CARE HOMES FOR OLDER PEOPLE
Dovehaven House 58 Moss Road Birkdale Southport Lancashire PR8 4JG Lead Inspector
Val Turley Unannounced Inspection 16th September 2005 09:45 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 House DS0000005973.V250660.R01.S.doc Version 5.0 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 House DS0000005973.V250660.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Dovehaven House Address 58 Moss Road Birkdale Southport Lancashire PR8 4JG 01704 564259 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) Mr Mark Jonathan Gilbert Mrs Wendy Josephine Gilbert Mr Peter Andrew Brookfield Care Home 40 Category(ies) of Dementia - over 65 years of age (40) registration, with number of places Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th February 2005 Brief Description of the Service: Dovehaven house is situated in the village of Birkdale with Southport town centre and all its amenities being a short drive away. The home provides 24hour personal care for up to 40 older people who have a dementia related condition. The home has been designed to provide care on two separate units, each of which has its own lounge and dining areas. The home has a passenger lift to the first floor. Single room accommodation is provided for all service users. Of the forty rooms, thirty have en-suite facilities. Security is a prime concern at the home. There is a secure internal courtyard with a lawned area and flowerbeds and a garden area to the rear of the home. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in September 2005 by one regulation inspector. The inspection involved discussion with relatives of service users living at the home and also discussion with and observation of the staff working there, an examination of records, policies and procedures and a tour of the premises. As part of the inspection, the inspector used “case tracking” as a means of assessing some of the National Minimum Standards. This process allowed the inspector to focus on two of the service users living at the home. All records relating to those individuals were inspected and discussion with the service users regarding their experiences at the home took place were possible. What the service does well: What has improved since the last inspection?
Since the last inspection there has been an improvement in the care plans developed for each of the service users. This has encouraged support staff to consider the support needs of service users in greater depth. The homes management of medication had improved greatly and senior members of staff had received accredited training, ensuring further the safety of the service users. The homes approach to training had also improved with induction training being provided. Staff were provided with at least three paid days training a year. A member of staff had qualified as a trainer in moving and handling and had started in house training for all new members of staff. These
Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 6 developments are seen to be a positive move aimed at improving further the standard of care provided. 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 House DS0000005973.V250660.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: None of these standards were inspected at this inspection. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 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 the following standard(s): 7,8,and 9 The care planning process and the delivery of care needs to be further improved to ensure that individual service user needs can be consistently met. EVIDENCE: The files of two recently admitted service users were examined. Discussion was held with staff who worked with the service users and with their relatives who were visiting on the day of the inspection. Both relatives expressed their satisfaction with the care provided with the first stating, ‘I am very pleased with the home, Mum seems happy’ and the second ‘I can’t fault the place. There was evidence on the files that both service users had seen a number of health professionals and receipts held with the service users monies in respect of chiropody fees confirmed some of these, as did information received from the visiting relatives. The care plans provided a good basis as information for support staff but they did not include all relevant information. Discussion with the staff did however indicate that they were aware of the service users support needs. The care plans had not routinely been reviewed on a monthly basis. It is recommended that service users preferred daily routines should be included as part of the care plan to enable staff to provide individual, person centred care.
Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 10 From examining the medication records for the two service users, the staff rotas and training records, records for the receipt of medications into the home, observation of staff administering medication and discussion with staff, there was evidence that great improvements had been made in the homes management of medication since the last inspection. The home was very dependent on its three senior members of staff in respect of its medication management and needed two of these on duty to ensure that appropriate dosing intervals were maintained. Unfortunately there were insufficient senior staff on duty at weekends to ensure that this could happen. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 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 the following standard(s): 13 The support staff at the home recognised the importance of family links and friendships and supported the service users and relatives to maintain these. EVIDENCE: The staff were observed to welcome visitors as they arrived at the home. Visitors appeared to be comfortable and in discussion two of them stated that they felt that they could visit at any time and could visit their relative in the privacy of their own room if they wished. One of the service users whose file was examined had developed a close friendship with another of the service users. Staff appreciated the importance of the friendship and described how they supported it. The homes policies and procedures were consistent with this approach. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 12 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 The home had good policies and procedures in place in order to protect service users. One amendment needs to be made to one policy to further protect service users. EVIDENCE: The home had a comprehensive complaints policy and procedure in place. Information was provided for service users within the service users guide and statement of purpose, giving them clear guidance as to how to make a complaint. No complaints had been made since the last inspection. The homes policy on the protection of vulnerable adults contained all the relevant information and guidance required to ensure that any allegations of abuse could be dealt with efficiently and to the benefit of the service users. It was recommended that the section dealing with restraint be expanded to make it clear that should restraint of a service user be required on a regular basis then a multi-disciplinary decision must be reached as to how it should be managed. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 13 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): 26 The home was clean and hygienic, providing a safe environment for both service users and staff. EVIDENCE: The home was observed to be clean and hygienic. Laundry facilities were sited so that soiled linen did not have to be taken through any areas were food was stored, prepared, cooked or eaten. Hand washing facilities were available within the laundry area and equipment within the laundry allowed soiled linen to be washed at appropriate temperatures, these both helped reduce the risk of cross infection. The home also had appropriate policies and procedures in place in respect of infection control aimed at providing a safe environment for service users and staff. Relatives visiting the home stated that the home was always very clean, tidy and well maintained. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 14 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): 29 and 30 The homes recruitment policies and procedures and training programmes do not ensure as far as possible the safety of the service users. EVIDENCE: The files of two members of staff were examined. There was evidence on the files that references had been obtained and that Criminal Record Bureau checks had been undertaken. Staff had been provided with a contract and a copy of the General Social Care Council had been made available to them. The home had therefore showed an awareness of the need to safeguard service users through thorough recruitment procedures. However discussion with the management indicated that some additional work needs to be undertaken to ensure that the correct procedures are followed in respect of POVA checks and Criminal Record Bureau checks prior to the appointment of staff, to safeguard service users still further. The training record for a recently recruited member of staff was examined. There was evidence that mandatory training had been undertaken as well as induction training. The member of staff confirmed this. The home was still working towards providing foundation training. A member of staff confirmed that a minimum of three paid days training a year was now being provided. A member of staff had qualified as a trainer in moving and handling and had commenced in house training. The manager stated that NVQ training had commenced for staff and a member of staff confirmed this. The manager recognised that the improvements in staff training will serve to improve the quality of care provided. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 15 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): 35 and 36 The homes system for dealing with service users monies was not sufficiently transparent to make it clear that the service users financial interests are safeguarded. EVIDENCE: The financial records for two service users were examined. A record of any financial transactions on their behalf was in place and appropriate receipts were kept. The monies for each service user were kept individually and were only handled by the manager or deputy manager. More care should be taken to ensure that the balance of monies held, corresponds exactly with the financial record for each service user. A requirement made following the last inspection had not been acted upon. The inspector had expressed concern over a situation where a service user had no relatives or advocate and had a considerable amount of money held for them. The inspector was informed that in situations such as these, the registered provider held any large amounts of money on behalf of service
Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 16 users. There were no records available at the home to indicate how this money was held and whether the arrangement was in the best interests of the service users. National Minimum Standard 36 was not fully assessed at this inspection, however the manager stated that the formal supervision of staff was not yet being undertaken on a regular basis. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 17 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 1 1 X X Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 Schedule 3 17(1) 13(2) 2 OP29 19 Schedule 2 3 OP30 18(1)(c) (i) Requirement Timescale for action 31/12/05 4 OP35 20 (1)(a)(b) The provider must ensure that arrangements are in place to ensure that adequate medication dosing intervals are maintained. (Timescale of 29/03/05 not met) Recruitment procedures must be 31/10/05 reviewed to ensure that the necessary checks are made on prospective members of staff. The registered person must 30/11/05 ensure that there is a staff training and development programme which meets National Training Organisation workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of the service users. (Timescale of 30/4/05 not met) An action plan of how this is to be achieved must be submitted to the Commission for Social Care Inspection. The registered provider must 30/11/05 provide evidence that service users monies not held at the home have (i) been paid into an account in the name of the service user and that (ii) the
DS0000005973.V250660.R01.S.doc Version 5.0 Dovehaven House Page 19 5 OP36 18(2) account is not used in connection with the carrying on or management of the care home. (Timescale of 30/04/05 not met). The evidence must be forwarded to the Commission for Social Care Inspection. The registered manager must 31/12/05 ensure that the persons working in the home are appropriately supervised. (Timescale of 30/04/05 not met) 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 OP7 OP7 OP7 OP18 Good Practice Recommendations The home should work towards producing care plans with some additional detail to ensure that staff can meet service users needs consistently. Service users care plans should be reviewed on at least a monthly basis. Service users preferred daily routines should be included as part of the care plan. The policy dealing which addresses the restraint of service users should be amended to make it clear that any restraint strategies should be decided at a multidisciplinary level. Dovehaven House DS0000005973.V250660.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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