Inspection on 13/12/07 for Dover House

This inspection was carried out on 13th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 House 20/09/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Dover House 30 Derbyshire Lane Stretford Manchester M32 8BJ Lead Inspector Helen Dempster Unannounced Inspection 13th December 2007 3:00 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 House DS0000069325.V354877.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dover House Address 30 Derbyshire Lane Stretford Manchester M32 8BJ 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) 0161 7180248 0161 7185125 Catherine Bernadette Conchie Mrs Patricia Carlon Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - code PC, to people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP. The maximum number of people who can be accommodated is 10. Date of last inspection 20th September 2007 Brief Description of the Service: Dover House is a care home which provides residential accommodation with personal care for up to ten (10) residents within the category of old age (OP). The home is situated in a residential area of Stretford, and is close to Stretford Arndale Centre and local public transport and motorway networks. Dover House is a large Georgian house set in pleasant grounds. The steps to the front and side of the property have blocked paving. The home has gates with an electronic security system. Car parking space is available at the front of the building and on the roadside. To the rear of the property is an extensive patio area. The grounds to the rear offer a secure external assembly area, which can be accessed via steps or via a recently built ramp from the lounge. The home has ten bedrooms, all of which are en-suite. The first floor has stair lift access. The communal rooms consist of a large lounge/conservatory style area and a designated dining area. The kitchen is open plan onto the dining area. The range of fees charged by the home are from £348:42 to £376:30 per week. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second key inspection conducted this year and focused on assessing progress made to address concerns identified at the earlier key inspection, which took place in September 2007. The owner of the service had filled in an Annual Quality Assurance Assessment (AQAA), in September 2007, to provide essential information about the way that the service was managed. The inspection included carrying out an unannounced site visit to the home on 13th December 2007, from 3pm to 8:30pm. During this visit, lots of information about the way that the home was run was gathered. Time was taken in talking with residents, the owner, the staff, and a resident’s relative, about the day-to-day care and what living at the home was like for the residents and how well the home was meeting the National Minimum Standards for Older People. Other information was also used to produce this report. This included reports about things and events affecting residents that the home’s staff had informed the Commission about. The main focus of the inspection process was to understand how the home was meeting the needs of the people who use the service and how the staff were supported to meet residents’ needs. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those people living at the home. What the service does well: What has improved since the last inspection? The owner had worked very hard to do the work required at the last inspection. A resident’s relative said that the owner had, “made an incredible Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 6 difference”, that the home was, “really good” and that staff did an “excellent job”. The relative concluded that, “things were going really well”. A resident’s relative talked about improvements to the premises, which included bedrooms being “done up”, and rooms being “colour coordinated”. Hand hygiene had also improved. The way that the service dealt with complaints and protection had improved so that residents’ views were heard and they were safeguarded. A resident’s relative said that the owner’s attitude was “good” and that the owner “listens” and made sure that any concerns were resolved Care plans and the way that residents were supported to take their medication had improved. Activities had improved through better assessment and more staffing to meet residents’ diverse needs and resident choice was better. Fire safety practice had improved greatly to better protect residents and staff. 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. The summary of this inspection report can be made available in other formats on request. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 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 House DS0000069325.V354877.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs were assessed, so that their needs could be met. EVIDENCE: The home was registered in May 2007 and, since that time; the new owner of the home was making a number of changes to policies, procedures and record keeping. The Statement of Purpose and Service User Guide were therefore under review at the time of the visit. It was recommended that when the Service User Guide has been updated, all residents’ be given a personal copy. There had been no new admissions since the last inspection, but the files of two existing residents were seen. These residents’ needs had been assessed Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 9 by a Social Worker. The owner said that wherever possible, the home’s staff visited residents’ prior to admission. It was seen that the owner of the home had developed a new form on which the assessment of needs would be recorded. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The privacy and dignity of residents’ was upheld and ongoing improvement of care plans and medication practice better protected residents. EVIDENCE: The files of two residents, whose files had also been looked at during the last inspection, were looked at again to assess progress made to improve care plans. Care plans had improved and improvements included the following: • Detailed personal profiles were in place Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 11 • A medical appointment record card had been introduced, which provided a detailed account of the reason for a medical visit and the outcome of such visits. Medication needs were clearly recorded. A “hospital form” had been put in place for all residents, which contained essential information needed when a resident was admitted to hospital. • • Some good practice was seen. This included detailed records of observation of residents’ needs and interactions with staff and other residents. Positive statements, which focused on residents’ existing skills and the need to maintain these, were also made. This included referring to a resident being, “proud of (their) achievements”. Risk assessments had also improved and usually explained how staff could minimise risk. The owner agreed that risk assessments could be further improved by always detailing control measures to minimise risk. The way that residents were supported to take their medication had also improved. Improvements included the following: • A detailed medication policy had been produced and a copy sent to the Commission’s Pharmacist Inspector. All staff had received medication training and this included filling in a workbook and being monitored, to make sure that they were competent. An error log had been introduced, so that staff noted any error and action taken to address this, e.g. the need to replace a dropped bottle. It was stressed that staff must support and monitor one another’s practice and any remedial action was signed off by the owner as part of ongoing review. There was evidence to show that medication reviews by residents’ doctors were taking place. • • • • These improvements made medication administration safer for residents. There were some further improvements needed. This included always signing the medication administration record to acknowledge receipt of medication, Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 12 always using symbols consistently to explain when medication is not given, always making sure that there were no gaps in the record, and always making sure that when new medication is prescribed (and the details are hand written onto the record), clear administration instructions are written on the record. A resident’s relative talked about the improvements in medication practice. This person said that staff, “know exactly where (the resident) is up to with medication”. This is good for the residents. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ social needs and choices are respected and access to activities had improved through better assessment and increased staffing to meet residents’ diverse needs. EVIDENCE: Care plans had been reviewed to include details of residents’ relevant family and employment history, which informed staff of what was important to residents. The social interests and preferred activities of residents were also recorded. Residents had enjoyed making cards on the day of the visit and one resident’s relative was pleased about this and the fact that staff were discussing activities with residents. This relative described a number of improvements at the Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 14 home. The relative said that the “atmosphere” was “nice”, the home was, “friendly and homely” and was “nice and relaxed”. The relative was very pleased about “better choice”. The example given was that if their relative did not want to eat in the dining room, they could eat in their own room, but that they were also encouraged to integrate with others. The degree to which residents were observed and encouraged not to be socially isolated was seen. The staff had made excellent progress in encouraging one resident, whose care plan noted a long history of “self imposed isolation”, to integrate with others, while retaining privacy with meals. Care plans stressed residents’ positive attributes. This included a care plan which noted that a resident was, “very articulate and can hold meaningful conversations”. Care plans also stressed the need to balance the need to promote independence with the, “responsibility to regularly offer help and assistance with more difficult tasks”. This is good practice. The owner had hosted an open day on 9th December 2007, to encourage good communication with residents and their relatives. The owner was seen to be focussed on positive change, including broadening the range of activities and including age appropriate activities and the celebration of historical events. One example was watching the ceremony on Armistice Day and wearing poppies. The owner had increased staffing levels on Wednesday, Friday and at weekend, specifically to deliver more activities. At the time of the visit, preparations for Christmas were ongoing and residents had enjoyed carol singers and had chosen to have their own Christmas tree in their bedroom. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that any issue they raised would be dealt with and improved familiarity with safeguarding procedures better protected residents. EVIDENCE: The protection of vulnerable adults policy was readily available and all staff had read it. Dates for the training of staff in the protection of vulnerable adults from abuse had been obtained and were being booked. The owner had written to residents and their relatives to advise them of a review of the complaints procedure. This included having an updated policy and a new form to record complaints. A resident’s relative said that the owner’s attitude was “good” and that the owner “listens”. This relative talked about their experience of raising a concern with the owner. The relative said that a meeting was held to resolve the issue, and then a follow up meeting was held some weeks later. The relative said Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 16 that the owner had a big focus on reviewing any issues to make sure they were resolved and continued to be resolved. This is good for residents. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ live in clean, warm, attractive and homely surroundings, which are subject to ongoing improvement. EVIDENCE: The home was clean, warm, attractive and homely and there had been lots of improvements to the premises since the last inspection. These included the following; • A ramp had been built to allow better disabled access to a raised patio area and handrails had been put in throughout the home. DS0000069325.V354877.R01.S.doc Version 5.2 Page 18 Dover House • • • • The bathroom had been retiled and redecorated and non slip flooring had been fitted. Liquid hand soap and paper towels were now in place Some redecoration had taken place. Fire safety had improved by fitting new fire doors, renewing smoke protection strips on others and installation of a magnetic hold off in the kitchen, so that residents can pass through with ease. Residents and a resident’s relative were pleased with the home. The resident’s relative said that rooms were “cleaner”, that bedrooms had been “done up”, and that rooms were “colour coordinated”. The relative was also pleased with the increased security, due to visitors signing in and out of the home. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good recruitment practice protected residents and improved staffing levels and staff access to training, better protected residents. EVIDENCE: Residents and a resident’s relative were pleased with the staff. The resident’s relative talked about, “much better staffing levels” and added that there were, “always more people in”. Staff had received competency-based training in medication administration and in fire safety since the previous inspection, and further training was planned. A staff member said that all staff had received a memo from the owner 2 weeks previously to inform them of the available dates for training in safeguarding, moving and handling and first aid. Staff said that the memo stated that these courses were “compulsory” if they had not already been done done. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 20 Staff files for 2 recently recruited staff were seen and, overall, recruitment practice was good, and included obtaining appropriate police checks. Some references were not on a file, but there was evidence from letters that they had been sought appropriately. The owner said that she would locate them and put them on the file. Some good recruitment practice was seen, including an application form identifying a gap in employment because of childcare, and this being clarified at interview. Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The owner was working hard to improve the service by developing positive relationships with residents, relatives and staff and fire safety practice had improved to protect residents and staff. EVIDENCE: At the time of the visit, the owner was continuing to make improvements at the home. The manager spoke highly of the owner and they clearly had a good Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 22 relationship. The manager said that she was due to retire early the following year. The owner was aware of this and was planning accordingly. A staff member said that the owner was “cool”, “caring” and “fair” and that staff, “can go to her with any concerns”. This staff member added that the owner was, “good with confidentiality”. A resident’s relative said that the owner had, “made an incredible difference”. The relative added that the home was, “really good” and that staff did an “excellent job”. The relative concluded that, “things were going really well”. Fire safety had improved greatly, in response to a requirement made at the last inspection. This included all staff having training, residents having a fire safety talk, completing fire safety checks consistently, and a recent service of fire safety systems. A letter from the fire service, dated 17/10/07, confirmed that the home had complied with the requirement to have a fire risk assessment. Other improvements included adding a magnetic hold off to the kitchen door, fitting a Carbon Dioxide detector in the boiler room, fitting a new fire door and improving existing ones. (See Environment for details). Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 23 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No. 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 OP7 Regulation 13 and 15 Requirement Risk assessments must be further developed to include control measures to reduce risks to residents. Timescale for action 30/01/08 2. OP9 13(2) 30/01/08 In order that residents are protected, medication records must be further developed to include a record of the receipt of medication, consistent use of symbols to explain why medication is not given, and always using clear administration instructions on the record. 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 OP1 Good Practice Recommendations It is recommended that the statement of Purpose and DS0000069325.V354877.R01.S.doc Version 5.2 Page 25 Dover House Service User Guide are updated and that each resident, and/or their relative, is given a personal copy of the Service User Guide and that it is adapted so that residents can access the information easily. 2. OP10 It is strongly recommended that residents be offered a locked room to which they could hold the key if they wanted this. It is recommended that a training audit is in place to ensure that the manager and all staff always have appropriate training to enable them to support and protect residents. This includes training in Moving and Handling and the Protection of Adults from Abuse The manager should provide regular supervision to all staff which addresses all aspects of their work, to support them in caring for residents. 3. OP30 4. OP36 Dover House DS0000069325.V354877.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 House DS0000069325.V354877.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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