Inspection on 07/06/05 for Dover Cottage Rest Home

This inspection was carried out on 7th June 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 15/12/05

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 Dover Farm Close Stoneydelph Tamworth, Staffordshire B77 4AP Lead Inspector Wendy Grainger Announced 07 June 2005 09:00 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. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dover Cottage Address Dover Farm Close Stoneydelph Tamworth Staffordshire B77 4AP 01827 331116 01827 261569 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) Dr Rais Ahmed Rajput Mrs Glenda Pollard Care Home 15 15 15 Category(ies) of DE(E) registration, with number OP of places Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NA Date of last inspection 8 November 2004 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 offeres 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 E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection commenced early to enable the inspector to meet the night staff and to observer their routine. Two staff had been on duty the previous evening. Five of the ten residents had been assisted to rise. These residents rose early as part of their routine. Each one had been provided with a cup of tea and toast. Other residents came into the home at various times each one was asked their preference for breakfast. No cooked breakfast was prepared. During the inspection documents were provided and inspected, staff and residents were spoken with and observed. One family member was spoken with. Located at the end of a small road the home provided accommodation for fifteen elderly mentally frail residents. At the time of this inspection there was ten residents present. Facilities within the home were located on two floors accessed via the shaft lift and or stairs. The home had two small lounges when the home was full occupied then residents would need to use both areas. Limited front of home usage suitable for staff vehicles only, the rear garden has a large willow tree and lawn, which slopes off; not particularly suitable for the older less mobile residents. Residents today were seen to respond to the sensitive manner in which they were addressed by staff. At the time of this inspection one resident was receiving full care. The management and the staff had commenced the relevant paperwork to ensure her nutritional balance was maintained. The Commission had received three comment cards from relatives, one person felt that there were insufficient staff on duty and was concerned about the staff turn over. The home had lost three staff recently but had recruited two other people. One relative was not aware of the pending visit although the notice was clearly displayed. One person did not have access to the previous inspection report. Four comments had been received from the residents, assisted by the staff. One resident only liked living at the home sometimes and one resident did not always like the food. One relative was very complimentary about the home their care of his wife. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 6 Catering and housekeeping staff were observed to come on duty, catering hours now included the preparation and serving of tea. Staffing levels on the day of the inspection were as normal. The inspector had concerns as to the amount of time that one resident in particular was taking to contain her within the home. The staff were extremely patient and good humoured with her. Many times they had to encourage her to not to leave the home via the front door or fire exit. The front door had a baffle handle; each door when opened alerted the staff. This resident uses the lift and returns via the stairs. The concerns were discussed with the provider, it was identified to him that there needs to be a one to one for this lady prior to and following her arranged reassessment by the Psychiatric Community Nurse (8 6 05) the general practitioner had prescribed a light medication.(10 6 05) contacted the home the resident had been placed on an increased dose of medication and will be further reviewed. Within the home the decoration programme was discussed with the provider and in the presence of the care manager. There was a need to consider refreshing the homes decoration during this year. What the service does well: What has improved since the last inspection? The care manager had been registered. A new washing machine had been purchased. A new gas cooker had been purchased. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 7 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 E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 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 standard(s) 1 3 5 The home provided the respective documents required to enable members of the public to make a placement to the home. Prospective residents had the opportunity to visit the home to assess its suitability. EVIDENCE: The Statement of Purpose was displayed in the entrance hall the care manager was to remove the “bank “ staff following their full time employment. No resident was admitted to the home without a full assessment. The care manager had plans to assess a new person on Thursday. A trial period and or day was always offered, during the trial period the home can further assess the needs of the resident. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 10 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) 7,8,9,10,11. The construction of the care plans, information provided and risk assessments within the care plans could be improved. It is hoped that the planned new format will provide the appropriate base to work from. Staff need to follow through the training in respect of medication administration and recording at the time. Staff did deliver a service that was supportive to the needs of the residents. EVIDENCE: Three care plans were sampled the inspector identified to the care manager the inaccuracies within the documents. One care plan needed reviewing to identify the current needs of the person receiving full care. One care plan had inaccurate information regarding sugar in drinks. A risk assessment provided did not clearly map out the action plan for this resident; who constantly tried to leave the home via any of two doors. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 11 Arrangements were in place for the continuation of care by other professional agencies. Equipment for one resident would be upgraded to meet her needs this week via the District Nurse. This resident was seen she was comfortable and warm, her fluid, food and turning charts were well maintained by the staff. The system for the administration of medicines was observed twice during the inspection the only comment made was for the staff to sign the records during the administration and not after. Staff had attended training courses for the safe handling of medicines; the certificates provided evidence for this. The night staff told the inspector that their night had been fairly quiet and routine. One resident required two staff members to turn her two hourly. Despite the staff being kept busy observing and monitoring the whereabouts of one resident they were sensitive to the needs of others. Because of the situation there was no time to undertake the planned activities (see standard 12) the staff on duty were pleasant and good humoured. They demonstrated their skills with the mentally frail residents. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 12 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) 12 13 14 15 The home needs to provide activities suitable to meet the mental and physical needs of each individual. Daily routines were flexible to encourage visitors to call. Meals provided were varied, there was evidence that residents were offered choice. EVIDENCE: There was a weekly activity programme displayed on the dining room door. Because of the activity of one resident today the morning staff had no time to stimulate the residents. Although two ladies spent time reading the newspapers, and one other was enjoying her knitting. The care manager maintained a record of activities, not all the residents participated. There was very limited if any external entertainment provided. One resident took the option to go into the community to vote recently in the general election. Visitors were welcome at any time, one family come daily. The inspector was told that he was very happy with the home the care and the staff were excellent, always willing to help. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 13 Where possible independence was encouraged, this could be for the simplest of daily tasks to assisting with the more pertinent daily hygiene routines. With the exception of contact with families the home did not have contact with any community groups. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 14 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 17 18 The home had a satisfactory complaints process displayed. The staff had an understanding of the need to monitor and report any concerns to the appropriate person. EVIDENCE: The home had received no complaints; the Commission for Social Care had received no complaints highlighted to them. Within the hall were the appropriate documents to enable any person to make a complaint. One resident told the inspector that she would tell someone if she needed to, she could not be more explicit. Staff confirmed that they were aware of the Vulnerable Adults process and felt that they could use the whistle blowing policy. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 15 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) 19,20,21,23,24,25,26, The standard of the hygiene in the home was good. The standard of the general environment needs reviewing to ensure that the decorating programme was maintained. The staff ensured that the home was a fairly safe place for residents to live in. there was a requirement to store the items hazardous to residents more appropriately. . EVIDENCE: The home is located at the end of a small road; a gate secures the entrance to the main door. Exit doors were fitted with a sensor; this was particularly evident with one resident constantly trying to exit through the fire and front door. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 16 The decoration in parts of the home was tired and needed refreshing. This was discussed with the provider, as was the need for suitable garden furniture. It appears that the home had more garden chairs available. The inspector had no evidence that residents sat out in the grounds. Bathing and toilet facilities were located on both floors. The decoration of the toilets and first floor bathroom were bland and would benefit from more thought to the colour scheme. The staff were aware of the need to monitor the home in respect of infection control. With the exception of the items left in the first floor bathroom, which could be hazardous to residents the home appeared satisfactory. The sample of the bedrooms evidenced that they contained items personal to the individual. Homely touches had been created by the staff in the communal areas for the residents to enjoy. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 17 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) 27,28,29,30 The staff were committed to caring for the residents in their care, they were stretched today because of circumstances. It is required that this is reviewed. The manager supported her staff by working various shifts. Residents were protected by the vetting and recruitment practices. Staff were trained and competent to meet the needs of the residents. There was a need to firm up the video training with more formal courses. EVIDENCE: The staffing levels at the time of the inspection were a concern; the staff were stretched monitoring one resident who chose to attempt to leave the home at regular intervals. This was discussed with the care manager and provider that if the future intervention by other professional agencies results in her remaining at the home then staffing levels need to be reviewed and increased by one on the day time shifts. The care manager worked various shifts including a night shift. The rota evidenced this statement. There was always two staff on duty at any one time during the twenty-four hours. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 18 The entire staffs Criminal Records Bureau documents were evidenced and found to be satisfactory. The care manager was waiting for confirmation clearance of one more person before she commenced her duties. Mrs Pollard was aware that she could use POVA first in the event of staffing the home. The staff received the mandatory training to meet the needs of the residents. With the exception of one night staff all the staff had achieved or involved in NVQ in Care at Levels II & III. The provider had purchased a number of training videos covering Dementia, Moving & Handling, and Fire. There was a need to firm up the training with formal training courses where necessary. This was part of the discussion with the provider. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 19 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) 31,32,33,35,37,38 The residents live in a relaxed style home where their well-being is a priority. The care manager and her staff were competent to address their needs. The rights of the residents were protected by the homes policies procedures and training. EVIDENCE: The care manager was finding it difficult to formally register for the Registered Managers Award due to there being lack of availability in the Tamworth area. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 20 There was evidence in the records that she completed any in house video training and other external courses. Staff told the inspector that they felt supported and could approach the care manager at any time. She had a relaxed style of management. Residents responded to her assistance. Records evidenced confirmed that residents and relative surveys were being completed. The responses were positive and constructive. Families were responsible for the finances of their relative. The home is currently viable and had the appropriate insurance in place until August 2005. The majority of the records were secured in the small office near the front door. Records evidenced that the management complied with the mandatory testing of systems in respect of fire, water, security, and risk assessments. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 21 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 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 2 x 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 3 3 2 Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 22 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(1) Requirement the registered person shall prepare after consultation a written care plan as to how the residents needs in respect of his health and welfare are to be met the registered person shall consult the residents or their representative about the programme for activities arranged on their behalf. having regard to the needs of the residents the registered person shall ensure that at all times there were suffcient staff on duty qualified and competent to meet the needs of the residents the registered person shall make arrangements to ensure that all parts of the home to which residents have access is free from hazards to their safety Timescale for action 1 7 2005 2. 12 16 (n) on going 3. 27 18 on going 4. 19 13(4)(a) on going RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 23 Dover Cottage 1. 2. Standard 9 19 to ensure that the staff sign on the administration of the medication. to review the entire home to ensure that the decoration is fresh. Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - 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. Extracts may not be used or reproduced without the express permission of CSCI Dover Cottage E51 E09 S4934 Dover Cottage V226742 080605 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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