Inspection on 13/02/06 for Dovercourt House

This inspection was carried out on 13th February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dovercourt House 13/07/07

Dovercourt House 23/08/06

Dovercourt House 21/09/05

Dovercourt House 10/02/05

Dovercourt House 21/07/04

Dovercourt House 05/03/04

Similar services:

Claremont House

Chesham House

Argyll House

Firstlings

Dorset Lodge

Fen Road

Acacia House

Falcon House

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

CARE HOMES FOR OLDER PEOPLE Dovercourt House 23 Fronks Road Dovercourt Harwich Essex CO12 3RJ Lead Inspector Steve Boyd Unannounced Inspection 13th February 2006 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 Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 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. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dovercourt House Address 23 Fronks Road Dovercourt Harwich Essex CO12 3RJ 01255 506010 01255 553099 miketibbles@fsmail.net 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 Michael Frederick Tibbles Mrs Amanda Jane Tibbles Mrs Amanda Jane Tibbles Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (4) Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who only fall within the category of dementia (not to exceed 27 persons) One named person, whose name was made known to the Commission in January 2003, under the age of 65 years, who only falls within the category of mental disorder (not to exceed 1 person) Person of either sex, aged 65 years and over, who only fall within the category of mental disorder (not to exceed 4 persons) The total number of service users accommodated in the home must not exceed 27 persons 21st September 2005 Date of last inspection Brief Description of the Service: Dovercourt House is a large property refurbished from two substantial buildings. The home provides accommodation for older people with varying needs, including some people with behaviours that challenge. The home is located close to local amenities and the sea front, and has good bus routes to other areas. Nearly 70 of the accommodation is available in single rooms, some of which have en-suite facilities. A range of communal space is available which includes gardens to the rear of the property. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on one day in February 2006. The inspector spoke with two service users in private plus a number of others in and around the home. Two visitors were spoken with during the inspection and three relatives over the telephone. Discussions were held with the proprietors, Mr and Mrs Tibbles, and other members of staff were also spoken with during the inspection. A tour of the premises took place and various records and policies were perused. A total of eighteen National Minimum Standards were assessed during the inspection, of which eleven were fully met, with seven needing some work to meet the Standards in full. What the service does well: What has improved since the last inspection? The proprietors have continued to improve the internal and external appearance of the home with redecoration having taken place to a number of bedrooms. Some bedrooms have benefited from new curtains and new furniture. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 6 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. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 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 Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 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): 2. Service users have a written contract. EVIDENCE: Service users’ files sampled showed that written contracts had been provided and signed by residents or representatives on their behalf. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 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 10. Service users’ plans of care need to be more specific in detail and person centred in make up. Service users are treated with respect. EVIDENCE: It was indicated in the previous inspection report that care plans needed to be more person centred and specific in the description of how needs are to be met. This inspection indicated that this was still the case and advice was given to the manager, Mrs Tibbles, on how this could be achieved. Care plans were also being reviewed six-monthly rather than monthly, as required by the National Minimum Standard. Health care needs are part of care plans but, as above, more expansion is needed as to how health needs can be met in practice. Records of visits to various health professionals are kept. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 10 Service users spoken to indicated that they were treated well and their privacy was seen to be upheld in a number of ways during the inspection, for example, by staff knocking on doors and ensuring bathroom and toilet doors were closed. Relatives of service users spoken with during the inspection stated they were happy with the way their particular relatives were treated at the home. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 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, 13 and 14. Service users maintain contact with family, friends and others as they wish. Activities are available for service users at the home, although these could be expanded. EVIDENCE: Service users able to comment, and relatives spoken to during the course of the inspection, indicated that there is as much contact as people wish with relatives, friends and others. During the inspection a relatively new service user was visited by a couple of church friends. Although some activities are taking place in the home, a planned activities programme was still unavailable. It is recommended that some staff undertake training with regards to provision of activities for people suffering from dementia and that individual care plans, when revised, look at individuals’ needs with regard to activities. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 12 Dovercourt House cares predominantly for people with dementia and as such their conditions always allow them to exercise a full independent choice and control over their lives. However, it was clear that staff do assist them to make as many choices as possible, for example, in what clothing to wear, what to eat, etc. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Service users can be better protected from potential abuse. EVIDENCE: A policy on the protection of vulnerable adults exists within the home and staff have had, or are to have, training in this respect. An examination of staff records indicated that a newly employed member of staff did not have a POVA “First Check” completed prior to commencing work at the home and the manager, Mrs Tibbles, was advised of the need to ensure this takes place as a minimum prior to someone starting at the home. CRB checks had been undertaken for other staff sampled. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The environment of Dovercourt House is safe and well maintained and was also found to be clean and pleasant. EVIDENCE: The premises of Dovercourt House had been a focus of the previous inspection where all Standards had scored “3”. Although not a focus of this inspection, no problem areas were noted and it was clear that continued improvements to the interior and exterior of the home had been made since the last inspection. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 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, 29 and 30. Service users’ needs are met by appropriate numbers of staff with an appropriate skill mix. Staff are trained and competent to do their jobs, although the recruitment procedure needs to be slightly more robust, as indicated under Standard 18. EVIDENCE: There are always three to four carers on each shift and these are supported by a care manager, as well as Mrs Tibbles as registered manager. There are separate cooks, cleaners, laundry and maintenance staff to aid the smooth running of the home. The home has staff trained to National Vocational Qualification Level 2 or above of a current rate of 80 . This is well above the 50 requirement of the National Minimum Standard. Upcoming training for the staff includes first aid, manual handling, continence care and diabetes care. The manager, Mrs Tibbles, was advised of the need to keep an individual “at a glance” training record on each staff member’s file. The staff recruitment process at the home includes potential staff filling in application forms, undergoing an interview process, references being taken up and CRB checks being progressed. As indicated under Standard 18, POVA “First Checks” must, as a minimum, be undertaken prior to anyone starting work in the home. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 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, 33 and 38. The home is operated by a caring and energetic manager. Some work needs to be completed on the quality assurance system within the home. The health, safety and welfare of service users is given a good level of attention. EVIDENCE: It was clear on the day of inspection that Mrs Tibbles is a hands on manager, and from comments received from visitors, relatives, staff and health professionals is well regarded. Her approach is both inclusive and open rather than exclusive and closed. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 17 The home was found to have carried out surveys of interested parties as to the quality of service given at the home. However, an audit of these responses plus an action plan of any points that need to be remedied was missing and, therefore, needs to be completed. There were no obvious safety hazards seen during the course of inspection. Safety certificates were seen for services and equipment such as electrical installation and equipment, the lift and fire equipment and safety. A certificate of safety for the gas installation was not available and needs to be produced. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X X 2 Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 15 Requirement Timescale for action 31/05/06 2. OP12 13,14,15, 16 3. OP29 19, Schedule 2 4. OP33 24 The registered person must ensure that service users’ care plans are person centred and contain adequate directions to inform staff how identified needs should be met. This is a repeat requirement. The registered person must 30/04/06 ensure that the wishes and preferences of service users in relation to activities are recorded and promoted. This is a repeat requirement. The registered person must 31/03/06 ensure thorough recruitment, induction and supervision procedures to ensure protection of service users and to comply with the relevant regulations. This is a repeat requirement. The registered person must 30/04/06 ensure further development of the home’s quality assurance process. This is a repeat requirement. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 20 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. Refer to Standard OP30 OP38 Good Practice Recommendations The registered person should ensure that each staff member has an individual training record. The registered person should ensure that the gas certificate is produced on annual basis. Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Dovercourt House DS0000033764.V281338.R01.S.doc Version 5.1 Page 22 - 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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