Inspection on 07/02/06 for The Dovecote

This inspection was carried out on 7th February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 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 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 Care Home The Dovecote Residential Home 69 Bagshaw Street Pleasley Mansfield Nottinghamshire NG19 7SA Lead Inspector Jayne Hilton Unannounced Inspection 7th February 2006 09:15 The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 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 Care Home DS0000008661.V279078.R01.S.doc Version 5.1 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 Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Dovecote Care Home Address 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 Residential Home 69 Bagshaw Street Pleasley Mansfield Nottinghamshire NG19 7SA 01623 480 445 01623 480 446 Dovecote@carehomenet.co.uk The Dovecote Trust Limited Mr Bryan Leonard Hogg Care Home 18 Category(ies) of Learning disability (18) registration, with number of places The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 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 Dovecote Trust 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. Sixteen of the home’s bedrooms are single, and 2 of the bedrooms have ensuite 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. The home has its own minibus. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on Tuesday 7th February 2006 and lasted 3.5 hours. The inspection focused on the requirements and recommendations set at the previous visit. The bungalow accommodation was particularly assessed at this visit due to follow - ups needed from the previous inspection. During the course of the inspection a sample section of three care plans were examined. 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. The manager was not available for the inspection due to attending a meeting. The manager was available for a shortened feedback session at the end of the inspection. The inspector was unable to undertake her responsibilities in assessing the suitability of training arranged for staff in dealing with challenging behavior due to lack of evidence provided by the manager. What the service does well: What has improved since the last inspection? The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 6 The care plan documentation does now reflect changing needs and personal goals of service users and it is felt that service users are being consulted more, and encouraged to make decisions and participate particularly regarding meal choices and in devising a weekly menu. Risk management processes have been further improved to ensure that all possible risks to service users are identified and that there is clear documentation in place to minimise these and where limitations or restrictions are in place these are fully authorised. It was reported by the manager that service users are now involved in meal planning by offering a suggestion for the menu for the following week. The protocols within the home have been improved in order to protect service users from abuse, however the system overall is not yet fully robust. What they could do better: Service users appear to receive personal support, which meets their needs, however staffing arrangements and the documentation regarding the healthcare needs of service users and monitoring and evaluation of behaviour can be improved. There are still some aspects of training provision to achieve to fully meet the standards in relation to dealing with challenging/violent/aggressive behaviour. There was not sufficient evidence to make a professional judgement in relation to the needs of service users with challenging behaviour and those of service users that live with them. Service users do not have an individual contract with the home as specified in St 5. Menus should be developed in picture or symbol formats. It would be good practice to have a house/service user meeting on a weekly basis to facilitate menu planning and minutes kept to evidence the process. It is recommended that at least two meal options are provided on each daily menu and the choices documented. Medication management is assessed as overall; safe in practice but improvement is required to meet the standard and regulations fully. There are some areas for improvement in relation to minor repairs and regarding health and safety issues which are outstanding from the previous The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 7 inspection. An immediate requirement is set in relation to ensuring service users health and safety in the activities room. Service users or their representative’s 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 still not satisfactory as a number of issues were identified. Therefore the service users health, safety and welfare may be compromised because of these issues. 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 DS0000008661.V279078.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5 Service users needs are assessed and reviewed and are generally met, however there was not sufficient evidence to make the same professional judgement in relation to the needs of service users with challenging behaviour and those that live with them. Service users do not have an individual contract with the home as specified in St 5. EVIDENCE: There was evidence within the three care plans examined that the manager had undertaken further review of the service users assessed needs and had identified any risk assessments from this, including where service users may present challenging behaviour, however there was not sufficient evidence in order to make a professional judgement that the needs of service users who present challenging behaviour and those service users who live with them are being met. [See standards 19 and 23]. At the time of the visit five service users were at home, only one staff member was on duty in the bungalow, which left some service users vulnerable, as there have been some incidents of challenging behaviour over the last few months this is not satisfactory. A care review had recently been held for one service user, but staff spoken with, were unaware of the outcome or whether any new strategies were to be introduced or implemented to safeguard the individuals concerned. There was some paperwork within the care plans that should be archived [bowel chart and a data sheet for reviews which, appeared to be not used [as The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 10 out of date] as the care plan documentation itself demonstrated some reviews had taken place. There was evidence regarding service users being involved in an advocacy group and staff were able to confirm that advocates were contacted when needed. No evidence of resolution has been provided of the issue identified at the inspection in June 05 as follows: 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 DS0000008661.V279078.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6.7,8,9, The care plan documentation does now reflect changing needs and personal goals of service users and it is felt that service users are being consulted more, and encouraged to make decisions and participate particularly regarding meal choices and in devising a weekly menu. Risk management processes have been further improved to ensure that all possible risks to service users are identified and that there is clear documentation in place to minimise these and where limitations or restrictions are in place these are fully authorised. EVIDENCE: Care plans were in place, and appear to have been expanded to include goal plans for service users. 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. In the sample of care plans examined no documentation was initially found in relation to the requirement of service users and relatives/representatives signing in agreement to the care plan or any limitations or restrictions that may be imposed. Whilst it was the inspectors professional judgement that the limitations imposed were in the best interests of those service users, service The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 12 users, relatives and staff need to be aware of the reasons/risks involved and agree in writing as required by regulation. In particular the use of bedrails, monitor alarms and access to the kitchen. After discussion with the manager at the end of the inspection this information was provided as evidence and was stored in a confidential file. The possible risk of the use bedrails was not clearly indicated for the relative and therefore it is advisable that relatives are given more information in relation to the risks involved. Although the care plan detailed that bedrails were in use, there was no reference to the authorisation declaration in the care plan. The manager opposed the need to include the signed authority within the care plan, however it should be cross -referenced within the plan of care as to its whereabouts and existence and staff need to have an awareness of the possible risks of the use of bedrails. Not all of the individual’s current care information/risk assessment/or agreements for imposed restraint and limitations is kept in the working care plan as the system at Dovecote is for three files to be kept. Two of the files are kept locked away with only authorised personnel having access to these. Some information held in the Dovecote other files, needs to be available for inspection and may be missed if the manager is not available during an inspection. It is recommended that where this is the case a cross reference system is used and that a sheet is placed at the front of the main working care plan file, informing inspectors and other authorised personnel that other information may be contained in the other files and how these can be accessed. There was no evidence that the bedrails in use have been assessed as appropriate to meet the needs of service user and the manager thought these had been purchased by the home. In order to ensure that the bedrails and the use of the bumpers are appropriate and safe for the individual it is strongly recommended that an appropriate professional assessment be obtained for this promptly. Once ascertained the details of the assessment and any identified risks need to be held on the working care plan file, to ensure staff are fully aware of how to use them. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 17, Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: One service user was still eating breakfast when the inspector arrived and this provided evidence that service users were allowed to eat at their own pace without being rushed. The variety of food recorded appeared balanced and nutritional. Food stocks were ample and fresh fruit was seen in the kitchen. The inspector found some evidence that service users had chosen alternatives to the main meal served, but again this needs to be developed further to ensure that service users have an informed choice. A good example would be to provide menus in picture or symbol formats. It was reported by the manager that service users are now 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 and minutes kept to evidence the process. It is recommended that at least two meal options are provided on each daily menu and the choices documented The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 14 The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 18,19,20 Service users appear to receive personal support, which meets their needs, however staffing arrangements and the documentation regarding the healthcare needs of service users and monitoring and evaluation of behaviour can be improved. Medication management is assessed as overall; safe in practice but improvement is required to meet the standard and regulations fully. EVIDENCE: There was clear evidence in the care plans examined, which demonstrated, choice about hairstyles, clothes and appearance. 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 psychiatrists and occupational therapists etc. The assessment identifies the healthcare needs of service users and there was improved record keeping of health checks. 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, but this is recorded on the calendar section of the daily diary and The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 16 therefore does not allow space for comments by staff regarding any significant weight loss or gain and effect on well being/mental health status. The inspector explained to staff that weight records were a fundamental component of a service users care plan/well being and the system in place should be reviewed to reflect this. At the previous inspection the manager stated that the local GP has refused to undertake well person screening for the service users. The inspector recommended that this decision is obtained in writing from the GP and the issue be taken up with the Primary Care Trust. The issue was discussed with the Responsible Individual and the inspector is awaiting the outcome of any discussions with the GP/PCT. Staff spoken with was not aware of any well person checks being undertaken and there was no record of these in the three care plans examined. At the previous inspection it was found that staff undertake, blood sugar monitoring for a service user with diabetes, records were satisfactory, however it became apparent that the district nurse draws up\insulin and staff inject the service user. Staff reported that they had been trained for this procedure by the deputy manager, however this is not satisfactory as any staff undertaking this procedure must firstly consent, be trained and competency assessed by the district nurse who must sign that the staff member has undertaken this training and is competent to carry out the task under the responsibility of the district nurse. This training is still outstanding. A staff member and the manager stated that this is to be arranged in the near future. Evidence of this must be submitted to CSCI by the set target date. Incidents of aggression are recorded on incident sheets and in care plans and the incident sheets assess the antecedent, behaviour and consequences. Care plans do inform staff of the likely situations that the service user may present challenges to the service, but overall the guidance for staff in dealing with challenging behaviour and strategies for minimising risks to other service users appeared insufficient. The manager reported that there was some evaluation ongoing currently regarding one service users behaviour and the inspector wishes to have a copy of the outcome when this is finalised. A recent meeting had been held regarding the same service user and the inspector was shown the minutes of these at a previous inspection. The inspectors professional judgement is that improved strategies are needed to ensure that the staff can continue to meet the needs of the service user, to protect other service users and that the bungalow accommodation may not be the appropriate environment for this service user, particularly as the other service users in this accommodation are more vulnerable at could be at risk from the service user. Staff have not yet been provided with adequate training regarding strategies for crisis intervention and prevention. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 17 The manager reported that he had organised conflict management training for staff. There was no information of the training programme available for the inspector to assess whether the particular training would be suitable. The manager was advised to look at other training providers such as The British Institute of Learning Disabilities [BILD] as they have developed a voluntary Code of Practice for Physical interventions trainers. The Department of Health guidance recommends service providers to refer to these when choosing a trainer. The manager should also seek guidance from www.doh.gov.uk/qualityprotects/index.htm and www.doh.gov.uk/learningdisabilities.htm Medicines management in the bungalow was assessed at the previous inspection. Overall the system was satisfactory. At this inspection it was found that but storage temperatures of the medication are now being taken. Medication Administration records were satisfactory. There are no service users reported to be self-medicating currently, however a risk assessment document was seen for this purpose should this be needed. There were no sample staff signatures for those authorised to give medication on the front sheet of the medication records and this is recommended. Individual photographs are now on the dividers between each individual record sheet. There is a list of homely remedies, but staff reported that advice is sought from the manager and GP and usually a prescription arranged. The manager is advised to obtain a copy of The Royal Pharmaceutical Societies Guidance booklet for care homes to ensure that medicines procedures are followed. Homely remedies lists must be obtained from the GP with the GP signature of consent for staff to give service users from the list. PRN [prescribed as required] medication is only given to service users under procedures for authorisation from the staff supervisor or deputy manager and recorded on the back of the MAR and in the care plan. Ordering and returns appeared satisfactory. There was very brief information on the medication policies about informing CSCI of any drug errors. A policy for drug errors is needed with clear instruction for staff of procedures to follow should an error be made in drug administration, e.g. how to seek medical advice/attention for a service user, who may have been given the wrong medication or wrong dose etc. It is recommended that a medication profile be included in the service users care plan, which details information on the service users prescribed medication, any changes and why and documents medication reviews. This would provide also a useful history record which staff may find beneficial when overseeing health care needs of service users. Staff spoken with and training records confirmed training in medicines management. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 18 It would be good practice to ensure that a copy of the drug error policy with clear direction for staff is kept accessible, at the front of the Mar sheets. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The protocols within the home have been improved in order to protect service users from abuse, however the system overall is not yet fully robust. EVIDENCE: The registered manager is appointee for several service users, which is not appropriate. [Reference Regulation 20 – Restrictions on acting for a service user] It is recommended that the registered manager seek advice from adult payment services regarding the issue. The inspector has not been informed that this issue is resolved. This is a long-standing issue, which needs addressing. The manager and the administrator informed the inspector that the process of assessment for mobility monies/costs/charges issue identified earlier in the year is still ongoing and that he will inform the inspector of the outcome and action decided. This now requires follow up. There had been some problems since the previous inspection regarding the manager not employing the correct Adult Protection/Safeguarding procedures. With input and advice from the inspector and Safeguarding Adults Unit, the manager is now fully aware of reporting/alerting the lead agency for these types of issues as they arise. Outcomes from recent safeguarding adults referrals are yet to be finalised. Regulation 37 notifications have been submitted since the last visit as requested. [See standard 41 for further action] The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 20 There is a policy in place for staff, regarding the use of service users monies and includes making purchases on service users behalf and states that staff must not benefit from service users. The policy has been further developed which clearly identifies that staff must not use their bonus point schemes, credit cards etc. There is a policy in place for dealing with violence and aggression which states “There will be sufficient trained staff on duty to deal with potentially violent incidents, and the staff themselves will know what to do and how to do it” and covers sections for Organisational responsibilities, Prevention, Management and follow up. As specified in other sections of the report, practices do not support this statement. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Service users live in a clean homely, comfortable environment. There are some areas for improvement in relation to minor repairs and regarding health and safety issues. EVIDENCE: Most of the service users’ bedrooms were inspected; all were personalised, clean and free from mal odour. 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. Disposable gloves and practices for infection control were observed in the home. Training is planned for staff in infection control over the next twelvemonth period. The activities room in the bungalow is also used to store broken chairs, the hoist and other items. A service user accesses the computer, which is in the activity room. The carpet is damaged which presents a trip hazard and needs repair/replacement. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 22 The stored items in the activity area, also pose a health and safety hazard, particularly as the items may block a fire exit route. The registered manager reported that this was on the agenda and agreed to organise action promptly at the previous inspection to ensure it was cleared See Requirements for St 42. This action had not been achieved. The manager and the administrator reported that there had been some ongoing problems in arranging suitable storage facilities on site. However there had been no action taken in the interim to ensure service users health and safety was safeguarded. Therefore an immediate requirement was served in relation to this. The home was found to be clean and free from mal odour. The bathroom cupboards have been removed and therefore the bathroom and toilets in the bungalow require re-decoration. There is some plaster damage in the entrance area to the bungalow, which requires attention. This is outstanding from the previous inspection. A requirement is now set to ensure this is completed. The electric fuse room is not kept lock and the inspector requires the registered manager to provide evidence from the fire officer that this is acceptable practice. The manager has verbally informed the inspector that the fire officer is happy with the situation but no written evidence of this has been produced. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Training for the staff team is generally satisfactory or in hand. There are still some aspects of training provision to achieve to fully meet the standards in relation to dealing with challenging/violent/aggressive behaviour. EVIDENCE: The manager explained that free training had been obtained for the next twelve months, which includes training in health and safety and infection control, risk assessment, fire safety, stress awareness and conflict management. [See comments in Standard 18]. Under The Care Home Regulations 2001,it is part of an inspector’s role and function to assess the suitability of training arranged for staff. The inspector was unable to obtain evidence in relation to training arranged for staff in conflict management. Evidence must be provided that training for staff in relation to dealing with service users aggression/challenging behaviour is suitable to meet the needs of the individual service users. The training for staff regarding use of insulin must be provided by the timescale set. It is recommended that the manager carry out periodic competency assessments on staff to ensure that they are practicing in a way they have The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 24 been trained, particularly in relation to unexplained bruising and manual handling techniques. NVQ’s are ongoing and the manager reported that three more staff are enrolled on NVQ2 and one enrolled for NVQ4. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,40,41,42 Service users or their representative’s 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 still no evidence of quality monitoring systems in the home, apart from the regulation 26 visits. 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 DS0000008661.V279078.R01.S.doc Version 5.1 Page 26 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 and there was now evidence of Regulation 26 reports in the home. The chairperson of the trust visited the home on the day of the inspection. Regulation 37 notifications are now being submitted for incidents. Fourteen incidents were noted in one service users records between August 05 and January 2006 and which not all had been notified to CSCI. Backdated notifications must be submitted for both The Lodge and The Bungalow for the last six months. A visitors book is used in the Lodge, however visitors to the bungalow are not always recorded in this. A visitor’s book should be provided in the bungalow. Staff reported that they have signed that they have read and understood the policy manual. The last recorded review noted in the policy file was 2003. Food safety issues were noted to be improved at this visit. The manager reported that regulating valves are fitted to all taps there were records of checks for these but temperatures recorded above 43 degrees did not indicate any action taken to remedy temperatures exceeding 43 degrees and a retest. [Fifteen recorded temperatures seen since October 2005 which were above 43 deg] The manager reported that the home allowed 1degree concession as accuracy could not be guaranteed and therefore when temperatures were measured below 44 degrees no action had been taken. It was recommended that the threshold therefore be lowered to 42/ 43 degrees. The health and safety posters were now completed. The fire safety tests were examined, several gaps were found in weekly fire testing and monthly emergency lighting tests. There was no evidence in the fire safety records of staff fire drills. The inspector recommends that the fire risk assessment process is reviewed and that the recommended format provided by the fire authority is used and a copy kept in the fires safety log. Not all radiators were off the low surface type and did not have safety covers. It was reported that covers are on order. There was still no evidence of risk assessments regarding surface temperatures of radiators and these should be The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 27 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. There was still no evidence regarding what is in place to control risk of legionella, this must be provided. The manager reported that discussions had taken place with the landlord and letters to the landlord provided evidence, however there was no evidence of any response from the landlord regarding a commitment to undertake the required work in writing. The manager assured the inspector that the landlord had stated the work would be carried out, however written confirmation is also required. There was liquid soap and paper towels were seen in bathrooms. The exterior door to the small office, which contains the care plans and medication etc was left ajar and this posed a security risk. The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 2 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X X X 1 2 2 2 X The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 29 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 Regulation Requirement At the time of the visit five service users were at home, only one staff member was on duty in the bungalow, which left some service users vulnerable, as there have been some incidents of challenging behaviour over the last few months this is not satisfactory. Ensure that the staffing numbers are sufficient to meet service users needs at all times. Ensure the service user or their representative has been informed fully of any risks or necessary details in relation to the use of bedrails. Staff must only be permitted to administer insulin with a] their consent, b] with training and a competency assessment carried out and documented by the district nurse. Outstanding Ensure staff are fully DS0000008661.V279078.R01.S.doc YA2YA19YA23 14,15,18 Timescale for action 14/03/06 2 YA6 14, 15, 17, 24 14/03/06 3 YA19 18 14/03/06 4. YA19 12, 13, 14, 14/03/06 Version 5.1 Page 30 The Dovecote Care Home 15, 18 equipped to meet all service users need regarding dealing with challenging behaviour and strategies for crisis intervention and prevention. Outstanding Provide the inspector with 14/03/06 sufficient details of the training organised for staff in conflict management in order for the suitably of the training to be assessed. Ensure that medication 14/02/06 procedures are safe and meet with the Royal Pharmaceutical guidance for medicine administration in care homes. A] Ensure there is an appropriate policy for drug errors, which informs staff of appropriate action to take and that it is placed in an accessible place for staff to use should an emergency arise. B] The homely remedies policy must be devised with the input of the GP and contain the GP’s signature of what homely remedies medication is permitted. 5 YA19YA35 17,18 6 YA20 Medicines Act 7 YA24 16,23 8 YA35 18 Re-decorate the bathroom and toilets in the bungalow and Repair and re-decorate the plaster damage to the entrance hall in the bungalow. Training must be provided for all staff for health and safety and infection controlOutstanding 30/03/06 30/03/06 The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 31 9. YA39 25 Quality monitoring and auditing systems must be implemented as specified in the report. Outstanding Failure to Comply may result in enforcement action being taken. 14/04/06 10 YA41 37 Backdated Regulation 37 14/04/06 notifications must be submitted for both The Lodge and The Bungalow for the last six months. Ensure water temperatures are regulated to 43 degrees. Outstanding from the previous two inspections Ensure covers are fitted to radiators where assessed as a risk. Outstanding from the previous two inspections Provide evidence that systems are in place for the prevention of legionella to CSCI. Outstanding Ensure fire safety checks including fire drills are carried and documented as required by regulation. 14/04/06 11 YA42 16, 23 12 YA42YA24 12,13,16,23 Ensure the carpet in the activities room is made safe Ensure the stored items in the activities room are cleared and the room made safe for use. Original target date of 14/12/05 not met An immediate requirement is 03/02/06 The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 32 set for The Registered Person to ensure that service users health and safety is safeguarded by interim measures to make the activity room safe until the room can be cleared fully and refurbished. 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 YA5 YA6 Good Practice Recommendations Supply a copy of the contract document as evidence that it meets standard 5 as specified in the report. It is recommended that a sheet be placed at the front of the main working care plan file, informing inspectors and other authorised personnel that other information may be contained in the other files and how these can be accessed. There was no evidence that the bedrails in use have been assessed as appropriate to meet the needs of service user and the manager thought these had been purchased by the home. In order to ensure that the bedrails and the use of the bumpers are appropriate and safe for the individual it is strongly recommended that an appropriate professional assessment be obtained for this promptly. Once ascertained the details of the assessment and any identified risks need to be held on the working care plan file, to ensure staff are fully aware of how to use them. The use of communication aids, such as menus in symbol or photographic formats should be explored and implemented to promote informed choice A pre-agreed menu offer at least two options to service users to choose from. Evidence of the choice should be documented. Service users participation in the civic process should be written into the care plan structure. 3 YA7 4 YA8 5 YA8 6 YA14 The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 33 7 YA19 8 YA19 Weight records are a fundamental component of a service users care plan/well being and the system in place should be reviewed to reflect this. Add a comments section to the weight record sheet. Obtain in writing the decision by the GP not to offer well person checks to service users and seek advice from the Primary Care Team regarding this. [Inform the inspector of the outcome] Ensure care plans, which address the ageing process, are implemented for service users over 60 years and are reflected in the policy for ageing and increasing frailty. Ensure staff who are authorised to administer medication have a sample signature documented at the front of the MAR [Medication administration records] file Include medication profiles in care plans, which document medication reviews etc. Seek advice from adult payment services regarding appointee ship for service users as discussed at the last two inspections. Continue and finalise the assessment in relation to service users use of transport and how mobility payments will be costed and send the outcome to the inspector. The registered person should undertake periodic competency assessments on staff to ensure good practice is maintained. Develop ways to obtain service users views, such as by using outside professional support or advocacy services in service user surveys etc. Consider use of an outside consultancy to audit the care services under standard 39. Review policies and procedures and provide a visitors book for the Bungalow. Review and take action in relation to the security risk of the small office in the bungalows 9 YA19 10 YA20 11 12 YA20 YA23 13 YA23 14 YA35 15 YA39 16 17 18 YA39 YA40 YA42 The Dovecote Care Home DS0000008661.V279078.R01.S.doc Version 5.1 Page 34 Commission for Social Care Inspection Nottingham Area Office 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. 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