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Inspection on 14/11/05 for Dovetail House Care Home

Also see our care home review for Dovetail House Care Home for more information

This inspection was carried out on 14th 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The only key standards not inspected at the last inspection were standards 32, 34 and 42 so the previous inspection should be seen for further details of what the home does well.

What has improved since the last inspection?

No requirements were set at the last inspection. An enclosed porch has been built to make a reception area. The home has revised the smoking policy and the home is now a no smoking home and the former smoke room is now being used s an occupational therapy room. The entrance flooring has been replaced for one more suitable for use by wheelchairs and a ground floor toilet has been made more accessible for wheelchair users

What the care home could do better:

All new staff should have a CRB check carried out, even if they already have one with their most recent employer.

CARE HOME ADULTS 18-65 Dovetail House Care Home Dovetail House Park Avenue Mansfield NG18 2AT Lead Inspector Stephen Benson Unannounced Inspection 14th November 2005 09:30 Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 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 Dovetail House Care Home DS0000043884.V267137.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 Adults 18-65. 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. Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dovetail House Care Home Address Dovetail House Park Avenue Mansfield NG18 2AT 01623 420690 01623 420699 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) Step Forward (Nottingham) Limited Margaret Ann Webster Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Category of registration is to be Learning Disability which is specific to those who have acquired Brain Injury caused by Trauma or Illness Up to 3 beds allowed to be used for palliative care as a result of a neurological disorder. 16th June 2005 Date of last inspection Brief Description of the Service: Dovetail House is a care home providing personal care and accommodation for 16 younger adults who have a traumatic or acquired brain injury and includes 3 beds that can be used for palliative care. The home provides individual programmes detailing the care to be provided and can provide long or short term care, assessments and rehabilitation programmes. The home also offers a buddy system to support service users who have moved out of the home and those needing support within the community. A day care service is also available. The home is owned by Stepforward (Nottingham Ltd), which is run as a family business. The home is located in a residential area on the outskirts of Mansfield town centre and is close to shops, pubs, the post office and other amenities. The home was opened in 2003 and consists of a former domestic dwelling, which was previously run as a nursing home. The current providers refurbished the building following purchase and prior to opening. .All of the homes bedrooms are single and have en-suite facilities. Bedrooms are located on the ground, first and second floors all of which are served by a passenger lift. The home has good-sized gardens that are well maintained and easily accessible. There is a small car parking area to the front of the property and further parking is available on the road. Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection lasted for 3 hours and the inspection focussed on key standards not inspected at the last visit.. The main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, care staff on duty and care practices were observed. No visitors came to the home during the period of inspection. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: 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. Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34 Staff receive the training they need to carry out their duties. The home operates a thorough recruitment process although had overlooked a change in guidance EVIDENCE: All staff undergo a training needs analysis to identify their training needs. The Nottingham Brain Injury Unit provides training on working with people who have a brain injury. All staff have either completed or re currently working towards NVQ level 3, with the exception of new starters who will be enrolled shortly. A recently started member of staff said that he had been through an induction period and was now signed off as competent for all care activities, but had been told not to carry out any duty he did not feel he was confident in doing correctly. Residents said that they were aware of staff having training sessions and their certificates are displayed so they can see what training staff have done. Residents said that staff were able to do their job. All new staff are required to complete an application form, attend an interview, provide 2 suitable referees, complete a health check and undergo a CRB check. The General Manager, who manages the recruitment of staff, was unaware of Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 14 the change in guidance concerning CRB’s where those carried out within the last 12 months they can no longer be transferred from one employer to another. A recently appointed member of staff said that this was the recruitment process he had followed. All new staff are issued with statement of terms and conditions, a code of conduct issued by the General Social Care Council and in formation about brain injuries. Residents said that they have an opportunity to meet prospective staff and are asked for their views. Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health, safety and welfare of residents is promoted. EVIDENCE: Training records show that all mandatory training is carried out on a rolling basis to ensure staff receive the required training. Staff said they had taken part in fire prevention training the previous week and training on infection control is to be provided shortly. The electrical hard wiring was tested as pat of the registration process when the home was opened 2 yeas ago and portable electrical appliances were tested in May 2005. The home is not connected to a gas supply. Residents said that there was a high standard of health and safety within the home and knew where the fire assembly point was. Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 4 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dovetail House Care Home Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000043884.V267137.R01.S.doc Version 5.0 Page 17 N/A 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 YA34 Regulation 19 Requirement Undertake a CRB check on all new staff Timescale for action 15/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA7 YA17 YA22 Good Practice Recommendations Indicate in care plans where there is a link between care plans and risk assessments Review the nutritional content of the food provided The complaints book should be available at all times Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Dovetail House Care Home DS0000043884.V267137.R01.S.doc Version 5.0 Page 19 - 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!