Inspection on 17/04/07 for Dovetail House Care Home

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dovetail House Care Home 14/11/05

Dovetail House Care Home 16/06/05

Dovetail House Care Home 28/01/05

Dovetail House Care Home 15/07/04

Dovetail House Care Home 10/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Dovetail House Care Home Park Avenue Mansfield Nottinghamshire NG18 2AT Lead Inspector Stephen Benson Key Unannounced Inspection 17th April 2007 09:30 Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 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.V334884.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 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.V334884.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dovetail House Care Home Address Park Avenue Mansfield Nottinghamshire 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.V334884.R01.S.doc Version 5.2 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. 13th October 2006 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. The manager wrote in the pre inspection questionnaire that the fees for the service are £820 per week with additional charges of £10.80 per hour when one to one support is required. There are additional charges for chiropody, activities, toiletries and transport. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2007 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The inspection looked at key standards for younger adults. The site visit lasted for 7 ½ hours and 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 senior team leader, staff on duty and care practices were observed. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. A pre inspection questionnaire was completed and survey forms sent to the home by The Commission for Social Care Inspection had been completed by 5 relatives. What the service does well: Any new resident to the home is fully assessed to make sure their needs can be met before they move into the home. Staff are shown the assessments and care plans are prepared so that staff will be able to meet their needs straight away. Residents are encouraged to make decisions they are able to, so that they have some control over their lives. Residents have opportunities to take part in education and employment according to their abilities, so they can learn and develop new skills. Residents are able to take part in activities and groups, which enable them to become part of the local community. Residents are able to keep in contact with their families and have personal relationships, which allows them to have meaningful relationships. The home provides different diets according to residents assessed needs. This ensures that residents’ meals are appropriate for their needs. Residents receive personal support in a way that respects their privacy and dignity. A new hoist has been ordered to replace one which has broken. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 6 Residents attend healthcare appointments and specialist services are used. Residents are encouraged to monitor their own health. This helps to promote residents health. Some residents attend local colleges and work placements. Other residents help prepare a weekly programme of things they want and are able to do. Residents are able to go out and use local facilities including groups and leisure facilities. Residents are supported to keep in contact with families and friends and have personal relationships. The home provides different diets according to residents’ needs. Some residents are able to shop, prepare and cook some of their own meals. Personal support is provided in a relaxed way and staff try to find out how residents like their support to be given. Residents have routine and specialist health care needs met through other professionals and are encouraged to monitor their own well being. There are systems in place for residents and other concerned people to raise any complaints they have, which are all documented and appropriate action taken. The home has got the up to date Adult Protection Procedures and have information about risks posed to and by any resident to others. The home is kept clean and well maintained. Staff know how to prevent the spread of infection. There are sufficient staff on duty and a manager is always available. The correct recruitment procedures for appointing new staff are followed including carrying out the necessary checks. Staff are provided with the training they need to do their jobs. The manager is experienced and trained to do her job Survey forms are given out so that relatives and other professionals can comment on the services provided at the home. Safety checks and tests are carried out on the building and equipment. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 8 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.V334884.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are fully assessed prior to moving into the home to ensure that their needs can be met. EVIDENCE: Any new resident is fully assessed before moving to the home to ensure that their needs can be met. Assessments are provided by the placing authority, which may be Social Services or Health Authority and those seen were dated prior to the resident moving to the home. The senior team leader said that two members of the management team will go to assess a prospective resident where they are currently staying, which may be in hospital or another residential home. The home has their own assessment form to complete to help carry out the assessment. Copies of these assessments were seen on residents’ files. If the resident has Huntingdon’s Disease a Huntingdon’s Disease specialist nurse also takes part in the assessment. Assessments included details of any specialist assistance a resident requires and information seen in assessments had been incorporated into care plans. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 10 The senior team leader said that anyone is welcome to apply for a place providing they fall within the registration category for the home. Staff said that they always see assessments for new residents before they come to the home and that care plans are prepared before anyone is admitted so they know how to meet residents’ needs. A care plan was seen describing how the admission of a new resident should be undertaken. A recently admitted resident could not recall someone from the home visiting him in hospital, but a completed assessment for this was seen. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents know their assessed needs and personal goals are reflected in their individual plan. Residents’ make decisions about their lives with assistance as needed. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Care plans were well-organised and broken down into sections, which had an index to make it easier to refer to. The information sheet at the front of the care plans did not include details of residents’ gender, ethnic origin or religious beliefs. There were care plans prepared for individual needs that have been identified but these did not always include sufficient detail, an example being one car plan stated ‘At times staff may have to use an override key’ to enter a Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 12 bedroom, but did not explain that this was if staff suspected a resident was having an epileptic fit. There as a space fore the resident and their keyworker to sign the plan, but not all of these had been signed by both the resident and the keyworker. There was also a system for updating the plans, but some of these had not been done and some plans that had now finisher had not been removed. They senior team leader said that there had been a change of staff and the unit coordinator who was responsible for checking care plans were up to date has left a new person has just taken up post. Staff said that they followed care plans to make sure they attended to residents needs properly, but felt that some plans could contain more detail. A resident said, “I have been told this will help me be able to leave here and go home again“ and another resident said “Staff go through this with me”. There was examples seen of residents making decisions about what they do in care plans which included going to work. The senior team leader said that residents are encouraged to make decisions and gave examples of personalising their rooms, what they have in their an dhow the furniture is laid out. The senior team leader said that one resident with Huntingdon’s Disease had said she wanted to have a peg feed fitted, and arrangements were made for the resident to be assessed for this at the local hospital. Staff said that some resident cook some of their own meals and they go to the shops to choose what they are going to cook. Staff said that they know signs made by residents without speech to indicate choices, but there are times when they are unable to get a response so make decision based on their knowledge of the residents’ preferences, for example the colours they prefer when choosing clothes. A resident said, “We sit and plan what I am going to do each week, I enjoy what I do”. There are risk assessments for all aspects of daily including behavioural and swallowing for residents with Huntingdon’s Disease. A new bath has recently been purchased which is a different design to the previous one. Risk assessments for using the bath have not been updated. The senior team leader said a risk assessment is being prepared for a barbecue to be held next week. Staff were seen discussing with one resident about them being able to go swimming. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 13 A resident said, “I visit my house once a month and I still have a car which I hope to be able to drive again”. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to take part in age, peer and culturally appropriate activities. Residents are part of the local community. Residents have appropriate personal, family and sexual relationships. Residents rights are respected and responsibilities recognised in their daily lives. Residents are offered a diet suitable to their needs and enjoy their meals and mealtimes. EVIDENCE: There is a noticeboard in the hallway showing what each resident is doing during the week. The senior team leader said that some residents are taking a certificated catering course at a local college and others are on a computer course. One resident with Huntingdon’s Disease attended a college course for as long as she was able to until symptoms of the disease made impossible to continue. Two residents have voluntary work placements. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 15 Staff said that when residents have not got an outside commitment individual programmes are prepared with them each week for what they are going to do. The senior team leader said it is important for residents well being that they have a structure. There was a lot of discussions taking place between staff and residents about what they were going to do during the day. A member of staff was seen involving a resident in writing a plan, including asking him to spell words. A group of residents went to play bingo at a local bingo hall. A resident said, “I am going shopping later today“ and another resident said, “I go out to work for some of the week, which I like”. The senior team leader said that residents go out to local pubs and leisure facilities including swimming pool and bowling alley. Some female residents attend a local woman’s group, which gives them further opportunities to mix with the community. Residents also attend the local Headway group, which is a charity that supports people with a brain injury. The only religious festival that the home celebrates is Christmas. Staff said that all residents are given opportunities to go out each week. A resident said, “I go to Headway each week and I like to go to the cinema”. There was information about residents contact with their families and friends in care plans. There was also information about residents’ sexuality and ability to have a consenting sexual relationship. A relative said on the survey form that they wished to speak to the inspector. On contacting the relative they said that they would like communication to be better as they only hear if there is a problem. The unit coordinator said she would contact the family to arrange what contact they would like. The senior team leader said that families are able to visit up till 11.00pm and that it is possible to arrange for a resident’s partner to stay overnight. Staff said that residents are able to have personal relationships and support is provided with contraception. A resident said, “I go and visit my children and they come to visit me” and “I go out on a date with my boyfriend each week and we are able to have private time together”. The senior team leader said that daily routines are made to be realistic. Some of the residents need to have a structure and the routine helps them know what to do. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 16 Staff said they try to find out what routines residents like and they help them to fulfil their weekly commitments such as work and any medical appointments. A resident said, “We write our routines on the board. There is one resident who doesn’t like going to work so he doesn’t have to go”. The home has to provide differing diets according to residents needs. These include soft diets for residents with Huntingdon’s Disease, a healthy eating diet, a diabetic diet and a gluten free diet. A record is made of what each resident has to eat in his or her care plan, however the home does not work to a menu making it difficult to know what options are available and there is not a list of residents likes and dislikes in the kitchen. Staff said that residents get a choice of meal each day but this doesn’t always reflect the preferences of residents. There is a record made of which food residents like and dislike and the cook has information about any special diets residents require. A resident said, “I enjoy the food, I try to eat healthily and have a lot of vegetables. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal support in the way they prefer and require. Residents physical and emotional health needs are met. EVIDENCE: Staff were seen providing varying support to residents, including helping them to eat and walk. This was done in a relaxed manner with staff talking to residents as they provided assistance and there was a lot of laughter. Staff were heard sharing appropriate details about themselves when speaking with residents, an example being when a resident got a member of staff’s name wrong the staff said that was what her father called her. A member of staff discussed with the senior team leader a resident’s reaction when supported to have a bath. This was part of an ongoing assessment to find how the resident best likes assistance to be provided. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 18 The senior team leader said that residents with Huntingdon’s Disease need a high level of personal support and that staff are aware of how to respect their privacy and dignity. Staff said they were having to move one resident without the proper hoist as it had broken, which they were uncomfortable with. The senior team leader said that a new hoist had been ordered but they were still waiting for it to be delivered. The care plan for the resident had not been updated to take this into account, which when bought to the attention of the senior team leader was updated by her. The general manager said she had chased up the delivery of the hoist again that morning and had been given a delivery date of early May and she was arranging for a demonstration on how to use it for the same day which staff will be asked to attend. A resident said, “I get the help I need. I can’t go in a bath on my own but I get myself ready first”. A record is made of all healthcare appointments residents attend. Records showed that residents receive routine health checks, including well women checks, speech therapy and visits to dentists and opticians. A Huntingdon’s Disease specialist nurse and a nuro consultant see residents with Huntingdon’s Disease. The senior team leader said that residents are encouraged to self examine themselves for any lumps when having a bath. Staff said that residents have regular checks and they take them to any appointment. If there are any worries about a resident’s health these are dealt with immediately. A resident said, “I have got a head injury which has made me poorly, I am getting a lot better and may be able to go home in the future”. Only senior staff who have been trained in medicine administration, and have been assessed as being competent of doing so by the manager are allowed to give out medication and the member of staff doing so wears a red bib saying they are not to be disturbed whilst giving out medication so they can concentrate on the task without being distracted. Staff were observed giving out medication and this was done correctly. A record was made of the administration once it had been given. Medicine Administration Records were fully completed, although one had been handwritten and not signed by the member of staff having done so or witnessed by another member of staff. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 19 The senior team leader said residents with Huntingdon’s Disease had difficulty in swallowing medication and this was given with food to help them with this. This is on the advise of the Huntingdon’s Disease specialist nurse and is recorded in the care plan. Staff tell the residents when they are giving them the spoonful with their medication in, which they are able to understand. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents views are listened to and acted upon and they are protected from abuse and self harm. EVIDENCE: The home has a complaints procedure and there are systems in place for residents to raise anything they wish with staff and/or management. This can be done verbally, in a residents meeting, using a resident to staff/management communication book or a residents complaints book. There have been 9 entries in the complaints book in the last year 4 of which have been upheld. Examples of issues raised include a heater not working, which was repaired, smoking restrictions where the home’s smoking policy was discussed and a request for a greater choice of food, which led to the resident starting to cook some of his own meals. There is also a central complaints log for other complaints and there have been 18 received in the last year, 4 of which were partially or fully upheld. Complaints have been received from staff, a neighbour, relatives and a number were made anonymously. Records made of these complaints included details of the investigation, the outcome and appropriate action has been taken. One complaint has been investigated by an independent investigator, however the outcome of this has not been shared with the home, who have requested Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 21 under the Freedom of Information Act that this be shared with them, but this has been denied. It was therefore not appropriate to discuss this complaint. The senior team leader said that any complaint is dealt with through the complaints procedure and this is seen as a way of improving services within the home. Staff knew about the complaints procedure and have used it to advocate on behalf of residents. A resident said, “You just have to tell someone when you want to make a complaint”. There was a copy of the Adult Protection Procedures, which were up to date and the home also access the Notts Adult Protection website. The home has a whistleblowing policy. There was information included in care plans about residents’ vulnerability and any risk a resident may pose to others, including children. Staff have received training on safeguarding adults and said they had not seen anyone being mistreated. There are occasions when residents with Huntingdon’s Disease have a support strap used to control their body movements when helping them to eat. This is only done with appropriate professional agreement and a record is made each time this is done. A new system for managing residents’ finances has been introduced so that every transaction made is signed for and witnessed. A resident said, “I feel safe here, everyone is nice”. The senior team leader said there have not been 2 referrals made under the Adult Protection Procedures following allegations made, which have been investigated and unsubstantiated. There was a delay in making one of these referrals due to sickness, however the home has now reviewed their procedures to ensure that any allegation is immediately reported. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a homely, comfortable and safe environment, which is kept clean and hygienic. EVIDENCE: The home employs a maintenance man to carry out any minor repairs and there is a maintenance book to record any repairs that need doing. All areas of the home are accessible to wheelchair users. All areas of the home were clean, tidy, suitably furnished and well maintained. The dining room has recently been decorated which looked pleasant and a new bath has been fitted. Staff said that building was easily accessible and they were able to carry out their duties without any difficulty, but thought a walk in shower would be a good idea for the future. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 23 A resident said, “I think it is lovely here, it is almost like my own house“ The senior team leader said that there is a red bag system in place for dealing with soiled laundry and protective clothing is provided. There is a washing machine provided for residents who are able, to do their own laundry. Staff said they have had training on infection control and always use protective clothing when needed. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported by competent and qualified staff and supported and protected by the home’s recruitment policy and practices. Residents individual and joint needs are met by appropriately trained staff. EVIDENCE: The home provides a minimum of 6 care staff during the day and 3 care staff at night. In addition the home employ a range of ancillary and support staff including general and catering managers. The home has team leaders, a unit coordinator and a senior team leader in addition to the registered manager. The home employs male and female staff of varied ages. All staff are currently of white British origin. The senior team leader said that there is normally more than 6 care staff on duty and efforts are made to cover any absence from work that the permanent staff cannot cover through bank or agency staff. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 25 Staff said that they are able arrange any cover for staff shortage in the absence of a manager. A resident said, “There are enough staff around. If I am upset they try and help me“ The home follows an Equal Opportunities policy for recruitment and this includes taking up 2 references and obtaining a satisfactory Criminal Records Bureau check. Staff files contained the required information and one member of staff who has recently been promoted had completed a fresh application form and been through the home’s recruitment process, including a competitive interview. Information provided with the pre inspection questionnaire showed that all mandatory training is provided as well as training required for working at the home, including training for working with people with brain injuries and Huntingdon’s disease. Staff are expected to undertake National Vocational Qualification training and records showed that staff have either achieved this, were currently working towards this or are planned to enrol shortly. Staff said that training is readily available and they feel trained to carry out their duties. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well run home. Residents are confident their views underpin all self monitoring, review and development by the home. The health, safety and welfare of residents are promoted and protected. EVIDENCE: The manager has appropriate experience for her position and has achieved National Vocational Qualification level 4 in care and management. Day to day management of the home is shared out amongst the management team. The senior team leader said that the manager ensured that the home’s policies and procedures were properly implemented. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 27 Staff said that the manager was competent and able to do her job and that the home was well managed. A resident said, “The home is very well run“. The home has distributed a questionnaire to relatives and other professionals asking for comments about the services provided. Some have been returned and the senior team leader said that these will be gone through when they have been returned. The senior team leader said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. Dates of tests were recorded in the pre inspection questionnaire showing they are regularly carried out. A sample of these were looked at and found to be correct. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 28 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 Standard No Score 1 X 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 4 X 3 X X 3 X Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 29 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 YA6 Regulation 15(2)(b) Requirement Care plans and risk assessments must be kept up to date and have sufficient detail in so staff know what support residents require When Medicine Administration Records have to be written out by hand the member of staff doing so must sign these, and then witnessed by another member of staff to make sure that they are correct so no drug administration error can occur. Timescale for action 01/06/07 1 YA19 13(2) 01/05/07 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 YA6 YA17 Good Practice Recommendations Include details of residents’ gender, ethnic origin and religious beliefs in the resident information sheet. Prepare a menu of food provided in the home in consultation with residents. Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Dovetail House Care Home DS0000043884.V334884.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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