Inspection on 11/08/05 for Dovers

This inspection was carried out on 11th August 2005.

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

Dovers 13/11/08

Dovers 20/11/07

Dovers 17/01/07

Dovers 29/11/05

Dovers 06/12/04

Dovers 09/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

Thorndene

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Dovers 9 Doversgreen Road Reigate Surrey RH2 8BU Lead Inspector Janet Daulton UnAnnounced 11 August 2005 10:00am 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. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dovers Address 9 Doversgreen Reigate Surrey RH2 8BU 01737 244513 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) The Field Lane Foundation Mrs Terry Christina Newton CRH 39 Category(ies) of DE(E) Dementia - over 65 Number 24 registration, with number OP Old Age Number 10 of places PD(E) Physical disability Number 5 Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) The age/age range of the persons accommodated will be: OVER 65 YEARS Date implemented 30 March 2004 2) One bed in the category DE(E) may be used to provide respite care Date implemented 25 January 2005 3) The age range of one named service user is AGED 60-65 YEARS Date implemented 1 June 2005 Date of last inspection 6 December 2004 Brief Description of the Service: Dovers is a care home, operated by the Field Lane Foundation,and has been operating since 1950. It is situated on the southern outskirts of Reigate in Surrey. The home is registered for up to 39 service users, 24 of whom may be suffering from dementia. Accomodation is arranged on the ground and first floor, accessible by a lift. All rooms are for single occupancy,and several of the rooms have ensuite facilities. There is a range of comfortable communal areas throughout the home. There is a large well maintained and secure garden, and car parking facilities are available in the grounds of the home. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours and was the first inspection carried out by the Commission for Social Care Inspection for the year 2005-2006. The inspection was carried out by Mrs. J Daulton, Lead inspector for the service. The Manager Ms. T. Newton was present for all of the inspection. The Manager was present for feedback at the end of the inspection. A tour of the premises took place. Six care plans, the complaints log, staff recruitment files, and a sample of safety certificates were inspected. The inspector spoke to 14 service users, and 2 visitors. The inspector also spoke with some of the staff on duty at the time of the inspection. This was a positive inspection. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the inspection. What the service does well: The home continues to provide a homely and attractive environment for the service users. The staff were seen to be caring for the service users in an friendly and respectful way. All service users contacted stated that they felt safe and well cared for in the home. Service users were encouraged to maintain control over their daily life as much as possible. Meals were varied, well balanced and nicely presented, offering a choice and variety. The service users care plans were detailed. They gave clear instructions to the staff about the service users needs and the care that had to be given to meet those needs. An experienced activities coordinator organised the activities and entertainment, providing good opportunities for service users to take part in activities inside and outside of the home. The home had a stable team of staff who knew the service users well. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 standard(s) 1,3,6 There was a range of information available to prospective service users and their relatives, which gave clear details about the home and the services provided. Service users had their needs assessed before they moved into the home to ensure that the home could provide for those needs. EVIDENCE: The Service User Guide provided clear information about the home. Prospective service users were encouraged to stay for a day or have lunch at the home, before making a decision about moving in. All the care plans inspected had a pre- admission needs assessment completed by the Manager of the home, or the Social Services Care Manager. The assessment covered all elements of physical, mental, and social needs. The home does not provide intermediate care. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 The service users health, personal and social needs were set out in an individual plan with all the needs clearly identified and there was documentary evidence of the identified needs being met. Medication procedures and practice were satisfactory. EVIDENCE: Service users and visitors spoken with were very complimentary about the care that they received at the home. Comments included “staff are very gentle and kind”, and “staff go out of their way to look after us” The six care plans randomly selected and inspected were very detailed and clearly set out the actions which needed to be taken by the care staff to make sure that all aspects of the health, personal and social care needs were met. All the care plans were signed by the service users to indicate that they were consulted when drawing up the care plans, and they were reviewed regularly. Staff were observed treating the service users in a friendly, and professional way. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 10 The service users received visits from Health Professionals when needed. There were very positive comments from a District Nurse who was visiting one of the service users on the day of the inspection. Records were seen of good communication between the home and professionals, such as the Continence Advisor and the Community Psychiatric nurse. Most of the service users were registered with one local GP practice. Medication records were examined. Medication was being stored and administered in accordance with the homes policies and procedures. The Manager provides training for staff in safe administration of medication. 2 service users were self-medicating and arrangements were in place for them to store their medication safely, and risk assessments were completed. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 standard(s) 12,13,14,15 The social and recreational activities were varied and appropriate. The catering arrangements and facilities were satisfactory and well managed. EVIDENCE: There was a programme of regular activities. There were several activity organisers who arranged a variety of pastimes such as art, music therapy, and reflexology. On the day of the inspection there was a quiz being held in one of the lounges. This was well attended by the service users. A church service was planned for the afternoon. Pets were allowed to stay in the home with their owners. Two service users had their dogs living with them, who were looked after appropriately and safely by service users and staff. Visitors were encouraged to visit at any reasonable time. This was confirmed by 1 relative spoken with who said that he was always made to feel very welcome. Most of the service users have their financial matters dealt with by their relatives. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 12 The choice of food offered was varied and appeared nutritious. A menu was displayed. All service users spoken with were satisfied with the quality of the food served. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 standard(s) 16,18 The home had a simple, clear and accessible complaints procedure, which included timescales for the process. The homes policy for dealing with allegations of abuse was not in line with Surreys Multi - agency procedures. EVIDENCE: The home had a complaints procedure, which was displayed, in the home. A complaints file was kept. The home has had 5 complaints during the last 12 months. These were seen to be dealt with appropriately. The homes policy detailing the action the person in charge must take following an allegation of abuse was not fully in line with the Surreys Procedure. The home must report any allegation to Social Services and CSCI, who will make the decision about the action to be taken. A requirement has been made in respect of this matter. The manager had received Vulnerable Adults procedure training this year. The staff-training file did not evidence that care staff had received vulnerable adults training. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 standard(s) 19,26 The location and layout of the home was suitable for its stated purpose. It was accessible, safe, and well maintained with a pleasant and homely atmosphere. EVIDENCE: During a tour of the home the premises were seen to be well maintained with service users able to access all areas of the home and gardens. On the day of the inspection the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping. The garden areas were pleasant and secure for service users. On the day of the inspection several of the service users were enjoying their morning coffee and afternoon tea in the garden. The home had infection control policies, and staff were seen to carry good basic infection control measures when caring for the service users. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 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) 27,29,30 The numbers and skill mix of the staff met the service users needs. Service users were protected by the homes procedures for recruitment. EVIDENCE: The staff rota inspected demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the service users living in the home. The manager informed the inspector that the staffing levels were constantly reviewed as the needs of the service users changed. Domestic and laundry staff were employed. All interactions observed between staff and service users during the inspection were seen to be caring and respectful. 3 Staff files were examined. The recruitment files were well organised. All necessary checks had been completed prior to employment, and staff received Statements of Terms and Conditions. Records of training evidenced that staff received induction training after employment, and staff had received dementia training appropriate to the specific care needs of the service users. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 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) 33, 35, 38 There were policies in place in the home to ensure that service users are protected. All staff must have mandatory fire training to protect the service users. EVIDENCE: Financial records of the service users were in place and a random check showed these to be in order. Written records of financial transactions were maintained. The fire records evidenced showed that only 5 staff had signed as receiving a Fire Safety Update in July 2005, and a requirement was that all staff must have a fire safety update. The manager could not locate the record of the servicing of the central heating boiler, or the electrical certificate, and a requirement was l made that a copy must be forwarded to the CSCI. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 17 One of the bedrooms had a broken window. The manager stated that action to repair this was in progress. Confirmation must be forwarded to the CSCI that this work has been completed. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 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 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 x 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 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 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 x 1 3 x x x 3 x x 1 Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 19 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 8 Regulation 12(1) Requirement The Policy for dealing with any allegation of abuse must be in line with Surreys Multi-Agency Procedures. THe Registered Person must ensure that all staff have training in vulnerable adults procedures. The Registered Person must ensure that all staff have had fire safety update training. The Registered Person must confirm in writing that the Central heating boiler has been serviced and the electrical certificate has been issued. The Registered Person must confirm in writing that the broken window identified at inspection. has been repaired Timescale for action September 30th 2005 November 30th 2005 October 31st 2005 September 30th 2005 September 15th 2005 2. 18 12(1) 3. 4. 38 38 23(4)(c 13(4) 5. 38 23(2) 6. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Dovers Refer to Standard Good Practice Recommendations H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 20 1. Dovers H58 H09 s13630 Dovers v244380 110805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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