Care Home: Dovecote Manor

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What the care home does well The atmosphere in the home is friendly and supportive. Residents have choice as to how they spend their day promoting their dignity and wellbeing. Resident`s nutritional needs are met and mealtimes are a sociable occasion. The home presents with a warm friendly atmosphere and the cleanliness was very good throughout. The home has a flexible visiting policy and welcome family, friends and any other visitors to the home. Relatives and friends are encouraged to visit and are made to feel welcome. The home has good working relationships with the local GP`s and community health services accessing them when appropriate. One GP who returned a comment card, sent out by the Commission prior to the inspection, indicated complete satisfaction with the standard of care provided stating `the home is very well organised.....they know the residents well and provide a very good standard of care`. What has improved since the last inspection? This is a newly registered service and their first inspection and therefore no previous inspections of this service have been undertaken What the care home could do better: The registered manager must amend the statement of purpose so that prospective and current service users have up to date information. Each resident`s care plan and risk assessments must be reviewed regularly and updated to reflect any changes to their care needs as necessary. The practice of placing medication in pots in advance of administering and placing in insecure accessible areas must stop. The registered manager must review the medication practices and monitoring of these practices to ensure the safe storage and administration of medicines. Staff must receive formal supervision at least 6 times a year.It is recommended that a nationally validated screening tool be used to carry out nutritional screening, including a body mass index, for all residents on admission. Where bed rails are to be used, a consultation should be undertaken with a relevant health care professional and document the rationale for the use of bed rails, the consultation process that took place, confirmation of the service users consent or that of their representative where the service user is unable to give consent, involvement of the service users representative and any risk management considerations. CARE HOMES FOR OLDER PEOPLE Dovecote Manor Whalley Drive Bletchley Milton Keynes Buckinghamshire MK3 6EN Lead Inspector Jane Handscombe Unannounced Inspection 13th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dovecote Manor DS0000069002.V336937.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dovecote Manor Address Whalley Drive Bletchley Milton Keynes Buckinghamshire MK3 6EN 020 8313 5000 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) Excelcare Holdings Alan Philip Haywood Care Home 40 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Dovecote Manor is a brand new purpose built care home for older people which opened in January 2007 and is operated by Excelcare. It is located in Bletchley, Milton Keynes close to local amenities. Dovecote Manor is a care home providing personal care and accommodation for forty older people. The home is divided into three units, the first unit being a 21-bedded unit which is leased and run by the primary care trust. The remaining two units are spread over two floors; the first floor being a twenty bedded frail elderly unit and the second floor being a twenty-bedded dementia care unit. Each unit has a lounge, seperate dining room, a quiet room and a separate smoking room. All the bedrooms are single bedded with ensuite facilities. There is a well maintained enclosed garden which is shared with the Primary Care Trust. Fees for the service range from £409.00 – £575.00 per week Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘baseline Inspection’, since it is a new service, which was undertaken on 13th June 2007. The inspection involved one inspector, which took place over eight hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the registered provider, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services, staff members and other people seen during the inspection or who responded to questionnaires that the Commission had sent out to the home for distribution. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Comments received from during the inspection process include: ‘the food is very good’ ‘its always nice and clean’ comments from family members: ‘I don’t think we could have found X (named resident) anywhere better….made to feel very welcome…I’m really happy with it..’ X (named resident) has been in over a week..he seems very happy…I joined in with the painting activity’ ‘there is a positive attitude to involving residents relatives’ ‘the care service is well managed by ‘caring’ senior staff’ ‘the stimulation for patients with dementia is good’ ‘on the whole from what I have witnessed everyone who is part of Dovecote Manor is very professional and helpful, not only to mum but also to me. They do an excellent job’ Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 6 The inspector would like to thank the residents, their families, staff members and other health professionals for their time and assistance during this inspection What the service does well: What has improved since the last inspection? What they could do better: The registered manager must amend the statement of purpose so that prospective and current service users have up to date information. Each resident’s care plan and risk assessments must be reviewed regularly and updated to reflect any changes to their care needs as necessary. The practice of placing medication in pots in advance of administering and placing in insecure accessible areas must stop. The registered manager must review the medication practices and monitoring of these practices to ensure the safe storage and administration of medicines. Staff must receive formal supervision at least 6 times a year. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 7 It is recommended that a nationally validated screening tool be used to carry out nutritional screening, including a body mass index, for all residents on admission. Where bed rails are to be used, a consultation should be undertaken with a relevant health care professional and document the rationale for the use of bed rails, the consultation process that took place, confirmation of the service users consent or that of their representative where the service user is unable to give consent, involvement of the service users representative and any risk management considerations. 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. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (standard 6 is not applicable to this home) Quality in this outcome area is good. Prospective residents are provided with information they need to make an informed choice about admission to the home, although details of the operations manager within the company structure need updating. Residents are assessed prior to admission to ensure the home can provide the care that is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All prospective and current service users are given information about the home through a service users guide and statement of purpose. Both of these are freely available in the reception enabling visitors to the home access to the information if required. It was noted that the statement of purpose needs amending; namely that of the company structure in which the named regional operations manager is out of date. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 10 Likewise the complaints procedure names the named inspector, which should be removed, as this is unnecessary and inspector’s change. The home is presently developing a brochure, which is to contain lots of photographs, which the manager explained is to be more users friendly. Once a care plan has been received from the referring local authority, the registered manager or team leader contact the prospective service user and invite them to visit the home and undergo an assessment of need prior to a service being offered. The assessment of need ensures that their needs can be met appropriately at Dovecote Manor. They are then provided with a carers diary in which they can record information such as memorable events, important dates, likes and dislikes, hobbies and interests which enables the home to formulate an individualised care plan which is person centred and holistic in nature. The registered manager explained to the inspector that he has plans to improve the pre admission procedure and is looking to include key care worker involvement in the assessment process, explaining that the involvement of key workers in the process would allow for familiarity when admitted to the home and continuity of care to the service users. From the evidence seen by the inspector and comments received, the inspector considers that this service is able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each user of the service has an individual plan of care setting out their health, social and personal care needs and how these are to be addressed. The homes policies around medication serve to protect the service users, however poor procedures around the storage of medication was evidenced during the inspection, which could compromise the safety of users of the service. EVIDENCE: A selection of care plans were observed during the inspection and those on the dementia unit were found to be of good content; they were individualised and person centred, regularly reviewed and updated, contained all the necessary moving and handling and risk assessments, giving a good all round holistic care approach. Care plans for those on the first floor unit were not of the same high standard. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 12 This was acknowledged by the manager who assured the inspector that their own quality assurance and monitoring process had flagged up the same findings and that training is being put into place to ensure that the care planning process and content is consistent throughout the home. Of one care plan viewed, the risk assessment was not signed by the assessor, the social care assessment was incomplete, there were no contact details for the resident’s care manager, the inventory was unsigned by either the resident/their representative or a witness and likes and dislikes within the care diary around food and hobbies was not completed. The daily notes within this residents file were very short and brief, failing to give a good picture of the care provided. A further care plan viewed was very dated detailing care needs and risks that were dated 2005 and no longer relevant to the resident. Each resident’s plan must be reviewed regularly and updated to reflect any changes as necessary. It was noted that one service user had been provided with bed sides, however there was no evidence of the service users/representatives consent within the file notes or consultation with a relevant health care professional, although the inspector was informed that the use of bedrails had been discussed with the residents GP. In situations where bed rails are to be used, a consultation must be undertaken with a relevant health care professional and document the rationale for the use of bed rails, the consultation process that took place, confirmation of the service users consent or that of their representative where the service user is unable to give consent, involvement of the service users representative and any risk management considerations. Any risks associated with delivering the care are acknowledged and actions to be taken to minimise them are recorded enabling staff to undertake the care in a safe manner. Current good practice recommends that care homes have a procedure for dietary assessment and nutritional screening using a nationally validated screening tool, such as MUST (Malnutrition Universal Screening Tool). This should be undertaken on admission and at appropriate intervals thereafter, with a record of nutrition, weight gain or loss and appropriate action taken. Some residents are being assessed using the home’s own assessment form, but this is not a nationally validated screening tool and therefore a recommendation has been made within this report. The commission has received a number of notifications from the service regarding a number of incidences in which service users have received falls. Upon enquiry it was acknowledged that the home is receiving advice and support from the GP’s, District Nurses and a falls co-ordinator, who visit the Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 13 home, to minimise such incidents and the monitoring of such events are taking place. The homes policy around medication serves to protect service users, however practices seen during the inspection place service users at risk. Whilst touring the home, 2 doses of medication were found stored in an accessible cupboard within the kitchenette in the dining area on the dementia unit. The inspector was informed that they were placed there for later use. These were immediately removed and the inspector was informed they would be returned to the pharmacy. Likewise, when the inspector asked to view the controlled drugs register on the dementia unit, the medication trolley was left in an unsafe manner and accessible to residents. The senior team leader and manager undertake regular medication audits in order that if any poor practices occur they may be addressed swiftly and appropriately. Throughout the inspection it was observed that the care provided is delivered in a sensitive manner, which respects the service users privacy and dignity at all times. The home has recently reviewed their end of life policy and plan to adopt the ‘gold standards framework’ at the appropriate time. The home has good working relationships with the local GP’s and community health services and accesses them when appropriate. One GP who returned a comment card, sent out by the Commission prior to the inspection, indicated complete satisfaction with the standard of care provided. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with good quality food, which meets their nutritional needs. Residents are enabled to spend their day as they choose and maintain contact with family, friends, representatives and the local community as they wish. EVIDENCE: Users of the service are enabled to spend their day as they choose and are encouraged to maintain contact with family, friends, representatives and the local community as they wish. The home considers that visitors, relatives, family and friends are important to the care provision and always provides a warm welcome at any reasonable time. The inspector spoke to a number of visitors to the home all of whom verified this to be the case. Discussions with service users regarding the meals provided at the home were all very complimentary. Service users informed the inspector that they enjoy Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 15 the meals provided, which are cooked freshly on the premises, are nutritious of good portion size and offer choice. Specialist diets are catered for where the need arises. The home employs an activities co-ordinator for 25 hours a week who provides a daily programme of activities, for those who wish to partake. Activities provided include art and craftwork, quizzes, music evenings and reminiscence. In addition to those provided by the activities co-ordinator, the senior team leader has introduced a regular activities programme for the dementia unit enabling them to use the skills they have at times that suit them either through group activities, one to one or in the equipped sensory room. The manager reported that residents and staff participate in these activities daily and have proved very beneficial to their well-being. There are regular residents meetings held in the home to which all residents are invited. These meetings are an open discussion in which residents can voice any concerns and make any suggestions and the management can address their issues and discuss points of interest relating to the home. The manager informed the inspector that the Alzheimer’s society have been invited to support the home and residents’ families, which the home plans to be looking at as a regular activity. Residents have been offered the facility of church services within the home, however this has lapsed, the last being held in January although the home is in the process of gaining a replacement in order that this service can resume. The home has recently acquired and installed a computer for residents’ use and computer activities are being developed and added into the activities programme. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear complaints procedure for residents to raise any concerns or complaints and any complaints are taken seriously. Procedures are in place to safeguard service users from abuse. EVIDENCE: Information about the complaints procedure is given to service users on admission. The complaints procedure is also displayed throughout the home and copies are also available on request. Discussions with users of the service and visitors to the home, informed the inspector that they are confident to take any concerns or complaints to the manager or staff member and trusted that any complaints they may have would be taken seriously and acted upon appropriately. The Commission has received no notification of any concerns, allegations or instances of abuse. The inspector viewed the complaints log and discussed two complaints, received directly to the home, since the service opened; one, which was responded to in a timely manner and dealt with appropriately, and the other being dealt with and still ongoing. The safeguarding of vulnerable adults is taken very seriously, and staff members receive training at induction and regularly thereafter. Robust Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 17 procedures are in place for responding to any suspicion or evidence of abuse, including whistle blowing, to ensure the safety and protection of those in their care. Staff spoken to during the inspection were aware of their responsibility to report any concerns or allegations and assured the inspector that any such incidents would be responded to promptly and acted upon appropriately. . Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Users of the service are provided with a pleasant, well-maintained and safe environment. EVIDENCE: Cleanliness within the home was extremely good and there were no unpleasant smells. The home provides safe, comfortable well maintained surroundings, which are equipped to meet the residents needs and presented as clean and tidy. All parts of the home are accessible to the service users, with the use of grab rails and a lift to facilitate mobility around the home. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 19 There are 40 single bedrooms, all of which have ensuite facilities. Each bedroom has an alarm near to the bed in order that assistance may be sought when required. Each room is furnished and equipped to assure comfort and privacy and meets the residents needs, however the home does encourage residents to bring small items of furniture and memorabilia to personalise their rooms to their own liking, if required, which was evident whilst touring the home. All residents are provided with a key to their bedrooms if required, within a risk management process and lockable facilities are provided for any valuables. All parts of the home are accessible to the service users, with the use of grab rails and a lift to facilitate mobility around the home. There are sufficient WC and bathing facilities with bath hoists in place. The registered manager has liaised with a hoist manufacturer as felt the hoist on the dementia unit needed replacing to one which is more appropriate for the service users needs. An assessment has taken place and a new bath hoist has been obtained to replace the existing model. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels appeared adequate to meet residents’ care needs. The home has good recruitment procedures, to ensure that suitable staff are employed to look after their vulnerable clients although any gaps in employment history should be recorded. Staff are trained to meet the needs of people using the service. EVIDENCE: The homes staffing levels appeared adequate on the day of inspection to meet the residents’ needs. There was a good feeling of teamwork amongst all the staff and those spoken to were happy to be working at the home, and appreciate their colleagues and the support they give each other. The recruitment systems in place are of a good quality; a selection of staff files were sampled for inspection all of which contained the relevant pre employment checks, references and their relevant qualification. However, where gaps in employment history are evident, the reasoning for the gaps should be recorded on the relevant personnel file. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 21 All new members of staff undergo induction training, upon appointment to their posts, and are provided with the necessary mandatory training and ongoing training to ensure they have the skills and knowledge to undertake their roles competently and safely. All staff are encouraged to undertake the National Vocational Qualification (NVQ) in care, which equips them to meet the assessed needs of the residents within the home and allow for personal development. From information received into the Commission, the home has 34 members of care staff all of whom have either attained the NVQ in care at level 2 or above or are working towards it; there are 16 care staff who have attained level 2 or above and a further 17 are working towards it. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed, delivering a consistent service to those who live there and is run in their best interests. Staff are well supported although it has been recognised that supervision has lapsed and needs to be addressed. Procedures within the home need to be adhered to, namely that of the recording of the administration of medication ensuring that service users health and safety is promoted and protected at all times EVIDENCE: Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 23 The registered manager displays a good sound knowledge of matters related to the management and running of the care home for older people. However, whilst he has achieved the NVQ level 4 Registered Managers Award, this did not include the care component and does not yet have a qualification at level 4 NVQ in care (or equivalent). Not having the NVQ in care at level 4 means that Standard 31 cannot be assessed as ‘fully met’ until this qualification is obtained. Whilst staff are provided with supervision these need to be undertaken more regularly to achieve supervision at least six times a year. The registered manager is aware of the shortfall and in the process of currently reviewing the supervision matrix in order that due dates are clearly identified in order that the objective is met. Excelcare has a quality assurance programme in place including surveys which are sent out to residents and their relatives to gain feedback and an analysis on the service and care provided. It is recommended that the annual questionnaire allows for family members, GP’s, social workers and any other health professionals involved with the home to take part. Internal audits are undertaken to regularly monitor standards, including examining care plans, fire log training procedures and other health and safety issues. Complaints (and compliments) are recorded. Residents meetings are held and minutes kept. Annual surveys are undertaken and analysed. It The inspector was informed that home does not act as agent or manage monies on behalf of residents; that where residents are not able to manage their own financial affairs, an advocate would become involved and if keyworkers were to assist residents with shopping any transaction would be recorded and receipts kept. The pre-inspection questionnaire showed that regular servicing and maintenance of equipment takes place. There are health and safety policies and procedures in place and generic risk assessments have been undertaken to promote safe working practices. The staff spoken to and personnel files viewed evidenced they had manual handling training and the inspector was informed that a programme was in place to ensure that all staff had mandatory health and safety training with annual updates where required. There are control of infection policies and procedures in place and safety checks relating to fire safety and infectious diseases are regularly carried out. Overall, the service is generally run in the best interests of those who use the service, however poor practices noted in the section headed Health and Personal Care could compromise the health and safety of those using the service. Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 24 Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 6 Timescale for action Amend the Statement of Purpose 31/08/07 to include up to date information required under regulation 4 and schedule 1 of the care home regulations and refrain from naming inspectors. Each resident’s care plan and 31/07/07 risk assessments must be reviewed regularly and updated to reflect any changes as necessary. Requirement 2 OP7 14 3 OP9 13(2) 4 OP36 18 Review the medication practices and monitoring of these practices to ensure the safe storage, administration and recording of medicines. Staff receive formal supervision at least 6 times a year. 31/07/07 31/07/07 Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 27 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 OP8 Good Practice Recommendations Implement a nationally validated screening tool be used to carry out nutritional screening, including a body mass index, for all residents on admission and reviewed at appropriate intervals thereafter. Where bed rails are to be used, a consultation should be undertaken with a relevant health care professional and document the rationale for the use of bed rails, the consultation process that took place, confirmation of the service users consent or that of their representative where the service user is unable to give consent, involvement of the service users representative and any risk management considerations. 2 OP7 Dovecote Manor DS0000069002.V336937.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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