CARE HOMES FOR OLDER PEOPLE
Dovehaven 22 Albert Road Southport Merseyside PR9 0LG Lead Inspector
Daniel Hamilton Unannounced 4th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Dovehaven Address 22 Albert Road Southport Merseyside PR9 0LG 01704 548880 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mark Gillbert Miss Laura Smith Care Home 42 Category(ies) of OP Old age 32 registration, with number PD(E) Physical Disability 10 of places Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 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 29th November 2004 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. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours. It was an unannounced visit and conducted as part of the regulatory requirement for care homes to be inspected at least twice a year. There had been no cause for any visits to the home since the last routine inspection in November 2004. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The manager, 3 staff members, 8 of the 36 residents and 3 relatives were spoken with during the visit and their views obtained of the home. Comments cards were also left in the home to enable residents and others to comment on the service provided. What the service does well:
All residents and relatives spoken with during the visit complimented the service provided at Dovehaven. One resident reported; “All the carers are lovely and provide tender loving care.” A relative said; “the staff are very kind and caring.” The home was suitable for the needs of the residents and was accessible, clean and well maintained. Pre-admission assessments had been completed for residents who had moved in since the last visit. The health care needs of residents were being met and one relative said; “They look after my mother’s personal and health care and keep me well informed about her welfare.” Daily life within the home and visiting times were flexible. One resident advised; “My visitors come when I want them to” and another stated; “I can please myself what I do and when I do it.” A range of nutritious meals was provided and residents praised the standard of food and choices available. A resident commented; “The food is wonderful, the care is unceasing and the staff never grumble whatever you ask for.” Complaints had been acted upon by the home and residents spoken with had no complaints. A resident advised; “If you’re worried about something you can approach Carol and Laura and they will sort it out.” Sufficient staff were on duty to meet the needs of residents and safeguards were in place to protect residents from abuse. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Assessments of need had been completed for new residents, to enable the home to identify the care needs of residents, prior to admission. EVIDENCE: Four files were viewed. Two files were for residents who had moved into the home since the last inspection and two were for residents who had lived in the home for over nine years. The home had completed comprehensive pre-admission assessments and care management assessments from Social Services were also in place for the two residents who had recently moved into the home. There were no assessments on file for the two residents who had lived in the home for a number of years. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 9 and 10 Care plans did not detail all the needs of residents. Furthermore, medication was not being correctly recorded and appropriate safeguards were not in place for residents who self-administer medication. These shortfalls have the potential to place residents at risk. Residents had access to health care services and care was provided in accordance with the needs and expectations of residents. EVIDENCE: Four files were viewed. Each resident had a plan of care that identified relevant aspects of their health, social and personal care. One care plan lacked detail of the action required by staff to meet the identified needs of a resident and another care plan did not detail all the needs of a resident. Risk assessments had been completed for each resident although a nutritional risk assessment had not been completed for a resident who was experiencing difficulties with dietary intake. Two care plans had not been signed by residents or their relatives. Discussion with residents and examination of health care records confirmed that residents had access to health care professionals including; doctors, hospital staff and chiropodists. A relative reported; “They look after my
Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 10 mother’s personal and health care and keep me well informed about her welfare”. The home had a medication policy in place. Staff responsible for administering medication completed a 12-week in–house training programme and training from the home’s pharmacist. Risk assessments had not been completed for two residents who self-administered medication and a medication record had not been correctly completed to record that a resident had refused medication. Staff spoken with during the visit demonstrated a good understanding of how to treat residents with respect and maintain their dignity and privacy. Residents spoken with were satisfied with the care provided. Comments included: “All the carers are lovely and provide tender loving care”; “The staff knock before they come in and treat you nice when you have a bath” and; “I am cared for well and made to feel comfortable.” A relative said; “The staff are very kind and caring.” Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14 and 15 Residents had control of their own lives and were able to maintain their relationships and preferred lifestyle. Meals were well managed and residents received a wholesome and balanced diet. EVIDENCE: Residents spoken with confirmed that visiting times were flexible and that they were able to maintain contact with people of their choice both inside and outside the home. One resident said; “My visitors come when I want them to visit” and another stated; “Anyone can come practically any time.” A relative reported; “I can visit whenever my mum wants me to.” Residents reported that they had the opportunity to maintain links in the local community and some residents visited libraries, attended church services and participated in trips organised by the home. Daily life within the home was flexible and residents were able to choose what they wanted to do each day. Comments from three residents included: “I am perfectly free to lead my own life”; “I can please myself what I do and when I do it” and “I have control of my life and do my own things.” Meals were served in the home’s dining room, which was pleasant and equipped with tablecloths, flowers and condiments. The home had a four-week menu, which showed residents received a choice of meals for each sitting and received a balanced and nutritious diet. A copy of the daily menu and options
Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 12 were displayed on the home’s notice board and on each table. Although meals were served at set times, arrangements were flexible to accommodate individual needs. Overall, residents spoken with complimented the quality of the food provided. One resident said; “The food is wonderful, the care is unceasing and the staff never grumble whatever you ask for.” Another said; “The food is good and there are different choices available.” Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 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 and maintained a record of all complaints received. Records showed that three complaints had been received since the last inspection. Two complaints concerned windows being closed in two areas of the home and the third complaint concerned visitors passing a resident on a staircase whilst using a stair lift. Records showed that the home had taken appropriate action to respond to each individual complaint. Residents spoken with during the visit had no complaints about the home and were confident that if they had a complaint the home would address their concerns. A resident said; “If you’re worried about something you can approach Carol and Laura and they will sort it out.” The home had a range of policies and procedures in place to provide guidance to staff on the correct procedures to follow in response to suspicion or evidence of abuse. Staff spoken with demonstrated a basic awareness of the concept of abuse and their duty of care to protect vulnerable people. Training on Abuse / Adult Protection was due to be provided for all staff members by the end of July 2005. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home was suitable for the needs of the residents and was accessible, well maintained and safe. The environment was clean, well furnished and homely and the comfort of residents was not compromised. EVIDENCE: The manager and handyman completed a health and safety risk assessment every 4 to 6 weeks to monitor the condition of the home. Jobs requiring attention by the home’s handyman were recorded in a maintenance book by the home’s staff. A maintenance plan was not in place as the home received ongoing investment and maintenance as required. Since the last inspection four rooms had been fitted with new carpets and two of the rooms had new curtains and bedroom furniture. All areas viewed during the visit were free from obvious hazards and were well maintained. The fabric and decoration was in good order and this provided residents with a pleasant and comfortable home in which to live. Residents spoken to confirmed that the home was kept clean and tidy. One resident stated; “The home is spotless. You can’t move at times because of hoovers.”
Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Sufficient numbers of staff were deployed to meet the needs of the people living in the home. There were gaps in recruitment practice that must be addressed to safeguard and protect residents. Some staff had not received all the necessary training, to ensure competency in their role. EVIDENCE: Inspection of the staffing rota and direct observation confirmed that three care assistants and the manager or a senior carer were on duty during the day. At night, two waking night staff were on duty with an additional member of staff providing a sleep-in service. Residents spoken with were satisfied that sufficient numbers of staff were on duty to meet their needs and spoke highly of the staff team. Comments included: “Generally there are enough staff to help us”; “I can’t fault the staff in any way” and; “The staff are very good and work hard.” One member of staff had commenced employment at the home since the last inspection without an up-to-date Protection of Vulnerable Adults (POVA) check. Furthermore, a Criminal Record Bureau (CRB) certificate was photocopied with one page missing and related to previous employment. Files viewed did not contain all the necessary information required under the Care Home Regulations and application forms did not provide sufficient space for applicants to record their full employment history. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 16 Discussion with staff and examination of personnel files confirmed that new staff received induction training. Staff had not completed all safe practice training and refresher training was needed for some staff members. Staff files viewed did not contain an individual record of all training completed. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Some important records were not being appropriately maintained, to safeguard the health, safety and welfare of residents and staff. EVIDENCE: Service, maintenance and insurance certificates were available within the home. Inspection of fire records showed that the fire alarm system had not always been tested on a weekly basis and that staff were not receiving fire instruction refresher training at the recommended intervals. All areas viewed during the visit appeared to be well maintained and free from obvious hazards. Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 2 Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Care plans must identify all the health, personal and social care needs of service users and detail the support required by staff to ensure that all the needs of service users are met.. A risk assessment must be completed for residents who selfadminister their medication.. Medication administration records must be accurately completed and the correct codes used when applicable.. Staff must only be confirmed in post if full and satisfactory information has been obtained via a POVA check and a CRB has been applied for.. All staff records must be brought up-to-date in accordance with schedule 2 of the Care Home Regulations.. Safe practice training must be completed by all staff and refresher training must be completed periodically.. Each member of staff must have an up-to-date record of all training completed. The fire alarm system must be tested on a weekly basis. Timescale for action 4/09/05. 2. 3. 9 9 13 (4) 13 (2) 4/09/05 4/09/05 4. 29 19 4/09/05 5. 29 19 4/09/05 6. 30 18 4/10/05 7. 8. 30 38 19 23 (4) 4/09/05 4/09/05
Page 20 Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 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 7 8 29 38 Good Practice Recommendations Care plans should be signed by service users and / or their representatives. A nutritional risk assessment should be completed for residents who have difficulties with their dietary intake. The application forms for the home should be revised to provide sufficient space for job applicants to detail their full employment history. Night staff should receive fire instruction refresher training every three months and day staff every six months and records should be maintained Dovehaven F53 F03 S5399 Dovehaven V229300 040705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Burlington House, South Wing 2nd Floor, Crosby Road North Waterloo Liverpool L22 OLG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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