Inspection on 31/10/07 for The Dovecote

This inspection was carried out on 31st October 2007.

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 6 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 16/04/07

The Dovecote 22/04/06

The Dovecote 07/02/06

The Dovecote 15/11/05

The Dovecote 20/06/05

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 69 Bagshaw Street Pleasley Mansfield Nottinghamshire NG19 7SA Lead Inspector Jayne Hilton Unannounced Inspection 31st October 2007 09:00 The Dovecote DS0000008661.V351941.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 The Dovecote DS0000008661.V351941.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. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Dovecote Address 69 Bagshaw Street Pleasley Mansfield Nottinghamshire NG19 7SA 01623 480 445 01623 480 446 Dovecote@carehomenet.co.uk 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) The Dovecote Trust Limited Mr Bryan Leonard Hogg Care Home 18 Category(ies) of Learning disability (18) registration, with number of places The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th April 2007 Brief Description of the Service: The Dovecote is a care home providing personal care and accommodation for 18 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 Dovecote Trust Limited runs the home, which is a registered charity. Leicester Housing Association owns the building. The home is located in Pleasley and is close to shops, pubs, the post office, a community centre and workingman’s club. The home was opened in 1987 and consists of a converted vicarage and purpose built, bungalow, which has disabled access. All of the home’s bedrooms are single, and three of the bedrooms have ensuite facilities. Bedrooms are located on the 1st and 2nd floors in the converted vicarage, which can be accessed by a staircase or stair lift. All bedrooms in the bungalow are at ground floor level. 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. The home has its own minibus. The Registered Manager provided information about fees on 31/10/07 Current Fees range between £377.50- £1250 dependent on needs. Service users are expected to contribute mobility allowances in relation to transport arrangements. The previous inspection report and Service User Guide is available but only in office hours. *Please note the new e-mail address of the Provider is dovecotetrust@yahoo.co.uk. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This key inspection was undertaken on 31st October 2007, was unannounced and took any previous information held by Commission for Social Care Inspection about the home into account. The inspection included a site visit, which took place over seven hours. On this occasion an Expert by Experience who spoke with three service users, contributed to the inspection process and provided a separate report, accompanied us. Comments and observations are reflected in this report The main method of inspection used was called ‘case tracking.’ This involves selecting three service users and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Five members of staff and the manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals. On the day of the visit most residents were only present periodically, as they attend various activities throughout weekdays. Surveys were returned by, fourteen service users, three relatives and one staff member. Their comments are included within the report. What the service does well: The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 6 Service Users have their needs assessed, care plans are in place and healthcare is well managed. Service users live in a comfortable environment and the garden area has various activity areas, including equipment such as an enclosed trampoline for service users activities. There is an excellent sensory room in the bungalow. Service Users confirmed that they were able to make choices and decisions about their lifestyles and care plans do address likes/dislikes, and preferences. They were also able to confirm that they were involved in Advocacy groups. Service Users know how to make a complaint if they are not happy and say their privacy and dignity is respected. Service Users said they were happy with the food provided and a good range of activities appears to be experienced by the residents. Service users have various contact with relatives and where possible relatives are involved in care reviews. Friendships between service users are promoted. Staff are friendly and seemed to support the people well. Comments from relatives made in the returned questionnaires are as follows: “They try their best for the service users and the carers do a great job” “The home provides disadvantaged people with quality of life and personal choices.” “My sister has always seemed happy” What has improved since the last inspection? There was noted improvement in the detail of care plans and record keeping. New towels and flannels have been purchased. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 7 Toiletries and other items, such as continence pads were stored in the right places. The home has been cleaned in higher places. What they could do better: Provide copies of the inspection report, Statement of Purpose and Service User Guide in each building should anyone wishes to access this out of office hours. Provide individual copies of ‘The Service User Guide’ to each service user. Expand the assessment documentation to embrace equality and diversity, to ensure any cultural, religious, sexuality, gender, disability needs are fully addressed. Provide a person centred approach to care planning. Improve the use of communication aids and use of pictures and symbols in the home. Improve choice options in meal planning and the documentation of this. Improve the systems in place for the management of medication. Provide training for staff in diabetes, food and nutrition, communication skills, key working, care planning, safeguarding adults, and equality and diversity Ensure the Commission For Social Care are notified of all events, which may affect the health and well being of service users. Ensure records are kept of any limitations agreed with the service user as to the service users freedom of choice, liberty of movement and power to make decisions. Take Action to eliminate offensive smells and stained carpet in the identified room. Ensure recruitment processes have a system in place for ensuring that references are obtained as required by regulation and are from the person’s previous employer. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 8 Improve quality-monitoring systems in the home. Improve food safety practices. Provide evidence in the fire safety records of which, staff and residents had participated in fire drills. Six requirements and fourteen good practice recommendations have been made in respect of the above. 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. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 9 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 The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 10 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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users have their needs assessed and Information is available for any new prospective residents but existing residents have not yet been issued with their own copy of The Service User Guide. EVIDENCE: A service user guide with symbols was viewed in the home, but residents still did not to have their own personal copy as required by regulation. The document does inform the reader how to access a copy of the inspection report, however this cannot be accessed out of office hours and does not give the CSCI web site details. It is recommended that copies of the inspection report, Statement of Purpose and Service User Guide are also made available in each building should anyone wishes to access this out of office hours. Resident’s needs are assessed prior to admission and the home undertakes its own social needs profile assessment which acts as a combined care plan and risk assessment. There have been two new admissions to the home since the last inspection. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 11 It is recommended that the document be further developed to embrace equality and diversity, to ensure any cultural, religious, sexuality, gender, disability needs are fully addressed. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 12 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): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users have their basic needs met however, a person centred approach to care planning is needed. EVIDENCE: Three service users care files were examined as part of the inspection. Care plans were in place. Diaries are used for each service users daily log. Although there is reference within the care review minutes of service users attendance, t here was still no evidence that service users or relatives are involved in the compilation of their care plans or that they have agreed to what they contain. There was noted improvement in the detail of care plans, however where restrictions of movement of freedom have been implemented, for example the use of door alarms, there was no documentation of agreement to their use or the reason for their use. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 13 The Inspector’s judgement was that the alarms were in place in the best interests of service users, however further consultation is to be taken with Community Learning Disability Teams. A staff member confirmed that a monitor was in use for a person with epilepsy and the service user or their representative, too, had not agreed this. The manager reported at the end of the inspection he had written to the service users relative in respect of obtaining this. Care plans varied as to the information on whether the residents hold keys to their bedrooms and lockable cupboards. Where service users have not got a key to either, his bedroom door or lockable cupboard, the reason why should be fully documented within the care plan. Risk assessments are integral within most of the care plans, some have been devised on a different system in respect of behaviour. Therefore the inspector continues to recommend that the system in place be reviewed and updated and that person centred planning is introduced and that the manager and staff receive training on appropriate care planning and record keeping. Staff spoken with reported that there are plans to introduce person centred planning, which was confirmed by the manager. The manager with a date stamp currently updates care plans regularly, but there is no evidence of a process in place of why the care plan has been changed. Regular review meetings take place, outcomes of these meetings are documented but contain a brief summary of action points but not an overview of the persons lifestyle/events/achievements or difficulties experienced leading up to the review. Key staff only has access to this information. Service Users spoken with and those that returned questionnaires confirmed that they were able to make choices and decisions about their lifestyles and care plans do address likes/dislikes, and preferences. They were also able to confirm that they were involved in Advocacy groups. The Dovecote DS0000008661.V351941.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): 12, 13,14,15,16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A good range of activities are experienced by most service users and staff and service users confirmed this however the current staffing resources may compromise the lifestyle of those service users who use wheelchairs. Service users enjoy their meals. EVIDENCE: Service Users are provided with a varied programme of activities including swimming, dances and bingo, which are specially organised for people with learning disabilities and usually go out to the pub at weekends. Some service users attend day centres and work experience also. Service users and staff spoken with informed me that holidays had been planned in Mablethorpe, Blackpool and Wales. Although a good range of activities appears to be experienced by most service users, comments were made about staffing levels which in the main are two The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 15 staff to seven residents in each building with one floating staff member between both buildings currently, however four service users in the bungalow require wheelchair provision for outings and some service users have one to one support provided, so the provision of two staff therefore limit the residents in relation to socialisation and activities. Records should be kept of each individual’s participation in activities and when they refuse what is on offer. Staff reported that they are planning more in house activities for evenings and weekends. A service user interviewed said he has a choice what to do. He said, “I go to the day centre I also do cleaning work here which I am paid for. On Sunday I walk to church I like swimming and horse riding and bingo”. There are a number of service users at The Dovecote who have limited communication skills. There are no communication aids available, pictures or symbols. Previous recommendations have been made, that the home be innovative and progressive in relation to exploring other methods of communication to benefit service users. There was some progress noted in relation to this at this inspection. A member of staff we talked to said “we do not have pictures or symbols for communication but some staff have makaton and use it to communicate to the residents.” Another staff member discussed communication training recently undertaken and showed the inspector some pictorial recipes to be used in the new programme of activities and that work was underway with pictorial menu books, although no evidence was seen at the inspection of this particular work in action. Service users have various contact with relatives and where possible relatives are involved in care reviews. Friendships between service users are promoted. The variety of food recorded appeared balanced and nutritional but there is much scope for improved practice in this area. Menus in the lodge building do not offer two choices, staff reported that service users choose the meal to be served over each week at a service user meeting, however there was no evidence of minutes from these meetings. Service users did confirm they are involved in choosing what they want on the menus and said they liked being in the home. However service users are not The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 16 involved in food shopping this is done by staff and delivered to the home from a supermarket and local farm shop. The Dovecote DS0000008661.V351941.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A good system is in place for monitoring the resident’s healthcare need, but the management of medication require improvement to ensure service users health and safety is not placed at risk. The privacy and dignity of service users are respected. EVIDENCE: The system in place for monitoring the resident’s healthcare includes follow up records of blood tests etc. The system could still be further improved however and should be integral to the individuals person centred plan. The area of food and nutrition needs to be more focused upon and included within a healthcare profile for each individual and in particular where specialist dietary needs are highlighted. It is therefore recommended that advice and training is sought from the dietician or district nurse services about introducing nutritional screening tools The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 18 for service users to identify where there are any specific risks to individuals and then to set up appropriate monitoring and recording systems. The provision of food and nutrition training for staff would benefit service users living in the home. Service users spoken with confirmed they their felt that privacy and dignity was respected. There were no issues highlighted at this visit in relation to privacy and dignity. Policies and procedures were in place. A procedure for dealing with drug errors was seen as accessible for staff, but it is recommended that a reminder note be added that all drug errors are to be notified to CSCI [Commission for Social Care] under Regulation 37. The management of medication was generally satisfactory, however handwritten prescriptions on the medication record charts had not been signed and witnessed by two members of staff and one entry of Paracetomol was found, not to have been prescribed at all by the GP. There are no service users reported to be self-medicating currently. Staff spoken with and training records confirmed training in medicines management. It is once again recommended that Medication Profiles should be developed for service users medication and which encompass medication reviews and changes and the reasons for this as part of healthcare monitoring. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improved systems are now in place to protect service users from harm, but staff require further input and guidance to ensure service users are safely supervised at all times and that notifications required by regulation are submitted appropriately. Service users know how to make a complaint if they are not happy. EVIDENCE: Records were examined for complaints received by the home, since the last inspection there have been no complaints made to the home. Service users and relatives confirmed that they knew how to make a complaint. The manager has submitted ‘Regulation 37’ notifications to the Commission for some events, but had not submitted notifications in respect of a service user wandering from the premises on three occasions as he said he had not realised these types of events were included in the criteria. Incident records were lacking in times between the service user being noticed as missing and when found and of any investigation into to how the event had occurred and any action taken to minimise further occurrence. The home was experiencing staffing issues and changes during this time and staff said they felt this had been a contribution to the events. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 20 There have been three Protection of Vulnerable Adults investigations during the past twelve months. The Community Learning Disability teams involved are currently dealing these with. Most staff have undertaken training in Protection Of vulnerable Adults, but not all and this should be provided for all staff. Staff spoken with was aware of the whistle blowing policy and demonstrated knowledge of reporting any poor practice. There were no recorded incidents of use of restraint during the previous twelve months. A sample of service users financial records were examined and were satisfactory. The registered person needs to be satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person, and has confirmed in writing to the registered person that he is so satisfied. [Please see Standard 34] The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 21 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): 24,26 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable environment. Further re-furbishment of the home will improve the quality of the environment for the service users. EVIDENCE: A range of comfortable and fully accessible shared space is provided both for shared activities and for private use. All of the communal areas in the Lodge were clean and smelled fresh, however the lounge in the bungalow did not. Action is needed by the registered person in order to eliminate offensive smells and stained carpet in the identified room. The registered manager reported that carpet samples had been obtained In August 2007, but a replacement carpet not yet ordered. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 22 Some redecoration has been undertaken and some was in process on the day of the inspection. There is an excellent sensory room in the bungalow. The garden area has various activity areas, including equipment such as an enclosed trampoline for service users activities. The service users’ bedrooms were inspected; all were personalised and clean and staff reported that new towels and flannels had been purchased. The staff offices are not fully secure as service users were observed to wander into these areas, where medication and records are also stored etc. Staff varied in comments about where they undertake their administration and record keeping responsibilities Staff confirmed that they were mindful of their practice and confidentiality when service users are present but that it did conflict in priorities at times. There is no workstation provided for staff and therefore it is recommended that the registered person look at health and safety aspects of this. The laundry area was not inspected at this visit. The home uses the ‘safer food better business’ system and staff, were observed wearing protective clothing as appropriate for the task they were undertaking, however there was some food safety issue identified. [Please see standard 42]. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 23 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): 31. 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided with a good level of mandatory training, however service users would benefit from staff receiving further input to provide them with the necessary skills and knowledge with up to date and current good practice. The Responsible Individual and Social Services are still debating staffing issues, however this must be addressed promptly to ensure that safe staffing levels are maintained at an appropriate level to fully meet service users needs. EVIDENCE: Records viewed and staff confirmed that a good level of training is provided. The service users lifestyle would be improved by all staff having further input/ training in key working, care planning, food and nutrition, communication skills, safeguarding adults, diabetes and equality and diversity The registered manager stated that above 50 of staff hold NVQ level 2 or above. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 24 The recruitment files for three staff were examined and found to be satisfactory in respect of criminal bureau record checks, however recruitment processes need to have a system for ensuring that references are obtained as required by regulation and are from the persons previous employer. Supervision is in place; staff, paperwork, senior staff and the manager evidenced this. However even with the annual appraisals held, the sessions fall short of six a year and one session, which should be observation of practice. The issue of staffing levels are still causing confusion. The Registered Person had carried an assessment about staffing resource issues, but evolving circumstances has altered this course. Discussions are still underway with Social Worker and Commissioning Teams currently. Rotas viewed showed that currently two staff cover 9am to 9pm with an overlap of night staff from 7am-9am in each building. On most days a third person is provided who acts as a floater between the buildings. Three staff work waking nights. Contract cleaners are provided but care staff are expected to undertake a daily routine of cleaning and catering duties also. There are currently seven residents living in the bungalow and seven residing in the Lodge There is a varying level of dependency needs for each resident, some of which require two staff for transfer and mobility assistance. Some service users attend day centres on weekdays. The home has suffered a recruitment crisis and the manager reported that currently, they are approximately 100 hours short in staffing compliment, which other staff and bank staff are currently covering. Most staff said they are happy with the opportunity to work overtime and evidence was seen that this is by volunteer basis, however some staff said they felt pressured to volunteer for this and that on one occasion 90 hours had been worked without a day off. However working time regulations declarations were viewed on some files. Staff are friendly and seemed to support the people well. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 25 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, 38, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration systems in the home require improvement to ensure that service users are fully consulted that record keeping meets the required standards and that service users health safety and welfare is fully promoted and protected. EVIDENCE: The manager has been in post for several years, he holds a social work qualification. The manager also has achieved a Master of Philosophy [in Social Work Practice] and DipYW. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 26 The manager had put systems into place for exchange of information and communication, such as the supervision and appraisals, through the staff structure, requests in writing, and a staff bulletin. The meeting structure was set up to address priority issues. Some staff still do not feel included in meetings and that they are not fully consulted with or informed as they should be, for example a recent change around in key-working responsibilities had caused some discontent. The manager stated that the way the change was communicated was a conscious management decision, made in order to achieve specific goals in relation to service users care. Staff reported that they respected management decisions and the need for the service to develop and grow positively, but felt that clearer exchange of communication and consultation prior to the directive would have lessened the impact of the changes for both staff and service users. There was limited evidence of quality monitoring systems in the home. The responsible individuals regulation 26 visits reports were viewed. There was evidence also of some internal auditing of care plans and reviews, however there was no evidence of service user, relative/representative or visiting professionals being consulted as to their views about the quality of service provided, which is integral to the outcomes for service users. Some areas of record keeping were noted to be improved at this inspection, however there was still no evidence in the fire safety records of which, staff and residents had participated in fire drills. There is a health and safety policy in place and generic risk assessments were viewed. The manager has completed a fire risk assessment in conjunction with the fire authority and regular checks were viewed. The five yearly electrical safety check has been undertaken and the certificate to be issued once any remedial work is completed. This has now been outstanding since the previous inspection and the manager agreed to follow this up. There was an issue of food safety observed. A packet of sliced cooked ham had been dated upon opening after being defrosted, but was still in use seven days after the ‘opened’ date and which was not air tightly sealed. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 27 The Dovecote DS0000008661.V351941.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 2 2 3 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X 2 2 X The Dovecote DS0000008661.V351941.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 YA7 Regulation 17 schedule 3, [q] Requirement Ensure records are kept of any limitations agreed with the service user as to the service users freedom of choice, liberty of movement and power to make decisions. This will ensure service users rights are upheld. 2 YA20 13[2] Ensure the medication systems are safe in respect of handwritten prescriptions discussed at the inspection. This will ensure service users are not placed at risk. Ensure notifications are made as required by regulation 37 and safeguarding referrals to ensure service users are protected from harm. Send backdated notifications to CSCI as discussed. Eliminate the offensive odours in the identified room to promote a comfortable and hygienic environment for DS0000008661.V351941.R01.S.doc Timescale for action 31/12/07 31/12/07 3 OP23 17,37 31/12/07 4 YA26 16[2][k] 31/12/07 The Dovecote Version 5.2 Page 30 service users 5 YA34 19 [4][c] Ensure recruitment processes have a system in place for ensuring that references are obtained as required by regulation and are from the person’s previous employer. The employer needs to be satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person, and has confirmed in writing to the registered person that he is so satisfied. This will ensure recruitment procedures are fully robust to protect service users. There must be a system in place to review and improve the quality of care provided at the home and to ensure service users and their representatives are appropriately consulted. 31/12/07 6 YA39 24 31/12/07 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 Refer to Standard YA1 Good Practice Recommendations Ensure all residents are given a copy of the Service user Guide, which informs the reader how to access a copy of inspection reports. Ensure information about the fees charged is included in the Service User Guide. The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 31 2 YA2 3 YA6 It is recommended that the assessment document be further developed to embrace equality and diversity, to ensure any cultural, religious, sexuality, gender, disability needs are fully addressed. A person centred approach to care planning is needed with the core care elements of an individual being consolidated into one care plan file which contains an holistic picture of the individuals lifestyle choices and monitors the input by staff to support this and evaluates how or if this is being achieved/or not. 4 YA7 Ensure the non-holding of keys to bedroom doors and lockable cupboards is fully documented and agreed within the care plan. Provide an overview of the persons life /events/achievements within the care review minutes, which will demonstrate the support offered in achieving goals and for meeting the persons needs and aspirations. 5. YA12 Ensure residents who use wheelchairs are provided with support to use the local community facilities and enjoy meaningful activities. Records should be kept of each individual’s participation in activities and when they refuse what is on offer. 6 YA16 The use of communication aids, such as menus in symbol or photographic formats should be explored and implemented to promote informed choice. Provide at least two options of menu items. Involve service users with shopping to promote a wider experience of what is available and to make choices from. 7 YA17 8 YA19 It is recommended that advice and training is sought from the dietician or district nurse services about introducing nutritional screening tools for service users to identify where there are any specific risks to individuals and then to set up appropriate monitoring and recording systems. DS0000008661.V351941.R01.S.doc Version 5.2 Page 32 The Dovecote The provision of food and nutrition training for staff would benefit service users living in the home. Step-by-step instruction for staff should be provided to follow in monitoring the service users healthcare needs. 9 YA20 It is once again recommended that Medication Profiles should be developed for service users medication and which encompass medication reviews and changes and the reasons for this as part of healthcare monitoring. Consent for medication is also a necessary component and the manager is advised to prepare for the implementation of The Mental Capacity Act, in April 2007. A reminder note should be added that all drug errors are to be notified to CSCI [Commission for Social Care] under Regulation 37. 10 YA24 YA42 YA32 Review the current staff office provision and facilities in respect of security and confidentiality aspects and in the ergonomic health and safety of staff when report writing. Service users, lifestyle would be improved by all staff having further input/ training in key working, care planning, food and nutrition and communication skills, diabetes, safe guarding adults and equality and diversity Ensure supervision sessions for staff occur at least six times year with at least one session of observation of practice. Provide evidence in the fire safety records of which, staff and residents had participated in fire drills. Improve food safety practices in the home, in respect of opened food products as discussed. 11. 12 13 14 YA36 YA42 YA42 YA30 The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 33 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 The Dovecote DS0000008661.V351941.R01.S.doc Version 5.2 Page 34 - 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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