected each month as recommended by the fire department. Service certificates confirmed that the fire alarm, extinguishers and emergency lights were tested by a contractor during June 2006. Records evidenced that night staff received fire refresher training every three months and day staff every six months. All staff had access to annual Fire instruction training. Dovehaven DS0000005399.V295725.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement Variable doses of medication administered must be recorded on Medication Administration Records. Timescale for action 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP1 OP7 OP7 OP9 Good Practice Recommendations The Statement of Purpose / Service User Guide and Contract should be updated to include details of the Commission for Social Care Inspection. Risk assessments should be reviewed on a regular basis and the date of the review recorded. Care plans should be updated to ensure the section entitled ‘Actions to be Taken’ by staff is completed in more detail. A copy of ‘The Administration and Control of Medicines in Care Homes and Children Services’ (Issued by the Royal Pharmaceutical Society of Great Britain) should be obtained for reference. The balance detailed on Medication Administration records
DS0000005399.V295725.R01.S.doc Version 5.2 Page 26 5. OP9 Dovehaven 6. 7. 8. 9. 10. 11. 12. OP7 OP18 OP28 OP29 OP31 OP29 OP33 13. 14. OP33 OP38 should correspond with the actual number of tablets in stock The risk assessments for Radiators and hot water should be updated to ensure the risks, hazards and control measures are identified and planned for. The home should obtain a copy of the City of Liverpool and Borough of Sefton Adult Protection Procedures. 50 of the care staff should have completed a National Vocational Qualification in Care at level 2 or equivalent by 31st December 2005. All existing staff records should be brought up-to-date in accordance with Regulation 19 and Schedule 2. The Manager should complete the National Vocational Qualification level 4 in Care award and ensure all Safe Working Practice training is up-to-date. The home’s policies and procedure should be kept under regular review. A summary of the results of quality assurance questionnaires should be produced and made available to current and prospective residents, their representatives and other interested parties. Minutes of residents meetings should be maintained and available for inspection. The fire extinguishers should be visually inspected each month and records maintained. Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Dovehaven DS0000005399.V295725.R01.S.doc Version 5.2 Page 28 - 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!
