Inspection on 15/12/05 for Dover Cottage Rest Home

This inspection was carried out on 15th December 2005.

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

Dover Cottage Rest Home 29/07/08

Dover Cottage Rest Home 07/06/07

Dover Cottage Rest Home 31/05/06

Dover Cottage Rest Home 07/06/05

Dover Cottage Rest Home 08/11/04

Dover Cottage Rest Home 24/08/04

Dover Cottage Rest Home 15/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Dover Cottage Rest Home Dover Farm Close Stoneydelph Tamworth Staffordshire B77 4AP Lead Inspector Mrs Wendy Grainger Unannounced Inspection 15th December 2005 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 Dover Cottage Rest Home DS0000004934.V271289.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. Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dover Cottage Rest Home Address Dover Farm Close Stoneydelph Tamworth Staffordshire B77 4AP 01827 331116 01827 261569 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) Dr Rais Ahmed Rajput Mrs Glenda Margaret Pollard Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (15) of places Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Dover Cottage is located on the periphery of an estate outside the town of Tamworth. The home is near to the A5 and M42 but not within walking distance of any major shops. Public transport is available at the end of the main road. The home is at the end of a cul-de-sac with a small parking area at the front of the home. At the rear of the home is a lawned area with a large weeping willow tree. The main door is located at the rear of the home. Dover Cottage offers accommodation to fifteen older people whose primary diagnosis was dementia. There were two lounges for the service users. Bedrooms were for single and shared accommodation. Only one of the shared bedrooms has an en-suite facility. Bathing and toilet facilities were available on each floor. The shaft lift or the stairs can access the first floor. Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed on the 15th December 2005, residents where able contributed to the inspection as did the staff and management. Documents and records were provided upon request. The residents at Dover Cottage were observed as were the staff who were addressing the needs of individuals. The lounges/dining rooms had been re-decorated since the previous inspection. Observed in the dining room were three of the six light bulbs not working. The smaller lounge had a homely ambience; residents tend to stay in the larger lounge and dining room. The ground floor bathroom has been decorated in a warm turquoise giving it a lift from the magnolia. The staff were observed to be respectful with the residents wishes to remain in the dining room or lounge. At the time of this inspection there were eight residents at the home. The staffing levels at the time of the inspection appeared to meet the needs of the present resident group. There is a vacancy for one member of the staff team; the hours were flexible. From the body language and from comments from some of the residents they were comfortable and satisfied with the care and environment. What the service does well: What has improved since the last inspection? The rolling programme for decoration continued with communal areas and the ground floor bathroom being decorated. To maintain the condition of cleanliness around the home a large carpet shampooer had been purchased. Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 Page 6 The second small lounge had been carpeted to match the other lounge and dining room, this room had a homely atmosphere being small and comfortable. 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. Dover Cottage Rest Home DS0000004934.V271289.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 Dover Cottage Rest Home DS0000004934.V271289.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): 1,3,5 Standard six is not relevant to this home. Based on the information in the Statement of Purpose and Service Users Guide a placement could be made to the home. No person was admitted to the home without a full assessment of their needs being completed. The policy of the home was to offer an introduction visit prior to placement. EVIDENCE: The information contained in the Statement of Purpose was readily available to any person visiting the home. There had been no reason for the document to be amended since the previous inspection. The records seen evidenced that assessments were completed prior to admission. It is the policy of the home to offer/arrange for the prospective person to visit the home prior to admission. Dover Cottage Rest Home DS0000004934.V271289.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): 7,8,9,10. The care plans had moved forward slightly, they remained deficient in some areas to completely meet the needs of residents. The staff on duty however were responsive to the needs and daily routine of the residents. To ensure that the residents were safe an arrangement was in place for the staff to receive further medication training. EVIDENCE: Three care plans were sampled during this inspection and discussed with the care manager. There was a need to have a risk assessment in place before the cot sides were considered, if not why were they in place in the first instance. The protocol of having the agreement of all parties was essential before this action was taken. One care plan required a photograph of the resident. There was evidence of arrangements and visits from other professional agencies. Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 Page 10 The care manager did not like the new format of the plans, there was scope within the plans seen to expand the information. This information should be based on the individuals needs and daily routines. It was discussed that she should create an alternative format for the plans that would suit the home and comply with Standard 7 of the National Minimum Standards. The inspector was disconcerted that some articles of clothing i.e. nightwear were folded and not ironed. The staff said that they do not iron all the washing if it is not necessary. In the inspector opinion the residents self-esteem was in question with crinkled clothes, which could, if the person was on bed rest create further problems.i.e. pressure areas. A two hour training session for the safe handling of medicines was provided in December 2005. The management or provider had not taken up the recommendation of a distance learning course for the safe handling of medicines. The records for the administration of medicines were current and satisfactory. Arrangements were in place for daily visits by the District Nursing service, the management had plans to increase the knowledge of the staff in taking blood sugars. A qualified person will provide this training early in 2006. The staff on duty were responsive to the needs of the eight residents. Each staff member was observed to be warm in their approach to the residents based on their knowledge of the individuals. Dover Cottage Rest Home DS0000004934.V271289.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): 12 15. To consider providing the information of activities in an alternative manner, to ensure that the residents can gather the appropriate information. The meal of the day was well presented and the choice offered accepted by some residents. EVIDENCE: While the staff had commenced a record of the activities for the home the detail could be more informative. The staff had written today’s activity on black paper with a lemon pen, not suitable for a resident with a visual impairment. During the inspection staff involved some residents with a game of “basket ball” the equipment was home made, staff had improvised; not withstanding this the residents that took part enjoyed the fun. There remained very limited external entertainment provided for the residents. The meal of the day was roast chicken the alternative was a chicken and mushroom pie, not really an alternative for service users not liking chicken, the sweets were treacle sponge, fresh fruit or semolina pudding. The meal was of a good portion. Some residents had chosen the alternative pie. Dietary needs were catered for. Dover Cottage Rest Home DS0000004934.V271289.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 18 The homes complaint procedure was displayed and would enable visitor to raise a complaint. The training programme both external and internal, ensured residents were protected from abuse. EVIDENCE: The Commission had received no formal complaint in 2005. The manager continued to monitor the working practice of the staff to ensure that complaints were not presented to her. The NVQ in Care training scheme that staff received ensured awareness training to be given so that residents were protected from abuse. Dover Cottage Rest Home DS0000004934.V271289.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): 19,20,21,23,24,25,26 Dover Cottage staff worked as a team to promote a good standard of hygiene throughout the home. There was a requirement for the manager to monitor the lighting to ensure that it was appropriate at all times. EVIDENCE: Located at the end of a small road, the home stands in its own grounds. The recent decoration of certain parts of the home was pleasant and lifted the home from the magnolia evidenced in some other parts of the home. The staff and management had made homely touches. There was a requirement to ensure that the lighting in all areas was sufficient and working at all times and to replace bulbs promptly when they fused. Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 Page 14 Personal areas were clean comfortable and personalised to suit individual taste. There was a need to audit the arm chairs to ensure that the cracks on the material did not progress further. The home in general was maintained at a high standard, staff worked as a team to promote this standard. Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 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 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 30 The staffing levels on the day of the inspection were satisfactory. Staff were committed to the wellbeing of all the residents. Via the continued training programme the staff employed were competent in their role as carers. EVIDENCE: The staffing levels at the time of the inspection were satisfactory. Dover Cottage had eight residents with two staff on duty at any one time. The manager is part of the working team; supported by her deputy and staff. At the time of this inspection there was a vacancy for one person the hours would be flexible. Ten of the staff were in the final stages of NVQ in Care level II two more staff were to register for the January intake. The care manager continues to do the registered managers award NVQ level IV. Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 Page 16 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, 32,34, 37, 38. Dover Cottage had a comfortable relaxed atmosphere created by the staff team who were competent in their roles as carers. The daily routine of residents was protected by the training and policies available to the staff. EVIDENCE: The home continued to be operated by a staff team where the priority for them was the resident’s well being and life style. No person employed at the home took responsibility for the financial accounts of the residents. Records evidenced that the required obligatory tests for fire were current. The majority of the records were secured in the small office, accessed by the staff when necessary. Dover Cottage Rest Home DS0000004934.V271289.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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 X X 3 3 Dover Cottage Rest Home DS0000004934.V271289.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? N/A 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 OP25 Regulation 23 (p) Requirement The registered person shall having regard for the number and needs of the residents ensure that adequate lighting is provided in all parts of the home used by the residents Timescale for action 01/01/06 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. Refer to Standard OP7 Good Practice Recommendations To ensure that the current care plans contain all the relevant information for the staff to carry out their job. To create an alternative format suitable for the home and compliant with the standards. To ensure where applicable that all linen including personal items are ironed before use To detail the records of activities with more information and to display the activities in a more resident user friendly manner To audit the condition of the armchairs in the larger lounge to ensure that they are in an acceptable condition without cracks/splits on the arms. DS0000004934.V271289.R01.S.doc Version 5.0 Page 19 2. 3. 4. OP8 OP12 OP24 Dover Cottage Rest Home Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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