Care Home: Dovehaven

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What the care home does well Dovehaven presented as a well maintained, friendly and comfortable home in which to live. Areas viewed were clean and hygienic and residents appeared relaxed in their home environment. Staff were observed to be attentive to the needs and support requirements of the people living in the home and residents spoken with complimented the standard of care received. Comments included: "The care is very good. I have no grumbles"; "They [staff] are kind and listen" and "Staff are wonderful". Residents spoken with confirmed they were positively encouraged to maintain links with their family and friends and to maintain as much independence and control over their lives as possible. Activities were coordinated for residents to participate in and this included a weekly trip to various destinations. A four-week menu had been developed which provided a choice of alternative meals for residents at each sitting. Menus viewed offered residents a balanced, wholesome and nutritious diet and health related and cultural needs were catered for. Feedback received from residents regarding the standard of catering was good and comments included; "We have well cooked food"; "I`d give them 90% out of a 100 for food" and "The food is very good and there are always choices." Systems had been established to enable residents and their representatives to provide feedback on the service and to express concerns or complaints. Likewise, policies and procedures had been developed to provide guidance to staff on how to protect residents from abuse. What has improved since the last inspection? Since the last inspection the home has received ongoing investment to improve the standard of accommodation offered to residents. A new care planning document had been introduced to outline information on assessed needs and the services to be provided together with objectives. Certificates had been obtained to confirm lifting equipment in the home was safe and had been serviced in accordance with the Lifting Operations and Lifting Equipment Regulations. A full assessment of needs had been undertaken prior to prospective residents being admitted, to ensure the diverse needs of the people using the service were assessed. Risk assessments had been updated to identify the hazard, risk rating, controls and action required to ensure potential hazards were appropriately planned for. Individual records of all health care appointments and the outcomes had been recorded to provide evidence that the service supports people to remain in good health. The majority of the staff team had completed training in the Protection of VulnerableAdults from Abuse, to help staff to understand how to respond to suspicion or evidence of abuse. A fire risk assessment had been completed to ensure compliance with fire safety laws and good progress had been made in supporting staff to complete training in safe working practice topics to safeguard the health and safety of the people using the service. What the care home could do better: The Statement of Purpose and Service User Guide should be updated to include details of the new Registered Manager, deputy manager and the name and contact details of the Care Quality Commission. This will ensure people have access to up-to-date information on the service. Information on ethnicity, weight, hearing and personal safety and risk should be included in the assessment tool and obtained as part of the assessment process to ensure an holistic assessment of needs. Care Plans should set out in more detail the action that needs to be taken by staff to ensure staff have access to comprehensive information on how the health, personal and social care needs of the service users are to be met. The temperature of the fridge used to store medication should be monitored and recorded on a daily basis to ensure best practice. Schedule 2 controlled drugs must be stored in a Controlled Drugs Cabinet to ensure medication is correctly stored in accordance with the Misuse of Drugs [Safe Custody] Regulations 1973. The balance of medication not received in blister packs should be brought forward and recorded on Medication Administration Records to provide a clear audit trail. Medication policies and procedure should be kept under review and one main policy should be developed for staff to reference to ensure best practice. The range of in-house and community based activities on offer should be kept under review in consultation with the people using the service, to ensure the recreational needs, expectations and preferences of the people using the service are met. The Registered Manager should check that prospective employees provide the full details of dates of previous employment to ensure a clear audit trail and any unexplained gaps should be explored as part of the recruitment process. The staff training matrix should be updated to include the dates that staff completed training. This will help to improve training records and confirm training is up-to-date. The home`s induction programme should be updated to ensure compliance with the `Skills for Care` Common Induction Standards. This will ensure staff are inducted inaccordance with national training standards. The staff training and development programme should be expanded to include additional training relevant to the care needs of older people. This will help staff to gain additional knowledge and develop professional competence. Night staff should receive fire instruction training at least every three months and day staff at least every six months to ensure staff are aware of fire safety procedures as recommended by the fire service. Monthly visual inspections of the fire extinguishers should be undertaken and records maintained to monitor the condition of fire fighting equipment. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Dovehaven 22 Albert Road Southport Merseyside PR9 0LG     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Daniel Hamilton     Date: 2 0 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Dovehaven 22 Albert Road Southport Merseyside PR9 0LG 01704548880 01704536647 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Mark J Gilbert,Mrs Wendy J Gilbert Name of registered manager (if applicable) Mrs Carol Leddy Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, Physical disability - Code PD (maximum places - 10). The maximum number of service users who can be accommodated is: 42. Date of last inspection Brief description of the care home Dovehaven is a residential care home for older people providing 42 registered places, 32 of which are registered for older people and 10 for older people with a physical disability. The home is situated close to Southport town centre and all its amenities and is within easy reach of shops, parks and public transport. The home has 38 bedrooms, 4 of which are double rooms however these are currently Care Homes for Older People Page 4 of 31 0 10 Over 65 42 0 care home 42 Brief description of the care home used for single occupancy. The communal areas consist of a dining room, large lounge to the front of the building with a conservatory attached and a smaller lounge. Toileting and bathing facilities are located throughout. The home has three levels with a passenger lift serving the main floors and chair lifts to the mezzanine floors giving residents access to all parts of the building. A call bell system is fitted in all areas of the home. There is a large garden to the rear of the home and parking facilities are available at the front of the property. The Care Home Fees currently range from £389.00 to £440.00 Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means that the people who use the service experience good quality outcomes. This unannounced inspection took place over one day and lasted approximately 9 hours. A partial tour of the premises took place and observations were made. Four care files and a selection of staff and service records were also examined and the owner, junior partner, registered manager, deputy manager, two care staff and 12 residents were spoken with during the visit. Survey forms were distributed to a number of residents or their representatives prior to the inspection in order to obtain additional views and feedback about the service. Care Homes for Older People Page 6 of 31 Reference was also made to an Annual Quality Assurance Assessment which was completed by a senior manager acting on behalf of the Registered Provider. This document enables a Registered Provider to undertake a self-assessment on the service prior to an inspection. It should be noted that a new manager has registered with the Care Quality Commission since the last inspection in May 2007. What the care home does well: What has improved since the last inspection? Since the last inspection the home has received ongoing investment to improve the standard of accommodation offered to residents. A new care planning document had been introduced to outline information on assessed needs and the services to be provided together with objectives. Certificates had been obtained to confirm lifting equipment in the home was safe and had been serviced in accordance with the Lifting Operations and Lifting Equipment Regulations. A full assessment of needs had been undertaken prior to prospective residents being admitted, to ensure the diverse needs of the people using the service were assessed. Risk assessments had been updated to identify the hazard, risk rating, controls and action required to ensure potential hazards were appropriately planned for. Individual records of all health care appointments and the outcomes had been recorded to provide evidence that the service supports people to remain in good health. The majority of the staff team had completed training in the Protection of Vulnerable Care Homes for Older People Page 8 of 31 Adults from Abuse, to help staff to understand how to respond to suspicion or evidence of abuse. A fire risk assessment had been completed to ensure compliance with fire safety laws and good progress had been made in supporting staff to complete training in safe working practice topics to safeguard the health and safety of the people using the service. What they could do better: The Statement of Purpose and Service User Guide should be updated to include details of the new Registered Manager, deputy manager and the name and contact details of the Care Quality Commission. This will ensure people have access to up-to-date information on the service. Information on ethnicity, weight, hearing and personal safety and risk should be included in the assessment tool and obtained as part of the assessment process to ensure an holistic assessment of needs. Care Plans should set out in more detail the action that needs to be taken by staff to ensure staff have access to comprehensive information on how the health, personal and social care needs of the service users are to be met. The temperature of the fridge used to store medication should be monitored and recorded on a daily basis to ensure best practice. Schedule 2 controlled drugs must be stored in a Controlled Drugs Cabinet to ensure medication is correctly stored in accordance with the Misuse of Drugs [Safe Custody] Regulations 1973. The balance of medication not received in blister packs should be brought forward and recorded on Medication Administration Records to provide a clear audit trail. Medication policies and procedure should be kept under review and one main policy should be developed for staff to reference to ensure best practice. The range of in-house and community based activities on offer should be kept under review in consultation with the people using the service, to ensure the recreational needs, expectations and preferences of the people using the service are met. The Registered Manager should check that prospective employees provide the full details of dates of previous employment to ensure a clear audit trail and any unexplained gaps should be explored as part of the recruitment process. The staff training matrix should be updated to include the dates that staff completed training. This will help to improve training records and confirm training is up-to-date. The homes induction programme should be updated to ensure compliance with the Skills for Care Common Induction Standards. This will ensure staff are inducted in Care Homes for Older People Page 9 of 31 accordance with national training standards. The staff training and development programme should be expanded to include additional training relevant to the care needs of older people. This will help staff to gain additional knowledge and develop professional competence. Night staff should receive fire instruction training at least every three months and day staff at least every six months to ensure staff are aware of fire safety procedures as recommended by the fire service. Monthly visual inspections of the fire extinguishers should be undertaken and records maintained to monitor the condition of fire fighting equipment. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given information and have their needs assessed before deciding to move into Dovehaven, so they know that their needs can be met. Evidence: A Philosophy of Care document had been developed in a standard format since the last inspection to provide information to prospective residents and their representatives on the service provided at Dovehaven. Brief information on the environment, values of the service, admission procedures, staff training and qualifications, arrangements made for consultation with residents about the operation of the care home, rights and responsibilities, activities and, religion and culture had been included. The combined Statement of Purpose and Service User Guide was also viewed. This document was in need of review as the details of the new registered manager, deputy Care Homes for Older People Page 12 of 31 Evidence: manager and the name and contact details of the regulator were incorrect. Advice was given to also date the document. The Registered Manager reported that the service would make arrangements to develop information on the service using large print and confirmed that the documents could also be produced in other languages, subject to individual need. The files of four residents who had moved into the home since the last visit were viewed during the visit. Each file contained a New Client Enquiry Form and Service User Assessment Tool which had been completed prior to prospective residents moving into Dovehaven. Information on the health, personal and social care needs of residents had been recorded however the manager was recommended to also include information on ethnicity, weight, personal safety and risk and hearing. Copies of assessments completed by health or social services care managers had also been obtained for people referred through care management arrangements. Examination of records, discussion with residents and information received via Care Home Survey forms confirmed that the people using the service had received a Contract and information on Dovehaven prior to admission. Signed copies of individual contracts had been stored within each residents personal file. The Registered Manager was advised to update the Contract as the document made reference to the National Care Standards Commission. Care Homes for Older People Page 13 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the care and support they need in a way that meets their expectations. Evidence: The Annual Quality Assurance Assessment (AQAA) for Dovehaven detailed that a policy on individual planning and review and the control, storage, disposal, recording and administration of medicines was in place to provide guidance to staff. The files of four residents who had moved into the home since the last visit were viewed during the visit. Examination of records revealed that the Registered Manager had introduced a new care plan tool since the last visit. The document included a photograph and outlined general and contact details, information on assessed needs and the services to be provided together with objectives. A review of care plan form was also included in the package and records were available to confirm each care plan / area of need had been kept under monthly review. Care plans viewed contained basic information on how the needs of residents were to Care Homes for Older People Page 14 of 31 Evidence: be met and needed more detailed information for staff to follow. Likewise, some objectives viewed were not clear. Examples were discussed with the manager during the visit. Discussion with the people using the service and examination of health care records confirmed residents had accessed a range of health care professionals. Files viewed contained evidence that residents had attended appointments with district nurses, chiropodists, general practitioners, audiologists, opticians and dentists, subject to individual needs. Supporting documentation including risk assessments, weight records and daily report sheets were also available for reference. Risk assessments viewed had been updated to include information on the controls and action required. The manager was recommended to develop a more comprehensive risk assessment for residents who may require assistance with moving and handling. The Registered Manager reported that the homes main medication policy was a one page document entitled Medication Administration and Recording. Other policies and procedures concerning medication were available for reference however these were in need of review. The manager was advised to review the medication policies and procedures and to develop one document for staff to reference. The AQAA confirmed staff responsible for administering medication had completed medication administration training and that this had been kept up-to-date. Records of staff authorised to administer medication were in place and a system had been established to check the competency of staff and the identity of residents prior to administering medication. Declaration forms had been completed by residents (where practicable) to confirm consent had been obtained for the administration of medication and a basic risk assessment had been completed for residents who self-administered medication as noted at the previous visit. The manager provided evidence that she had designed a more detailed risk assessment and advice was given on how this could be further developed to address all potential risks. Medication was dispensed by a local pharmacist using a blister pack system. Medication Administration Records (MAR) viewed had been correctly completed to record the details of medication received and administered in the home. The manager was advised to record the balance brought forward on MAR for medication not received in blister packs and to establish temperature records for the fridge used to store medication. It was also noted that a schedule 2 controlled drug (Morphine Sulphate) Care Homes for Older People Page 15 of 31 Evidence: was not being stored correctly in accordance with the Misuse of Drugs [Safe Custody] Regulations 1973. The manager was therefore requested to obtain a suitable cabinet to store controlled drugs. Staff spoken with during the visit demonstrated a satisfactory understanding of the principles of good care practice and the needs of the people living in Dovehaven. Staff were observed to be attentive to the needs of residents during the day and feedback received from residents via surveys and discussion confirmed they received the care and support they required. Comments received from the people living in the home included; I was admitted from hospital on two weeks respite. I really enjoyed staying here and decided this was a better place for me to be; I couldnt be better looked after. They couldnt treat me any better and The care is very good. I have no grumbles. Care Homes for Older People Page 16 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Daily life, activities and meals were flexible and varied to meet the preferred routines, expectations and preferences of the people living in the home. Evidence: A programme of activities was displayed on a notice board in the reception area and records of activities had been recorded for reference. The programme advertised the following activities for residents to participate in: Hairdressing on a Monday, Trip to a choice of destinations in the homes mini bus on a Tuesday afternoon, bingo on a Wednesday and Saturday and exercise with musical movements on a Thursday afternoon. The registered manager reported that outside entertainers also visited the home periodically and ministers of religion from two different denominations continued to visit the home. Feedback received from the majority of residents confirmed they were satisfied with the programme of activities provided, despite the range of activities having remained unchanged since the last inspection. The weekly trip out continued to remain a favourite activity. Feedback from residents included: We have a small selection of activities but I very much enjoy the trips. I recently went to Beacons Fell and The Care Homes for Older People Page 17 of 31 Evidence: trips in the bus are always popular and its nice to visit different places of interest. Two residents reported that they would like to see a greater variety of activities and this should be reviewed. Residents spoken with confirmed they were positively encouraged to maintain links with their family and friends and to maintain as much independence and control over their lives as possible. The lifestyle experienced by residents appeared relaxed and flexible to enable people to follow their preferred routines. The home had a four-week menu, which provided a choice of alternative meals for residents at each sitting. Meals were served in the homes dining room, which provided a good view of the garden area. Tables were furnished with condiments, table mats and flowers. Staff were observed to provide discreet support and assistance to the people using the service and it was evident that mealtimes were viewed as a social occasion by residents. Menus viewed offered residents a balanced, wholesome and nutritious diet. A copy of the daily menu was displayed on the homes notice board and on each table for residents to view. The manager reported that the service was able to meet the assessed dietary needs of prospective and current residents and was providing low fat, high fibre, diabetic and a Kosher diet. Feedback received from residents via Care Home Surveys and discussion confirmed residents were very satisfied with the range and quality of meals provided. Comments included; We have well cooked food; Id give them 90 out of a 100 for food and The food is very good and there are always choices. Care Homes for Older People Page 18 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems had been developed to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. Evidence: A complaints policy had been developed to provide information for residents or their representatives on the procedure to follow if they wished to express concerns regarding the standard of service. Details of the procedure were included in the homes Statement of Purpose and Service User Guide and a copy of the policy was displayed on notice boards throughout Dovehaven. The Registered Manager was advised to update the policy to ensure the name and contact details of the Care Quality Commission were included. The Annual Quality Assurance Assessment detailed that there had been no complaints about the service in the last 12 months. Examination of the complaints record book detailed that two concerns had been received. One concern was from a relative and concerned poor television reception for one television channel. The other issue was raised by a resident and concerned another resident wandering into a bedroom without permission. Records confirmed that both issues had been responded to promptly and discussion with the people using the service confirmed people were aware of how to complain and had confidence that any concerns would be listened to and acted upon. No complaints, concerns or allegations had been brought to the attention of the Care Care Homes for Older People Page 19 of 31 Evidence: Quality Commission in the last 12 months. The Annual Quality Assurance Assessment (AQAA) confirmed that policies and procedures were in place for responding to suspicion or evidence of abuse and whistleblowing, as noted at the last inspection. The manager and experienced staff spoken with demonstrated a satisfactory awareness of the different types of abuse and reporting procedures. One employee reported that she had completed training in abuse awareness but needed to attend the training again. The training matrix detailed that all staff employed at Dovehaven except for two (who had been absent on the training days) had completed training in abuse awareness. Care Homes for Older People Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is clean and comfortable with pleasant surroundings providing the people using the service with an attractive and well maintained home in which to live. Evidence: The home employed a handyperson who worked two days a week. Contractors were also hired for major and specialised work as and when required and to maintain the grounds. A maintenance book was in place to record work in need of attention and a health and safety checklist was completed by the manager and handyperson every month, to monitor the condition of the home. Areas viewed during the visit were well maintained and homely. Discussion with the Registered Manager and examination of the Annual Quality Assurance Assessment (AQAA) confirmed the environment had received ongoing investment and maintenance. Since the last visit, a toilet on the ground floor and six rooms had been refurbished and redecorated, ensuites have been fitted in 3 rooms and new vanity units had been installed in 5 rooms. New light fittings had also been installed in the reception hallway and lounge areas and new furniture had been purchased for the garden. The front entrance of the home was accessed via steps however the rear entrance was Care Homes for Older People Page 21 of 31 Evidence: accessible to wheelchair users. The home was equipped with a call bell system, stair lifts and a passenger lift and assisted bathing and toilet facilities were available for residents to use. Residents were observed to have access to personal mobility aids, subject to individual needs. (Please refer to the Brief Description of the Service section for more information on the premises). Rotas showed that the home continued to employ four part-time domestics and a laundry assistant. Areas viewed during the visit were clean and free from offensive smells. The AQAA confirmed that policies and procedures had been developed for communicable diseases and infection Control and training records provided evidence that the majority of the staff team had completed infection control training. Feedback received from the people using the service confirmed the home was kept clean and hygienic. Care Homes for Older People Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements, recruitment and ongoing training opportunities ensure that people are cared for and supported safely. Evidence: Discussion with the Registered Manager and examination of staffing rotas confirmed staffing levels at Dovehaven remained the same as at the last visit. Three care assistants and the manager or a senior member of staff were on duty during the day, with two waking night staff and an additional member of staff providing a sleep-in service throughout the night. The Registered Manager was allocated one to two days per week supernumerary time, to complete administrative duties. Residents spoken with during the visit complimented the standard of care provided by staff. Comments included: They [staff] are kind and listen; Staff are wonderful and Everybodys marvellous. The Annual Quality Assurance Assessment (AQAA) for the service confirmed that a recruitment and employment policy was in place as noted at the last inspection. Since the last visit, ten new staff had commenced employment at the home. The recruitment records of seven staff were viewed. Overall, files contained the necessary records required to safeguard the welfare of the people using the service. It was noted that Care Homes for Older People Page 23 of 31 Evidence: three files did not contain a photograph and another did not include a health declaration. Likewise, some application forms did not provide a clear audit trail for the dates of previous employment. These issues were brought to the attention of the Registered Manager. Records of in-house inductions were available for all new staff however the format was not compliant with the Skills for Care common induction standards. The manager was recommended to update the induction programme to ensure it complied with the Skills for Care common induction standards and advice was given on where to download a managers guide, progress logs and certificates of completion. The Registered Manager reported that twenty care staff were employed in the home and seven staff (35 ) had completed a National Vocational Qualification (NVQ) at level 2 or above in Care. At the time of the visit certificates were available for only five staff (25 ). A further six staff were working towards the award. Once the outstanding staff have completed the award and all staff have received their certificates, 10 of the staff (65 ) will have completed the qualification. Examination of the homes training records showed that progress had been made in supporting staff to complete mandatory in safe working practice topics. Gaps were noted for eight staff however these employees were new staff. The manager was advised to update the training matrix to include the dates of training completed by staff. Care Homes for Older People Page 24 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Dovehaven is being run in the best interest of the people using the service so that their welfare is promoted and protected. Evidence: Since the last visit a new manager had been appointed at Dovehaven. The manager (Mrs Carol Leddy) was registered with the Commission for Social Care Inspection during March 2009 and had previously been employed as the deputy manager of the home. Examination of records confirmed that the Registered Manager had completed the National Vocational Qualification level 4 Registered Managers Award and other training relevant to her role. The manager was able to demonstrate that she had undertaken periodic training and since the last visit had completed training in dementia, effective communication, death dying and bereavement, adult abuse, supervision, risk assessment for moving and handling and health and safety. It was noted that the Care Homes for Older People Page 25 of 31 Evidence: manager was in need of refresher training for first aid at the time of the visit. Staff and residents spoken with during the visit reported that they were pleased that Mrs Leddy had been appointed as the Registered Manager of Dovehaven and confirmed that she was a caring and approachable individual. Prior to the inspection an Annual Quality Assurance Assessment (AQAA) was completed by a senior manager on behalf of Mrs Leddy. The AQAA is a self-assessment tool that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information on the service. Overall, the document was completed to a satisfactory standard however the review dates of policies and procedures had not been included. Policies and procedures should therefore be reviewed to confirm they are up-to-date. The Registered Provider continued to commission an external consultant to undertake an annual quality assurance assessment. This was last completed during March 2009 and involved the distribution of survey forms to residents or their representatives during August 2008 and February 2009. The results of the surveys had been displayed in the reception area of the home for people to view. Meetings with residents were also organised periodically. The owner and junior partner continued to visit the home frequently. Both the owner and junior partner were observed to visit the home during the inspection and were spoken with as part of the inspection process. At the time of the visit the Registered Manager did not act as an appointee for any of the residents. The manager confirmed that all the residents looked after their financial affairs independently or with support from family members or solicitors. The organisations head office was responsible for invoicing and administering fees as noted at the last visit. The manager looked after the personal spending money for fifteen residents. Records checked were up-to-date, receipts had been obtained and balances were correct. The dataset part of the Annual Quality Assurance Assessment (AQAA) detailed that equipment within the home was regularly inspected and serviced. Service records for Portable Appliance Testing and Gas Safety were reviewed as the last recorded service / maintenance dates in the AQAA had recently exceeded 12 months. Furthermore service records pertaining to the maintenance of lifting equipment was reviewed as a requirement had been issued concerning this matter at the last inspection. Documentation was available to confirm all the equipment had been recently serviced. Care Homes for Older People Page 26 of 31 Evidence: Fire records were also examined. Records confirmed that the fire alarm system was tested on a weekly basis and the emergency lighting on a monthly basis. No records could be located to confirm visual inspections had been undertaken on the fire extinguishers. A certificate was in place to confirm the fire alarm system, extinguishers and emergency lights had been serviced. A fire risk assessment was available for reference however records of fire instruction training for day and night staff could be located. Training records confirmed good progress had been made in supporting staff to complete training in all the necessary Safe Working Practice topics. Care Homes for Older People Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 38 23 (2) (C) A certificate must be obtained to confirm lifting equipment used by the people in the home is safe and has been serviced in accordance with the Lifting Operations and Lifting Equipment Regulations. 15/06/2007 Care Homes for Older People Page 28 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Schedule 2 controlled drugs must be stored in a Controlled Drugs Cabinet. This will ensure medication is correctly stored in accordance with the Misuse of Drugs [Safe Custody] Regulations 1973. 20/06/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The Statement of Purpose and Service User Guide should be dated and updated to include details of the new Registered Manager, deputy manager and the name and contact details of the Care Quality Commission. This will ensure people have access to up-to-date information on the service. Reference to the National Care Standards Commission should be removed from Contracts to ensure people have the correct details of the current regulator. Information on ethnicity, weight, hearing and personal safety and risk should be included in the assessment tool and obtained as part of the assessment process to ensure Page 29 of 31 2 2 3 3 Care Homes for Older People an holistic assessment of needs. 4 7 The temperature of the fridge used to store medication should be monitored and recorded on a daily basis to ensure best practice. Care Plans should set out in more detail the action that needs to be taken by staff to ensure staff have access to comprehensive information on how the health, personal and social care needs of the service users are to be met. Medication policies and procedure should be kept under review and one main policy should be developed for staff to reference to ensure best practice. The balance of medication not received in blister packs should be brought forward and recorded on Medication Administration Records to provide a clear audit trail. The range of in-house and community based activities on offer should be kept under review in consultation with the people using the service, to ensure the recreational needs, expectations and preferences of the people using the service are met. Monthly visual inspections of the fire extinguishers should be undertaken and records maintained to monitor the condition of fire fighting equipment. Night staff should receive fire instruction training at least every three months and day staff at least every six months to ensure staff are aware of fire safety procedures as recommended by the fire service. 5 7 6 9 7 9 8 12 9 38 10 38 Care Homes for Older People Page 30 of 31 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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