Inspection on 23/11/05 for Home Covert

This inspection was carried out on 23rd 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

Home Covert 21/05/07

Home Covert 07/06/06

Home Covert 05/07/05

Home Covert 04/01/05

Home Covert 09/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Home Covert The Avenue Bentley Doncaster South Yorkshire DN5 OPS Lead Inspector Janet McBride Unannounced Inspection 23rd November 2005 09:50 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 Home Covert DS0000032140.V262330.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. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Home Covert Address The Avenue Bentley Doncaster South Yorkshire DN5 OPS 01302 875325 01302 822831 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) Doncaster Metropolitan Borough Council Carol Ann Morley Care Home 35 Category(ies) of Dementia - over 65 years of age (24), Learning registration, with number disability (11) of places Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user over the age of 65, named on variation dated 08 September 2004, may continue to reside at the home on Fern Unit. 5th July 2005 Date of last inspection Brief Description of the Service: Home Covert is registered for thirty-five beds, providing accommodation and personal care to two different service users groups, and registered for thirtyfive beds. All accommodation is on ground floor level and is in three units; two with twelve beds and one with eleven beds, and each unit has its own lounges and dining facilities, and staffed individually. Doncaster Metropolitan Borough Council is the owner of Home Covert, which was purpose, built, and is situated in the heart of the village of Bentley, within easy reach of the local amenities. Fern Unit Provides accommodation for eleven service users ranging from 36yrs to 69yrs old with Learning Difficulties. These service users are independent and go out to centres during the day Monday to Friday. Rose and Daffodil Unit Provides accommodation for twelve service users who are elderly mentally infirm. The unit is accessed via a secured digital locks, and it has it’s own enclosed courtyard, and CCTV is fitted to the outside of the building for security purposes. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Home Covert Home, on the 16th and 23rd of November 2005, commencing at 10:30 and finished at 16:20,the visit on the 23rd November was to discuss any issues that were raised with the manager and feed back about the Inspection. This was the home second Inspection since April 2005,any standards not covered in this inspection was covered in the unannounced inspection that was conducted early in the year. It may be the case that some standards will be covered twice in the inspection year 2005/2006, which is considered good practice, and consistent with a professional approach to regulation. During the Inspection we looked at chosen number of documents, sampling of records, tour of the premises and direct and indirect observation of staff interaction with residents, this Inspection also included individual and group discussions with residents, and feedback from relatives and visitors on the day. Any issues or concerns that were raised were discussed with the Manager during and at the end of the Inspection. Immediate Requirement Notice was issued for the home to address a number of issues immediately. DMBC responded with an action plan to the CSCI of how they addressed the issues raised. What the service does well: Home Covert provides a good standard of accommodation, with easy access to all parts of this single-storey building, the home has a good standard of furnishings throughout, and the atmosphere within the home is good. Residents that were spoken too feel they live in a safe, comfortable environment and allowed to have some of their own possessions around them, and both residents and visitors spoke highly of the staff team at the home. They were observed to carry out their duties in a professional manner and show consideration for the residents individual needs Residents are fully assessed before admission, can read the last Inspection report, have day care and respite care before living there permanent, and encourage them to visit other homes before making final decisions about where they are going to live. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 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. Home Covert DS0000032140.V262330.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 Home Covert DS0000032140.V262330.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): 346 Most service users needs are met and they receive a good standard of care, but one issue raised at this Inspection, puts one-service users at potentially at risk, and their needs are not met. EVIDENCE: Evidence was seen in care plans that service users are assessed before admission, evidence that other professionals were involved and that some service users had been to the home either for day cay or respite before being admitted on a permanent basis. A number of assessments are carried out to ensure the home will meet the service users care needs and those service users care plans seen on Daffodil and Rose reflected this, however one service users one on Fern unit their needs were not being met. This service user day care had been cancelled, and evidence in care plan this was the right decision as there was a safety issue. Staff at the home tried to arrange alternative day care, and a place was found, however for some reason Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 9 this was stopped by management at DMBC and no recorded evidence who made this decision and why. This raised concerns as this service users is the only person left on this unit, and when short of staff has been placed on the elderly dementia unit, this is in Breach of Registration and failure to meet service users needs could have a serious effect on the health and welfare of this resident. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 10 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): 789 Limited progress has been made on documentation in care plans, accident reports and completing Regulation 37 reports, these shortfalls have a potential to place residents at risk. EVIDENCE: Three service users care plans were examined; and discussed with the senior person on duty. The care plan for all service users are developed shortly after the admission, using the initial assessment of need and any other relevant information gathered by professionals and family and friends. The family and the service user would agree the plan prior to its implementation. During the checking of care plans a number of issues were raised; documentation not completed on admission e.g. medical and physical health history, social and leisure. Some risk assessments appeared to be out of date and did not reflect the current needs of the service user, or provide evidence what action had been taken to prevent this happening again when there had been an incident or accident? Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 11 Accident records checked which also raised issues about documentation, accident reports not always completed, reports not clear or concise and did not contain enough information. Regulation 37 are not completed and sent to the Commission for Social Care Inspection. The District Nurse provides the main link to all medical services including pressure area care, adaptations e.g. airwave and other pressure relieving mattresses, continence advice and general health checks as required by the G.P. Medication policy and procedure was discussed with the manager and records checked. The local chemist that supplies the Nomad system currently used at the home visits the home periodically. The Pharmacist is responsible for carrying out audits and give advice to staff at the home. Staff responsible for the administration of medication has completed the accredited medication training. An audit of the records and stock were found to be satisfactory with no issues raised. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Social activities on Fern unit provide stimulation and interest for those service users, but on the elderly unit it is dependant on staffing numbers, and therefore those service users do not get they same stimulation are satisfaction. Dietary needs of service users are well catered for, and offer a varied diet to meet service users tastes and choices. EVIDENCE: There are different needs of the two categories of residents who live at Home Covert. The residents on Fern Unit go out to various day centres during the day five days a week, and their evenings are filled with their own choice of leisure activities, supported by staff. One service user on fern who as been discharged from day care, this as raised an issue about meeting this persons needs. The home don’t employ an activities organiser, therefore activities are only organised for the residents on the two elderly units, if there are enough staff on duty, no activities were taking place on the day of Inspection, although staff had ensured that appropriate music and TV programmes were available on both of the units. There is a Physiotherapist who attends weekly, and she organiser’s activity to music. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 13 Residents on Daffodil unit were spoken to, and they stated they, watch TV and have newspapers to read, but would like more activities. Visiting is allowed at any reasonable time, and this was confirmed by visitors seen on the day, they also stated that their relatives came to the home for either day care or respite before being admitted and feel that’s why they settled at the home. Capacity to exercise choice within the service users lives was discussed with both the manager and staff that were spoken to. All service users are able to personalise their room, and this was evidenced during the inspection. Some service users on Fern Unit chose to decorate their walls with posters of their favourite pop and TV stars. Staff stated they encourage all service users to make choices whenever possible. Food and mealtimes were discussed with staff on all of the units and it was found that service users on the elderly unit have more structured meals, and the cook provides these. The meals are transported to the two units via hot trolleys and served in the dining rooms by the staff. Observations during mealtimes confirmed that they were unhurried and assistance was given when required. Service users spoken to said they had enjoyed their meal and liked the food at the home. Service users on Fern Unit have a different routine at mealtimes, breakfast can be a little rushed, due to them leaving early for the centres, but weekends is very relaxed and they have breakfast as and when they get up and this is prepared by staff on the unit. They also eat their main meal at the day centre and teatime is usually dependant on activities that are taking place during the evening, as they may go out for a meal or arrange takeaways in the home. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staffs have knowledge and understanding of adult protection issues, which promotes protection of service users from abuse. EVIDENCE: Home Coverts has DMBC policy on Adult Protection and Whistle blowing, and therefore have the appropriate policies and procedures in place for dealing with adult protection. Discussion with staff confirmed they were aware of these polices and procedures, some staff requires training and updates on adult abuse, and this is being addressed by the manager, and inhouse training will be implemented to all staff. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 15 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): 26 The appearance of the home creates a comfortable, clean and safe environment for those living there and those visiting. EVIDENCE: Tour of the premises found the home has a good standard of furnishings and decoration throughout. It was kept clean, tidy and free from offensive odours and domestic staff is employed in sufficient numbers to ensure standards are maintained to high levels. The home has three sluicing facilities one for each unit and a communal laundry that is equipped to deal with all of the homes laundry. Washers meet the required safe washing temperatures to control the risk of infection. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 16 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 29 30 The home has a very enthusiastic staff group that work positively with service users to improve their quality of life within the home, but inconsistent staffing numbers on night duty results in a unsatisfactory service and puts peoples health and safety at risk. EVIDENCE: Staffing was discussed with the manager and staff rotas were examined. The registered manager continues to work on rota, when they are short staffed, this restricts her ability to develop the service further and deal with management issue. Although there was adequate cover to meet service users needs during the day, night duty shows inappropriate staffing levels to meet the assessed needs of service users. On previous Inspection it recorded 4 waking night staff, these rotas show two waking staff and one staff doing a sleeping shift. This puts health and safety of service users at risk and requires addressing immediately. Ancillary staff is employed in sufficient numbers to ensure that all standards relating to food, meals and nutrition are met, and that the home is maintained in a clean and hygienic state. The staff team were observed to carry out their duties in a professional manner and show consideration for the service users individual needs, and are highly regarded by the service users. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 17 Staff personal employments files are kept centrally by DMBC and have to be requested to examined in the past have always met the standards, and not requested at this inspection, but discussed with the manager. Training files were examined and training opportunities were discussed with the registered manager, new staff at the home receive a structured induction programme that is recorded and signed by the individual, and by the senior who will continue to mentor the staff member throughout their probationary period, this was confirmed when speaking to a new member of staff on the day. There appears to be some difficulties in the amount of staff that can access training courses, and updates in training. This remains outstanding from the previous inspections and must be addressed by DMBC to ensure staff has the necessary training and updates to meet the needs of service users. Staff employed to work specifically on Fern Unit are now able to access Learning Disability Award Framework accredited training, and staff spoken to have recently registered and are awaiting commencement of their training. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 18 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 33 35 37 38 The registered manager is skilled and experienced to manage the home to ensure the safety and protection of service users, and tries to run the home in the best interest of service users. Staff must ensure that record keeping is accurate and up to date; this provides evidence that service users are safeguarded and protected. EVIDENCE: The registered manager of the home has a HNC in managing care and has been in post for a number of years. She has clear roles and responsibilities that are identified in her job description. The registered manager is working towards the Registered Managers award and is hoping to attain the qualification soon. She continues to work on rota, when they are short staffed, which restricts her ability to develop the service further and deal with management issue. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 19 The registered provider has developed quality assurance systems, and the Inspector examined these. Surveys are used to gather views of service users, and visitors to the home; the registered provider develops action plans from the data collected. A number of CSCI comment cards had been completed, and these generally had positive comments about the care at Home Covert. Visitors to the home also confirmed that they were happy with the care at the home, but feel that staff work very hard and under pressure at times, as they are short staffed. The registered manager enables service users to maintain control of their own finances, and families are involved in this, but the home also provides a secure facility for those who are unable to make that choice. A ledger is available for those individuals choosing to leave money for safekeeping. These records were checked against monies held on site and were found to be accurate. Supervision was discussed with the manager and her line manager on behalf of DMBC gives her supervision monthly. Staff records show a big improvement since the last Inspection, most staff has received formal supervision on a regular basis and received their annual appraisal. Safe working practice was discussed with the manager and checking of records and observation of staff during the Inspection. Fire records indicate that fire tests are carried out and drills had taken place, and fire training for staff had been completed. Records required by regulation were checked and found that most records were up to date and accurate with the exception of accident records, some documentation in care plans. Discussed with the manager about regulation 37 notifications, has the CSCI had only received these in the event of a death, but not when other incidents had taken place at the home. This was discussed at the last Inspection and a copy of scope of notifications was given to manager to inform her when these must be sent. Immediate Requirement Notice was issued for the home to address this immediately. Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 2 3 Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 21 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 OP4 Regulation 4(1)(b) 12(1)(2) Requirement The Registered person must demonstrate they are meeting the needs (including specialist needs) of individuals at the home. Care Plans; 1) Staff must complete all documentation when service users are admitted to the home. 2) Service users must be reassessed to state what action as been taken when their care needs change, e.g when an accident or incident as occurred. 3) Documentation must be clear and legible. Accident Records, 1) Must be completed as policies and procedure state. 2) Documentation must be clear and legible with enough information. 3) Staff must complete Regulation 37incident form and send to CSCI DS0000032140.V262330.R01.S.doc Timescale for action 01/12/05 2. OP7 14(2)(a) (b) 01/12/05 3. OP8 17(2) schedule 4 01/12/05 Home Covert Version 5.0 Page 22 4. OP12 16(2)(m) (n) 5. OP27 18(1)(a) 6. OP30 18(1)(c) 7. OP37 17(1) Schedule3 Social contact and Activities, service users must have the opportunity to satisfy there social and recreational interests. Re activities organiser being employed. Staffing must be appropriate to meet service users needs and layout of the home in accordance with the guidance recommended by the department of health. Staff Training, The Registered provider must ensure that staff can access and receive training and updates, so they are trained and competent to do their job. Regulation 37 notifications, The registered manager must inform the CSCI of any occurrence that happens within the home. 31/03/05 01/12/05 31/01/05 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP28 OP31 Good Practice Recommendations A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 31st December 2005, excluding the registered manager. The registered manager must gain the NVQ level 4 in Management and care or equivalent by 31st December 2005 Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Home Covert DS0000032140.V262330.R01.S.doc Version 5.0 Page 24 - 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. 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