Inspection on 05/07/05 for Home Covert

This inspection was carried out on 5th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 23/11/05

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 05 July 2005 :10.00. The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Home Covert Address The Avenue, Bentley, Doncaster, South Yorkshire, DN5 OPS 01302 875325 01302 822831 bron.sanders@doncaster.gov.uk Doncaster Metropolitan Borough Council Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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 CS0000032140.V185990.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 Date of last inspection 4-Jan-2005 Brief Description of the Service: 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. The home offer residential accommodation for thirty-five service users. Daffodil and Rose are for people who are elderly mentally infirm, with Fern unit offering accommodation for people with learning disabilities, whose ages range from 36yrs to 69yrs. 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. The grounds can be accessed via several exits and there is a secure courtyard for service users with Dementia HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A statutory unannounced Inspection was carried on the 5th July 2005,this was conducted by one Inspector and commenced at 10.00 and finished at 15.00 hours. During the Inspection we looked at a chosen selection of the National Minimum Standards, sampling of records, document reading, included talking to the manager, residents and any visitors seen on the day, tour of all units and direct and indirect observation during the Inspection. Comment cards were also left at the home for service users and relatives; who wish to make comments relating to the home. Any issues or concerns that were raised were discussed with the Manager at the time of Inspection, and verbal feedback session to the manager at the end of the Inspection. Immediate Requirement Notice was issued for the home to address this fire training for staff, which had not been addressed since the last Inspection; therefore an Immediate Requirement Notice was issued for the home to address this immediately. What the service does well: What has improved since the last inspection? Since the last Inspection some mandatory training as taken place, and they have accessed a dementia course for staff at Selby College. HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 6 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 CS0000032140.V185990.R01.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed at this Inspection. EVIDENCE: HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 8 9 10 Residents are treated with respect, and their health care needs met. Medicines in the custody of the home are handled according to the requirements of the Medicines Act 1971,with the exception of some documentation. EVIDENCE: Residents who are referred to the home had been assessed by their social worker prior to admission, and care plans for all residents are developed shortly after their admission, using the initial assessment of need and any other relevant information gathered by professionals, family and friends. The resident (if capable) and family would agree the plan prior to its implementation. Care plans were examined; and discussed with the manager, they were found to be comprehensive, concise and easy to follow. Two issue were raised, one regarding staff had highlighted a residents skin breaking down, and not recorded what action they were going to take. Risk assessment must be completed when toiletries are left in vulnerable resident bedrooms to ensure these residents will not drink these items. HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 10 Residents retain their own GP or where this is not possible the home arranges for them to be registered with a local GP. Residents on Fern Unit are encouraged to visit the GP surgery for appointments, accompanied by staff. 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 procedures checked and records examined and random MAR sheets were examined and found satisfactory, with the exception of; Mar sheets that are hand written must have two signatures ensure accuracy of medication, and some mar sheets did not give any reason why medication was omitted. During this inspection there were many examples of good practice, from the staff on duty, they were observed to knock on residents bedroom doors before entering, and interacted with respect addressing service users by their preferred name. HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed at this Inspection. EVIDENCE: HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Residents and relatives are provided with information to enable them to raise concerns or complaints about the home and the care provided. EVIDENCE: The organisation has a comprehensive Concerns Complaints procedure (DMBC View Point). There is also a monitoring form that is used to record complaints, this meets the requirements and includes timescales for complaints to be acknowledged and investigated. Discussed with the manager and examined the homes records, this was able to confirm that there have been no complaints recorded since the last inspection. HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 20 24 Residents live in a safe, well- maintained and comfortable environment with their own possessions around them. EVIDENCE: Tour of the home found it to be a well-maintained environment, looked very homely and comfortable. Communal areas had a good standard of furnishings throughout and the decoration in the three units reflects the names of each unit. Bedrooms on all the three units were furnished and equipped to assure comfort for the residents and found to be clean and tidy. Residents are encouraged to bring personal items with them and most had been personalised with pictures, photos and ornaments. Digital locks on the entrance of each unit for security purposes and safety of residents. HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 30 Staff are trained and have the skills and knowledge to fulfil their roles within the home. On going development of staff was evident by some staff achieving NVQ qualifications, but staff working on the learning disabilities unit are not able to access the appropriate training to carry out the work they perform. EVIDENCE: New staff completes a well-structured induction programme, then on to the LDAF programme and can access NVQ training. Existing staff that works on the learning disabilities unit cannot access the LDAF programme (which is specific training to meet the needs of those service users) therefore this must be offered to staff working on this unit has part of their development and ensure they are equipped meet the needs of these particular residents. Since the last Inspection some mandatory training as taken place, and the manager informed the inspector that they have accessed a dementia course for staff at Selby College. The home is well on its way of meeting the target for 50 of staff to be NVQ trained. HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 36 37 38 Some practices do not promote and safeguard the safety and welfare of residents within the home. EVIDENCE: The manager is qualified and competent to run the home and aware of her role and responsibilities. Staff training files show that all staff has received their annual appraisals, and most had recent formal supervision, however not all staff has received supervision on a regular basis e.g. (6 sessions yearly). 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, but emergency lights had not been checked on a regular basis and fire training for staff had not been addressed since the last Inspection when this was a requirement, therefore an HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 16 Immediate Requirement Notice was issued for the home to address this Immediately. Records required by regulation were checked and found that regulation 26 visits are carried out with reports available. Discussed with the manager regulation 37 notifications, has the CSCI had not received any from the home, or had any on file. Advised when these must be sent to the CSCI, copy of scope of notifications given to manager to inform her when these must be sent to the CSCI. HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x x 3 x x STAFFING Standard No Score 27 x 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x x 2 2 2 HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 18 yes 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 OP7 Regulation 12(1)(a) Requirement Care Plans; risk assessment must be completed if toiletries are being left in service users bedrooms. Care Plans;staff must document what action as been taken when issues are raised regarding care of residents. Medication;Two signatures verify the accuracy of handwritten entries on MAR sheets and when medication is omitted state reason why on MAR sheet. Staff Training;must be appropriate to the work they perform.E.G.Dementia and LDAF courses. Supervision all staff must receive formal supervision six times a year (Timescale of 1st may 2005 not met). Regulation 37 notifications;The registered manager must inform the CSCI of any occurrence that happens within the home. Safe working practice;Staff must receive fire training and emergency lights must be checked on a regular basis (Timescale of 31st January 2005 not met). Timescale for action 22nd August 2005 22nd August 2005 22nd August 2005 1st September 2005 1st September 2005 22nd August 2005 1st September 2005 2. OP7 15 3. OP9 13 4. OP30 18(1)( c) 5. OP36 18(2) 6. OP37 17(1) schedule 3 23(4)(d) 7. OP38 HOME COVERT CS0000032140.V185990.R01.doc Version 1.30 Page 19 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 CS0000032140.V185990.R01.doc Version 1.30 Page 20 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire 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 CS0000032140.V185990.R01.doc Version 1.30 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. 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