Inspection on 20/06/05 for The Dovecote

This inspection was carried out on 20th June 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 no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Dovecote 24/04/08

The Dovecote 31/10/07

The Dovecote 16/04/07

The Dovecote 22/04/06

The Dovecote 07/02/06

The Dovecote 15/11/05

The Dovecote 20/01/05

The Dovecote 27/04/04

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 09/07/2008.

CARE HOME ADULTS 18-65 The Dovecote Care Home 69 Bagshaw Street Pleasley Mansfield, Nottinghamshire Postcode Lead Inspector Jayne Hilton Unannounced 20th June 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Dovecote Care Home Address 69 Bagshaw Street Pleasley Mansfield Nottinghamshire NG19 7SA 01623 480445 01623 480446 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) The Dovecote Trust Limited Mr Bryan Leonard Hogg Care home 18 Category(ies) of LD Learning disability, x 18 registration, with number of places The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 20th January 2005 Brief Description of the Service: The Dovecote is a care home providing personal care and accommodation for 18 younger adults who have a learning disability and has facilities for some who also have a physical disability. The home provides long-term care and will take emergency admissions.The home is owned by The Dovecote Trust, which is a registered charity. The home is located in Pleasley and is close to shops, pubs, the post office, a community centre and working man’s club. The home was opened in 1987 and consists of a converted vicarage and purpose built, bungalow which has disabled access. Sixteen of the home’s bedrooms are single, and 2 of the bedrooms have en-suite facilities. Bedrooms are located on the 1st and 2nd floors in the converted vicarage where I stair lift has recently been fitted and ground floor level in the bungalow. Ramps provide access in the two buildings and gardens. The home has an enclosed garden and a nature trail in the grounds and there is car parking available for 6 cars and 2 mini buses, which belong to the home` The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on Monday 20th June 2005 and lasted 4 hours. The majority of service users were away on holiday in Scarborough. The inspection focused on key inspection standards not inspected at the previous inspection. During the course of the inspection five care plans were examined, three service users were case tracked and judgments and findings are based on information gathered through this inspection method. Difficulties were experienced in securing involvement of service users in this inspection due to communication limitations as a result of their disabilities so there are few service user comments in this report. Other methodology used were examination of records, a tour of the building and discussions with three staff and the manager. A second visit was made on 29th June 2005 to investigate a complaint regarding use of mobility payments to service users and the findings are included in this report. The registered manager was spoken with and 17 care plans were examined. Budget information was also examined and further examination of the service user guide. What the service does well: Service users can obtain information about the home from the Statement of Purpose and service user guide and have a detailed assessment undertaken to ensure the home can meet their individual needs. Confidentiality practices are adhered to in the home. Service users are supported with personal, family and sexual relationships and there was evidence that their rights are respected. Service users enjoy a varied and balanced diet and their complaints are listened to and acted upon. Staff have clear job descriptions and undertake the home’s induction training on employment. Training provision and staffing numbers appear overall satisfactory, The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 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. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3,5 Service users can obtain information about the home from the Statement of Purpose and service user guide, and have a detailed assessment undertaken to ensure the home can meet their individual needs. There is no contract document currently and this is to be developed and include agreement to transport contributions. EVIDENCE: A combined Statement of Purpose and Service users guide has been produced by the home and there is also a copy available in symbol/pictorial format. The service user guide makes a statement regarding the provision of transport and that service users’ mobility payments are accepted by the Trust as a contribution towards general transport costs. A very detailed assessment was seen on the five care plans examined, which identifies areas for specific care plans. The assessments include service user preferences, such as bedtimes, getting up and likes and dislikes. The assessment does not identify risks as required by standard 2.3[iv] and the inspector advised that a further section be included to remedy this. Healthcare issues are identified but this is not followed through within the care plan structure for monitoring and evaluation. From observations made during the inspection staff interacted well with service users and appear to be aware of the individual needs. A training programme The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 9 including an induction supported this. There was no information seen regarding advocacy services, despite the statement of purpose saying this could be provided. Staff were unaware of any information relating to advocacy apart from one service user attending a group with the day centre. From the assessment and care plan documentation the overall general needs of service users, appear to be met. The landlord provides a tenancy agreement but there was not enough evidence to meet the specification of standard 5.2, part of this and there is need for a contract between the care provider [home] and the service user, which covers the specification 5.1-5.5. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10 The care plan documentation does not reflect changing needs and personal goals of service users and it is felt that service users should be consulted more, and encouraged to make decisions and participate particularly regarding meal choices and in devising a weekly menu. Risk management processes should be improved to ensure that all possible risks to service users are identified and that there is clear documentation in place to minimise these. Confidentiality practices are adhered to in the home. EVIDENCE: Care plans were in place, but these should be expanded to include goal plans for service users as the ones seen were really brief statements. Care plans are reviewed regularly and updated as necessary. Diaries are used for each service users daily log. Care plans cover financial details and a statement that mobility allowances are used as a contribution for transport provision in the home. [See Standard 23] The information for assessing standard 7 was limited and as previously stated there was no information regarding advocacy services in the home. The inspector was unable to obtain any information regarding advocacy services from the staff members interviewed, neither was there any information posted The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 11 on the service users’ notice board. In discussion with a staff member about decisions for food choice and access to the kitchen it was evident that staff make some decisions on behalf of service users. There were some justified safety reasons and there was some evidence of this in the care plans examined. The assessments do contain information regarding choices made by service users. There was evidence of a service user forum, where service users had been invited to give their views on the home held in January 2005, however there had been nothing since. The service users could be involved in meal planning by offering a suggestion for the menu for the following week. It would be good practice to have a house/service user meeting on a weekly basis to facilitate this. There was evidence of service users being able to take responsible risks and risk strategies implemented, one example seen was for a service user who had a job doing the ironing. There were no risk assessments carried out however for activities and holidays and household tasks in general. There is a confidentiality policy in place, service users information was stored securely. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15, 16,17 Service users are supported with personal, family and sexual relationships, however documentation regarding this was poor. Service users’ rights are respected and enjoy a varied and balanced diet. EVIDENCE: The assessment documentation provides information on family contact and relationships, however two service users are currently in a relationship and there was no reference to this on one of the service users file [the other was not examined] despite professional input being sought. A specific care plan for this topic would ensure that there was clear monitoring and support for the individuals concerned and would evidence the work of the staff team in seeking appropriate counselling and providing support for health checks, contraception and education. Observation on then day evidenced that service users have a key to their bedroom and the assessment documentation provides information regarding ability to open mail. Staff were observed interacting with service users, not exclusively with each other, Service users were observed having unrestricted access to the home and grounds [where applicable upon risk assessments]. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 13 The statement of purpose states that pets may be allowed at personal discretion. ‘Lunchtime’, was observed by the inspector, cheese on toast was served, staff eat alongside service users. The menu is recorded in a diary with food probe temperatures [some had been missed]. The variety of food recorded appeared balanced and nutritional. Food stocks were ample and fresh fruit was seen in the pantry. The mealtime was unhurried and was flexible with service users’ activities. There is one service user who is a diabetic and careful management of his diet has maintained his condition as stable. One service user chose to remain in his room for his lunchtime meal. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 21 Service users appear to receive personal support, which meets their needs, however there is inadequate documentation regarding the healthcare needs of service users and this should be implemented within care plans and should include monitoring and evaluation of behaviour. The wishes of service users have been obtained regarding the end of life plans. EVIDENCE: There was clear evidence in the care plans examined, which demonstrated, choice about hairstyles, clothes and appearance. Service users were observed to be dressed in, individual style and one service user proudly showed me his choice of shorts for the hot weather on the day of the inspection. A key worker system is in place and staff work 1:1 with named service users. The bungalow provides suitable accommodation, aids and equipment to maximise independence. Care plans provided evidence of specialist input regarding psychiatrist s and occupational therapists etc. The assessment identifies the healthcare needs of service users but there was poor record keeping of health checks, which had been set as a requirement at the last inspection. There was evidence that an attempt had been made to get staff to document this, however the inspector recommended that the old system once used for separate sheets for each topic be reinstated and key workers be made responsible for ensuring these checks are routinely carried The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 15 out and documented. Healthcare checks should include an annual well person check, hearing checks and smear and breast screening as applicable. Where service users reach 60 years plus their care plans need to address ageing processes and ensure that regular reviews are held to ensure the home can continue to meet the individual needs. Weight records are in place, a section should be added for comments by staff regarding any significant weight loss or gain and effect on well being/mental health status. Staff undertake, blood sugar monitoring for a service user with diabetes, records were satisfactory. Incidents of aggression are recorded on incident sheets, however these had not been transferred to the care plan regarding evaluation and monitoring of incidents. The wishes of the service user at the end of life were documented. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Service users complaints are listened to and acted upon. The financial protocols within the home are not sufficient to protect service users from potential financial abuse. EVIDENCE: The complaints procedure was fully assessed at the previous inspection and a requirement made for complaint investigations to detail whether substantiated or not. Evidence of this was seen on the one complaint received since the last inspection. This provided evidence that service users views are listened to. The inspector did note that the policy manual copy of the complaints procedure requires updating to CSCI from NCSC. A complaint had been submitted to the Commission in relation to mobility allowances and was investigated on the second visit. The complaint was, found to be partly upheld. The registered manager is appointee for several service users, which is not appropriate. [Reference Regulation 20 – Restrictions on acting for a service user] The manager reported that this has been looked into, but there has been difficulty finding alternative appointees to act on service users’ behalf. It is recommended that the registered manager seeks advice from adult payment services regarding the issue. The financial records of service users were examined. There was evidence that one member of staff had benefited from service user expenditure in the form of bonus point cards, and loyalty points etc, which is illegal practice. The records overall were satisfactory and receipts were provided. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 17 Mobility allowances are pooled to cover the costs of the provision of the minibus, taxis and public transport. There was evidence that this was documented within individual care plans and in a statement in the service user guide. The manager reported that audits had shown that transport costs for the home were well in excess of the contributions by service users. The inspection found that the system in place was not a fair and appropriate one as service users were awarded differing rates of allowance and there was no evidence regarding whether or when the service user had actually used the transport. An appropriate record of service users financial outgoings must be kept, which identifies; • • When service user’s expenditure on transport occurs. [Activities participated in] What contributions are based on, and reflect the appropriate level of allowance. and: • Where service users are found to be contributing and not using the facility, appropriate reimbursement should be made to the service users and/ or a system be devised where contributions are calculated at a rate per mile used only. Therefore the financial procedures within the home are not robust and require review to ensure service users are protected from potential financial abuse. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26, 28 Service users bedrooms are individually personalised and appropriately furnished, however attention is needed to eradicate mal odours. The also home provides sufficient accessible shared space. EVIDENCE: Three service users’ bedrooms were inspected, all were personalised, two had some malodour, which staff reported that they had endeavoured to remove. The use of deodoriser systems was suggested to help. One room however would benefit from a new carpet. Service users can provide furniture of their choosing and evidence was seen of this. A range of comfortable safe and fully accessible shared space is provided both for shared activities and for private use. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36 Staff have clear job descriptions and undertake the home’s induction training on employment. The induction and process does not meet skills for care units or appear to lead/link to the foundation elements or for the LDAF [Learning Disability Accreditation Framework]. Training provision is generally satisfactory, however there is a lack of training in health and safety practices. The numbers of staff provided on each shift appear satisfactory, however the recruitment procedures are not robust enough to protect service users and the Registered Manager must ensure that he is knowledgeable and up to date regarding the Protection of Vulnerable Adults checks and Criminal Records disclosure checks. Formal supervision is in place but this needs expanding. Further support for staff is needed in the form of staff meetings. EVIDENCE: Staff have clear roles and responsibilities which is detailed in job descriptions. A staff member explained the varying roles of carer, supervisor and qualified [to give medication]. Staff are given a copy of the General Social care council’s code of conduct booklet when newly employed. It was suggested that the topics of the booklet be used either in supervision sessions or team meetings to ensure that staff adhere to the code and responsibilities under the code. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 20 An in house induction has been devised by the manager, but there was no evidence of skills for care induction booklets which covered the mandatory training topics within 6 months of employment. Training in NVQ 2 and 3 was evident but there was nothing on LDAF [Learning Disability Accreditation Framework]. The registered provider wishes the report to state that Staff are always advised to choose the NVQ units which relate directly to LDAF. Staffing rotas were examined and found to be satisfactory. There was no evidence of staff /team meetings and these should be implemented. Staff spoken with commented that ideas put forward were not listened to or taken forward. It was suggested that there was some conflict within the staff group and it was felt that the provision of staff meetings would promote more open and honest working, where staff could exchange views on/discuss openly, good practice and not so good practice without being held to blame. Recruitment at the home appears steady. A sample of three staff personal files were examined, One, belonging to the newest appointed staff member found that a Criminal Records Disclosure from 2 years previous had been accepted and a POVA first check had not been carried out. This practice is in breach of the regulations. Staff must not be employed before the return of a satisfactory POVA first check and a new CRB disclosure check if there is a break in service or the disclosure is more than twelve months old. Training records indicated that training has been provided in manual handling, food hygiene, fire safety, medicines management, adult protection first aid, aggression management, infection control and the managers own training on working with strengths and needs of people with learning disabilities. There was no evidence of health and safety training. A staff member reported that she had recently completed the intermediate food hygiene by a ‘distance learning’ course. There was evidence of staff formal supervision in place but this was not routinely taking place up to six times a year. Evidence was seen of annual appraisals. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41, 42, 43 Service users or their representatives views are not obtained and evaluated within a quality assurance process and this is not satisfactory. The policies and procedures for the home are not reviewed and require standardising. Record keeping in the home should be improved and should be audited regularly. Health and safety practices were not satisfactory as a number of issues were identified. Therefore the service users health, safety and welfare may be compromised because of these issues. EVIDENCE: There was no evidence of quality monitoring systems in the home. The registered person now needs to address this issue as four years on from the Care Home Regulations 2001 and the National Minimum Standards. An annual development plan is needed for the home, based on a systematic cycle of planning-action –review, reflecting aims and outcomes for service users. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 22 There should be continuous self-monitoring as specified in standard 39.2 and a service user survey a standard 39.4-39.10. The manager reported that the chairperson of the trust visits weekly, however there was no evidence of Regulation 26 reports in the home, these must be carried out monthly. The policy manual was examined, many policies were in varying formats and styles and it would be good practice to standardise the format and review the policies and procedures on an annual basis. The review should use Appendix 3 as a guide to what needs to be included. Incident records were seen for incidents of aggression, there were no copies of Regulation 37 notifications. The Registered Manager should ensure that any incidents as listed under regulation 37 are notified to the Commission. Accident records were examined and found to be satisfactory. The fire safety tests were examined, several gaps were found. A number of health and safety issues were identified. Food safety issues were identified regarding out of date foods in the fridges in both the lodge and the bungalow. Opened food items, such as cheese and packet ham and meat paste had not been sealed or date when opened. Where service users have fridges in their rooms, temperature checks should be recorded. The health and safety posters were not completed or up to date. There was some missing window restrictors noted throughout the Lodge, these must be repaired. Not all radiators were off the low surface type and did not have safety covers. There was no evidence of risk assessments regarding surface temperatures of radiators and these should be carried out and where high risk areas are identified such as bathrooms, behind chairs/beds, where service users have epilepsy, these should be made priority. The manager reported that regulating valves are fitted to all taps, but there were no records of checks for these. Records should be kept to ensure that water outlet temperatures in service users’ sinks and bathrooms are maintained to 43 degrees and document the temperature at the time of the test, any action taken to remedy temperatures exceeding 43 degrees and a retest. There was no evidence regarding what is in place to control risk of legionella, this must be provided. It is advisable that guidance is sought from a registered plumber. Risk assessments were in place for fire safety and generic work topics. There was no liquid soap or paper towels seen in bathrooms. Pull cords for light fittings, should be changed when they become grubby. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 23 Service users’ personal toiletries should not be stored openly in bathrooms. Gas and electric safety certificates were seen and in date; servicing invoices were satisfactory. Service users should have their own personal towels. The Insurance certificate was up to date. The income and expenditure account was made available upon request. Travel expenses, outings and holidays are noted to be included in one heading. In light of the recent complaint is advised, that separate accounting headings be used for service users contributions and transport costs. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 2 Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 1 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x 2 x 3 x x Standard No 11 12 13 14 15 16 17 x x x x 2 3 3 Standard No 31 32 33 34 35 36 Score 3 2 2 1 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Dovecote Care Home Score 3 2 x 3 Standard No 37 38 39 40 41 42 43 Score x x 1 2 2 2 3 C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 25 Yes YA9 and YA19 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. 2. Standard YA 2 YA8 YA 39 Regulation 12 25 Requirement Ensure risk assessments are completed for all identified risks. Service users must be consulted, particularly in relation to menu provision andregarding their views of the overall services in the home. A specific care plan must be implemented regrding the srevice users who are engaged in a personal relationship. The healthcare needs of service users, including an annual well person check should be fully documented and followed up within the individuals care plan. Care plans must evidence the monitoring and evaluation of behaviour and include reference to any incidents recorded. The financial systems in the home must be reviewed to ensure service users are protected from potential financial abuse. Particularly in relation to staff use of credit cards, bonus points and service users mobility payments. Timescale for action 20th August 2005 20th August 2005 20th July 2005 20th August 2005 20th August 2005 20th August 2005 3. YA15 14, 15 4. YA19 12, 13, 14, 15 5. YA19 12, 13,1 4, 15 13, 17 Financial Act 6. YA23 The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 26 7. 8. 9. YA26 YA26 YA 34 12, 16 16, 23 13,CSA section 62, No Secrets 25, 26 Eradicate the malodour in the identified bedroom. Replace the carpet in the identified bedroom. The Registered person must ensure that recruitment practices are robust and that the new guidance regarding POVA first checks and Criminal Records checks is obtained and followed. A quality monitoring system must be implemented and which includes provider visits and reports as specified under regulation 26. Ensure appropriate notifications are made to CSCI under Regulation 37 requirements. Ensure appropriate systems, staff training and records, are in place to safeguard the health safety and welfare of service users as identified within the report. 20th August 2005 20th August 2005 Immediate 10. YA39 20th August 2005 11. 12. YA41 YA41, YA42, YA 35 37 12, 13, 16, 23 20th August 2005 20th August 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA5 YA7 YA32 YA33 YA36 Good Practice Recommendations A contract should be provided the home and service user as specified in standard 5 and which should include arrangements for the contribution of mobility allowances. Provide information in the home and training for staff regarding advocacy services. Implement an induction process which, conforms to skills for care standards and links to Ldaf accrediation. Implement staff meetings to encourage sharing of ideas, open discussion and discuss practices in the home. Formal supervision with individual staff should take place six times a year. C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 27 The Dovecote Care Home 6. 7. 8. YA40 YA42 YA 43 Review policies and procedures and provide evidence that staff have been issued with a copy or read and understood them. Service users should be encouraged to use their own towels and personal toiletries should be stored in their bedrooms. The budget heading for transport , outings and holidays should be seperated out. The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Dovecote Care Home C53 C03 S8661 Dovecote V234250 200605 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!