Inspection on 29/11/05 for Dovers

This inspection was carried out on 29th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dovers 13/11/08

Dovers 20/11/07

Dovers 17/01/07

Dovers 11/08/05

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 Dovers 9 Doversgreen Road Reigate Surrey RH2 8BU Lead Inspector Sarah Radlett Unannounced Inspection 29th November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dovers Address Dovers 9 Doversgreen Road Reigate Surrey RH2 8BU 01737 244513 01999 999999 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) Field Lane Foundation (The) Mrs Terry Christina Newton Care Home 39 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (10), of places Physical disability over 65 years of age (5) Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/ age range of the persons accommodated will be: OVER 65 YEARS One bed in the category DE(E) may be used to provide respite care. The age range of one named service user is AGED 60-65 YEARS Date of last inspection 11th August 2005 Brief Description of the Service: Dovers is a well established care home operated by the Field Lane Foundation, who are a non profit making Christian organisation founded in 1841. The home has been operating since 1950 and is located on the southern outskirts of Reigate. Accommodation is arranged on the ground and first floor, accessible by a lift. There is a range of comfortable communal area. The home is in a semi-rural location with a large well-maintained garden, parking facilities are available. The home is currently registered for 39 service users, 24 of whom may be suffering from dementia. The home plans to convert the home to only provide dementia care and currently has an application with the Commission for Social Care Inspection to increase the number of service users with dementia. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4½ hours and was the second inspection carried out by the Commission for Social Care Inspection for the year 2005-2006. Sarah Radlett carried out the inspection. The Registered Manager, Mrs Terry Newton, and the Deputy Manager, Mrs Pam Gibson, were present throughout the inspection. A tour of the premises took place and various written records were examined, including five care plans and service user assessments, staff recruitment files, staff training records and induction, the complaints log and a sample of the medication administration records. The inspector spoke to Service Users, and some of the staff on duty at the time of the 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: What has improved since the last inspection? Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 6 The home is introducing a series of fine dining evenings. The Service Users were able to invite guests to dine with them. The ‘A La Carte’ menu and wine list were seen and were of a high standard. During the evening the staff adopt the roles of waiters and waitresses. The evening is intended to provide Service Users with a complete restaurant experience and has met with a great deal of excitement from Service Users, their relatives 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. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 The information enabling Service Users to make an informed choice about where they live was available to all existing and prospective Service Users. Prospective Service Users are encouraged to spend a day at the home and have a full needs assessment prior to their admission. EVIDENCE: The home has an appropriate Statement of Purpose and Service User Guide. Service Users guide had been distributed to all Service Users. A full assessment of Service Users needs is carried out prior to admission to ensure that the home can meet their needs. Samples of the Service Users assessments were seen and found to be comprehensive. All prospective Service Users are encouraged to visit the home prior to their admission; this includes Service Users admitted for respite care. Intermediate care was not provided at the home. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Comprehensive care plans were in place, they were well organised and clearly set out the Service Users health, personal and social needs. Risk assessments were comprehensive. The recording, administration and storage of medication were satisfactory. Care was provided in a dignified, respectful manner. EVIDENCE: Five care plans and Service User assessments were randomly selected for inspection. The care plans set out in detail the action that needed to be taken to meet the assessed needs. There was evidence of regular review. Samples of risk assessments were inspected. comprehensive and up to date. They were found to be The home conducts a monthly audit of falls to determine any patterns to the incidents and regularly monitors Service Users deemed at risk of falls. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 10 All Service Users were registered with a local GP. Service users had access to visits from a variety of other health care professional services including district nurse, community psychiatric nurse, dentist, optician and chiropodist. The homes recording, administration and storage of medication were seen and satisfactory. No Service Users self-administer their medication. Staff were observed to carry out their care duties in an appropriate manner and to respect the service users privacy and to treat them with dignity. Service Users spoken with were complimentary regarding the home. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 15 Service Users are encouraged to make choices. The provision of food within the home was of an exceptionally high standard. EVIDENCE: Service users are encouraged to personalise their rooms, evidence of this was seen on the day of the inspection. Staff were observed to give the service users appropriate choice. Service users are offered a varied and nutritious diet. Some of the Service Users were observed to eat lunch during the inspection; the food was presented in an appealing manner and was met with positive comments from Service Users. Food was readily available to Service Users. Fresh fruit, biscuits, crisps and other snack items were seen in the communal areas. A small fridge was located in the main dining room containing soft drinks and a selection of desserts. Sandwich making items were also accessible to Service Users. Service Users were actively encouraged to help themselves to the food as they wished. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 12 The home is introducing a series of fine dining evenings. The Service Users were able to invite guests to dine with them. The ‘A La Carte’ menu and wine list were seen and were of a high standard. During the evening the staff adopt the roles of waiters and waitresses. The evening is intended to provide Service Users with a complete restaurant experience and has met with a great deal of excitement from Service Users, their relatives and staff. The homes catering manager is to be commended for his attention to detail, commitment to improvement and providing an exceptionally high standard. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 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): 16 & 18 The complaints procedure was available to all Service Users. Care staff have not received protection of vulnerable adults training. EVIDENCE: A copy of the homes complaints procedure was contained within the Service Users Guide, which was accessible to all Service Users. Two complaints had been received since the last inspection that had been appropriately investigated and recorded. The staff training records were examined and despite the requirement made at the previous inspection, the care staff had still not received training in the protection of vulnerable adults. The requirement has been repeated. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 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 & 26 The home was suitable in layout for its purpose. The home was found to be accessible, safe and well maintained with a pleasant homely atmosphere. EVIDENCE: The inspector toured areas of the home. It was seen to be warm and bright with a high standard of housekeeping. The garden area was well maintained and secure for Service Users to access. A new accessible nature trail had been recently completed in the grounds. The premises were well maintained and a decoration programme was in progress. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The staffing arrangements in place on the day of the inspection were sufficient to meet the needs of the Service Users. Service Users were protected by the homes recruitment procedures. Staff received appropriate supervision and induction. 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 staffing numbers are constantly under review in view of the changing needs of the service users. The home is committed to NVQ training, ten staff members had currently completed level 2 and three had completed level 3, the home had three NVQ assessors and an ongoing NVQ training programme. Samples of staff files were examined at inspection and the induction plan of new staff members were seen. The induction plans were comprehensive and fully completed. All new staff are supervised during their induction period. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 37 & 38 The Registered Manager is competent and capable to manage the home. EVIDENCE: The Registered Manager demonstrated good leadership qualities at inspection, all staff and Service Users observed to respond to her in a positive manner and appeared very pleased to see her. All interactions observed between the manager, staff and service users evidenced an open, positive and inclusive atmosphere. During the inspection, the Registered Manager presented a clear understanding of the home’s purpose and a grasp of the management challenges. There was clear evidence of teamwork between the Registered Manager and the Deputy. A sample of the records within the home were inspected and found to be accurately completed and up to date. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 17 Required health and safety training had taken place, including fire prevention. Required servicing certificates had been previously inspected and seen to be in order to ensure so far as is reasonably practicable, the health, safety and welfare of service users and staff. Dovers DS0000013630.V262825.R01.S.doc Version 5.0 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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 3 3 Dovers DS0000013630.V262825.R01.S.doc Version 5.0 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 OP18 Regulation 12 (1)(a) 13 (6) Requirement The Registered Manager must ensure that all staff receive training in the Protection of Vulnerable Adults. This is the second time this requirement has been made. Timescale for action 29/12/05 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 Standard Good Practice Recommendations Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Surrey Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Dovers DS0000013630.V262825.R01.S.doc Version 5.0 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!