Care Home: Dover Cottage Rest Home

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What the care home does well Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 People who use the service are supported by the staff team who were observed to be committed to meeting the individual’s needs. The service continues to be upgraded with new carpets, matching curtains were to be delivered. We spoke where possible and observed other peoples body language. Comments made were positive about the staff and meals. ‘I have enjoyed my fish and chips’, ‘I am happy or mum to stay at the home she is well looked after’, I can honestly say there is nobody here that I don’t like’. What has improved since the last inspection? New carpet had been fitted in the two lounges and the corridor off the main entrance. New dining room tables have been purchased. The kitchen has been refitted including new white goods and a larger cooker. Both lounges and the dining room have been decorated the areas have been lifted with the choice of a light colour on the walls. A new housekeeper has been employed. The main bathroom has been decorated. Some bedrooms have been decorated since the previous inspection. What the care home could do better: During this inspection there were a number of areas that the management has failed to accomplish including reviewing documents and implementing documents relevant to the running of the service and meeting the National Minimum Standards.Dover Cottage Rest HomeDS0000004934.V375231.R01.S.doc Version 5.2 We had received the AQAA within the timescale required; the content and details were meagre and did not provide information in sufficient detail. This was part of our inspection discussions with the manager. The service users guide was not current it contained a report document dated from 2003. The Statement of Purpose needs to be reviewed to ensure that all the relevant information was contained in the document and made available at all times. Care plans need to reflect and ensure that the needs of individuals were recorded including risk assessments. Staffs were working from their knowledge of individuals and not from the care plans which were poor in their content. There was no written evidence on file of correspondence to confirm acceptance of the placement. When we looked around the premises we found that one room on the ground floor had a strong odour. It would appear that the odour was emitting from the carpet. We were satisfied that all attempts had been made to control the odour. Consideration should be given to replacing the carpet to benefit the life style of the person using the service. The times people choose to rise needs to be reviewed with care plans to ensure that individuals are not assisted to rise just because they are incontinent, that is their choice to rise at that time. The provider needs to provide a medical fridge and an approved controlled metal drugs cupboard. Medication not required or stopped should be returned to the pharmacy. No unnecessary non medication items should be stored in the medication trolley. The AQAA told us that the service had a record of activities, the record was not current and the service could not provide written evidence of activities. We were told that a new activity co-ordinator was to commence. The complaints process displayed in the entrance hall needs to be reviewed to reflect the current Care Quality Commission details. Staff files seen during the inspection were incomplete; this could put people using the service at risk. Staff supervision had not been recorded since 2008. The management needs to ensure that the staffs are supported in their training and roles of care. We were unable to evidence current staff training records.Dover Cottage Rest HomeDS0000004934.V375231.R01.S.doc Version 5.2 Page 8The service needs to review the fire contingency programme, and to ensure that the fire risk assessment was available to the commission. Key inspection report CARE HOMES FOR OLDER PEOPLE Dover Cottage Rest Home Dover Farm Close Stoneydelph Tamworth Staffordshire B77 4AP Lead Inspector Wendy Grainger Unannounced Inspection 5th May 2009 07:00 DS0000004934.V375231.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dover Cottage Rest Home Address Dover Farm Close Stoneydelph Tamworth Staffordshire B77 4AP 01827 331116 01827 261569 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) Dr Rais Ahmed Rajput Mrs Elsa Lille Badger Care Home 15 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (15) of places Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provided 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 (OP) 15 Dementia (DE) 15 The maximum number of service users who can be accommodated is: 15 29th July 2008 2. Date of last inspection Brief Description of the Service: Dover Cottage provides accommodation and personal care to fifteen older people who have a primary diagnosis of dementia. The service is located on a residential estate on the outskirts of Tamworth. It is not within walking distance of any major shops. Public transport is available at the end of the main road. The service is situated at the end of a cul-de-sac. It has a small parking area at the front. The main door is located at the rear of the building. The service’s Statement of Purpose and Service users Guide documents provide some information and include the current weekly fee rates, which range from £388 to £398. These fee rates applied at the time of our inspection the reader may wish to obtain more up to date information from the care service. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means that people who use the service experience adequate quality outcomes. One inspector carried out this unannounced inspection on one day between 07:00am and 16:00 hours. The service completed an Annual Quality Assurance Assessment (AQAA). This is a self assessment tool, which was used as part of this key inspection. The completion of the AQAA is a legal requirement and it enables us to see how well the service focuses on the outcomes for people to make sure that their needs are being met. The AQAA also gives us some numerical information about the service. We had requested ‘Have your say’ surveys to obtain further feedback from the staff and people using the service. We collected them during the inspection. We observed and spoke to people and staff during the inspection. Surveys told us ‘I am happy to be here made a few friends’, ‘ Nice food, looked after, loved and cared for’, ‘ I would like to go out more’, ‘Nice and clean, whatever I ask them to do they will do it for me’, ‘Nice meals, they look after me’, Just comfortable and always have a laugh and joke’. Comments what the service could do better included: ‘Make sure the carers have proper time off work so they could look after us’, ‘I don’t know how to make a complaint’, ‘I would like to go out more’, We spoke to people about what it was to live at the service we were told ‘Elsa is very good’, ‘The meals are good’, and ‘The girls know what I want’. We observed the staff especially in the morning and their interaction with the people using the service. We looked around the premises to see the standards and comfort and safety for the people and staff. We looked at the menus and the kitchen area to assess their standard in terms of meeting peoples’ needs. What the service does well: Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 6 People who use the service are supported by the staff team who were observed to be committed to meeting the individual’s needs. The service continues to be upgraded with new carpets, matching curtains were to be delivered. We spoke where possible and observed other peoples body language. Comments made were positive about the staff and meals. ‘I have enjoyed my fish and chips’, ‘I am happy or mum to stay at the home she is well looked after’, I can honestly say there is nobody here that I don’t like’. What has improved since the last inspection? What they could do better: During this inspection there were a number of areas that the management has failed to accomplish including reviewing documents and implementing documents relevant to the running of the service and meeting the National Minimum Standards. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 7 We had received the AQAA within the timescale required; the content and details were meagre and did not provide information in sufficient detail. This was part of our inspection discussions with the manager. The service users guide was not current it contained a report document dated from 2003. The Statement of Purpose needs to be reviewed to ensure that all the relevant information was contained in the document and made available at all times. Care plans need to reflect and ensure that the needs of individuals were recorded including risk assessments. Staffs were working from their knowledge of individuals and not from the care plans which were poor in their content. There was no written evidence on file of correspondence to confirm acceptance of the placement. When we looked around the premises we found that one room on the ground floor had a strong odour. It would appear that the odour was emitting from the carpet. We were satisfied that all attempts had been made to control the odour. Consideration should be given to replacing the carpet to benefit the life style of the person using the service. The times people choose to rise needs to be reviewed with care plans to ensure that individuals are not assisted to rise just because they are incontinent, that is their choice to rise at that time. The provider needs to provide a medical fridge and an approved controlled metal drugs cupboard. Medication not required or stopped should be returned to the pharmacy. No unnecessary non medication items should be stored in the medication trolley. The AQAA told us that the service had a record of activities, the record was not current and the service could not provide written evidence of activities. We were told that a new activity co-ordinator was to commence. The complaints process displayed in the entrance hall needs to be reviewed to reflect the current Care Quality Commission details. Staff files seen during the inspection were incomplete; this could put people using the service at risk. Staff supervision had not been recorded since 2008. The management needs to ensure that the staffs are supported in their training and roles of care. We were unable to evidence current staff training records. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 8 The service needs to review the fire contingency programme, and to ensure that the fire risk assessment was available to the commission. 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 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. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 9 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 Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3,6. People using the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, and a visit to this service. People using the service were not always provided with information to enable them to make a decision about the service and how it can meet their needs. EVIDENCE: We were told in the AQAA that individuals who choose to move into the service receive an assessment prior to admission to ensure that the service can meet their needs. This was evidenced in one of the care plans seen during the inspection. We were unable to evidence written confirmation following the assessment to confirm that the service could meet the person needs. The AQAA told us that people receive information about the service. We evidenced the Statement of Purpose displayed in the hallway; details need to Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 11 be reviewed to ensure that they are current. The Service users guide was incomplete, information was not current and did not provide the relevant information required enabling people to understand what is available and their needs can be met. This service does not provide intermediate care. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. While the outcome for people using the service is satisfactory, written information regarding health and personal needs would give people greater confidence that their ongoing needs will be met if it were better completed. EVIDENCE: The AQAA told us that each person had a detailed care plan for their health and personal needs which is reviewed on a monthly basis and updated as necessary. We evidenced two care plans one being the most recent admission. The content of the plan was poor. There was no evidence of a risk assessment for Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 13 action to be taken for a recorded allergy, no social care, no action recorded in the event of a medical condition that the person may experience. The daily reports by the staff were informative and detailed where this persons medical condition had been evidenced. The second care plan for a person who had resided at the service for some time contained more details of their care and needs. We were concerned that no risk assessments were in place in the event choking and bedrails which were in place. We evidenced from the review for this person and with the family that ‘I am happy for mum to stay at the home she is well looked after’. We were concerned when entering the service the number of people (nine) in the lounge/dining room at 7am, we were told that it was the individuals who were incontinent and restless who were assisted. The first care plan clearly told us that the person rises and 6:30 given a cup of tea and then likes to go back to bed until 8am. This was one of the people observed to be in the lounge. Arrangements were in place and evidenced in the records for the continued health care from other professional agencies. Staff were seen to interact with the people using the service during the inspection. They were friendly, assisted when necessary; staff took time to assist people to complete the ‘Have your say’ surveys this was done with banter obtaining the opinions of certain people. Staff were aware of the needs of the individuals; they were working from knowledge and not from the collated information in the plans. The AQAA told us that staff had received training in the administration and safe handling of medication. The administration of the breakfast medication was observed, staff were advised not to take open pots to the person but to take the container. Records for administration were satisfactory. A number of non medical items were removed from the medication trolley and we advised that these should be stored else where. Medication no longer prescribed should be returned to the pharmacist. A small pipette used for olive oil had been left in a cup of water; this was being used for two people using the service. It is poor practice to use one pipette for two people and not individually as medication could be contaminated and then be a risk to these people. Dover Cottage Rest Home DS0000004934.V375231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,14,15 People using the 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 using the service are supported in their daily routines and encouraged to maintain contact with family and friends. Meals provided are appropriate to peoples needs. EVIDENCE: The AQAA told us that the service offers a range of in- house activities on a regular basis and that they had documentation and photographic evidence to show us. We did evidence that there had been no records of activities recorded since 2008. We did see staff involved with people in the lounge, spending time with them and talking to them. We were told that the service has approached a member of the staff team to be the activity co-ordinator and will commence in the near future. We were told by the staff that twice in February 2009 people from the Princes’ trust had visited the service and some people had planted Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 15 bulbs, decorated pots and spent time in the service. Evidence in the ‘Have your say’ surveys told us ‘I would like to go out more’, ‘nice meals’. The meal on the day of the inspection was from the local chip shop this occurs once a month. The menus remain unchanged. This week ( two according to the menus) people are offered fish five times over seven days which may not be satisfactory to some, this was pointed out to the manager and cook who changed the tea time meal due the change of the lunch today. The catering staff was aware of the needs of the people using the service, preparing diabetic and a soft diet with thickeners. We were told by two people ‘I have enjoyed my lunch’, ‘ I always get enough’. The kitchen has been refurbished since the last inspection, with new cupboards, large cooker, and white goods. The catering staff told us that she was undertaking the National Vocational Qualification level 3 in care to help support the care staff. Dover Cottage Rest Home DS0000004934.V375231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18. People using the 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 who use the service are able to make a complaint and are supported by the staff team. EVIDENCE: The AQAA told us the service continues to make sure the complaints standards are met and no improvement is needed. We were told that the service had received one complaint since our last inspection. This had been a problem with the main entrance and the five bard gate, and has been addressed. The complaints process is displayed in the hallway, but it needs reviewing to provide the current details of the new Commission. There have been no referrals to the safeguarding team or to us since the last inspection. The manager was advised to incorporate more information in the records if formal complaints were received. Two of the three ‘Have your say’ survey told us they would know how to make a complaint the third person did not. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 17 Staff confirmed in the completed ‘Have your say’ surveys that they were aware of the complaints procedure to implement on behalf of the people using the service and personally. Dover Cottage Rest Home DS0000004934.V375231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26. People using the 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 people who use the service are provided with a warm, clean and comfortable environment. EVIDENCE: The AQAA told us that the service is maintained to a good standard and with the exception of one bedroom free from odours. The service provides a safe, comfortable environment. People using the service are encouraged to personalise their bedrooms. This was evidenced when we looked at the premises. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 19 Following our last inspection the provider has arranged for the lounges/dining room and some bedrooms to be decorated. The lounges and dining room have been re-carpeted. New dining tables have been purchased. The size and shape of the rooms help to make mealtimes a more social event. The recent decoration has improved these areas, which are now bright and give the appearance of being spacious. We looked around the premises and found that the AQAA was accurate. One room we found to have an odour we suggested that consideration for a new type of floor covering may assist the housekeeping staff. The environment was a credit to the house keeper on duty. Externally there is limited space for the people using the service to relax in the rear garden due to its unsuitability. One of the completed ‘Have your say’ surveys felt that ‘If the garden was landscaped it would benefit the people’. Located at the end of a cul-de-sac the service is secure and stands in its own grounds. Dover Cottage Rest Home DS0000004934.V375231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A committed staff team support the people who use the service while ensuring their needs are me but people could be at risk by the required documents and training not being available. EVIDENCE: We were told in the AQAA that’ staff are trained to ensure they are competent, induction training CRB and POVA checks and references are taken up prior to employment. We were told that we can evidence this statement from the records. Recently the service has employed a new housekeeper and a tea time person’. We observed and heard staff on duty assist the people using the service with the ‘Have your surveys’ this was done with light banter for all. Staff were observed to assist one person with their meals in a sensitive manner. We were told during the inspection by people using the service that ‘I am happy here I have made friends’, ‘ I don’t think there is nobody I don’t like’, ‘ I Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 21 am looked after very well’, ‘ They should have more time off to look after us, I would like to go out more’. We were told that the manager has plans to employ a deputy, to assist her with the paperwork. The training records were not current and did not give a full picture of the skills of the staff. We were told by the manager that she was aware of this and had planned to address this. We evidenced from the records that a number of mandatory training practices were out of date this included : Moving & Handling, First Aid, Fire, Food & Hygiene, we were told by the manger that she was waiting for dates for the training. Records evidenced that staff and this was confirmed by the staff, that the safe handling of medication had been undertaken. We discussed with the manager the need to explore other training relevant to the services category, including the mental capacity act, Deprivation of Liberty Safeguarding, nutrition in the elderly and infection control. A number of the staff team have achieved the National Vocational Qualification (NVQ) levels 2 and 3 other staff have signed up for or are in the process of completing the training. We were told in the AQAA that ‘Criminal Record Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) and references were taken up prior to employment’. We were provided with two staff records chosen by the manager. One file was incomplete with no references, a part completed induction programme, a part completed application form, there was no start dates, no training records no job description or contract or photograph. The other file only had one reference and it was observed that the names provided on the application form for references were not the people the service approached. There was however a number of training certificates on file. The manager did have the opportunity to find documents for both of these staff without success on the day. Both people did have a Criminal Records Bureau (CRB) and a protection of Vulnerable Adults ( POVA) list check. The system used for the retention of staff files was disorganized and would benefit from a review to ensure all the required documents were together. To ensure that vulnerable people who use the service are properly protected better recruitment processes are needed. Dover Cottage Rest Home DS0000004934.V375231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31.33,35,38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care people may receive might be compromised by insufficient quality assurance systems and records to promote good outcomes for people who use the service. EVIDENCE: Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 23 We were told in the AQAA that ‘we manage the home well with people’s interest being important’ ‘record keeping policies and procedures ensure the welfare of the people are met’. The completed AQAA had only minimal information in parts of the document, there appeared to be a lack of understanding of the purpose of the AQAA. Areas were only adequately completed and did not give us a reliable picture of the service. More work is required by the manager to ensure that staff were aware through training the manner in which the service needed to move forward. We were provided with evidence in records that supervision was last completed in 2008, this was confirmed by the manager. It is important that staff receive regular supervision to discuss their training requirements and their care practices to promote safeguarding for all the people using the service. The manager has been in the caring profession for a number of years she has achieved the Registered Mangers Award and is in the process of doing NVQ level 4. The service does not maintain finances for the people using the service. During the inspection we found evidence to show that recruitment processes are not as robust or safe as they should be to make sure that the vulnerable people using this service are properly safeguarded. We evidenced from the records that the fire records for testing and fire drills were current. The home since the last inspection has failed to complete a contingency plan in the event of an emergency. The manager had not followed up a suggestion made on the last inspection to have flash cards for the hearing impaired people who may have a problem hearing the bells at night. The manager was unable to find the annual fire risk assessment. We were provided with certificates confirming that the lift, hoists, gas and electric circuits have been serviced and found satisfactory. Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 24 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X N/A 2 2 3 Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 Requirement The registered person shall ensure that peoples health and welfare needs are met by staff from a written plan The registered person shall ensure that recruitment information required is collated and current; failure to do this could put people using the service at risk. The registered person shall ensure that staff employed to work at the home receive appropriate training as referred to in the report to make sure that they are fully able to meet the needs of people who use the service Timescale for action 10/06/09 2 OP29 19 10/06/09 3 OP30 18 10/06/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 26 1 2. 3 OP1 OP7 The registered person shall produce a written service users guide and provide to all the people who use the service with the guide. It is recommended that each persons plan is reviewed ensuring the rising and retiring times are accurate. The provider is required within the next three months to provide a medical fridge and a controlled metal drugs cupboard Medication no longer required should be returned to the local pharmacy. Non medical items should not be stored in the medication trolley. The registered person should maintain a record of the interests and activities on a daily basis. To prevent risk and make sure that people are safe development of the annual fire risk assessment is needed as are contingency plans in the event of an emergency. The details of the commission should be current and displayed in documents To consider replacing the carpet in the room referred to in the report. The registered person should ensure that staff employed to work at the home receive appropriate training as referred to in the report to make sure that they are fully able to meet the needs of people who use the service The registered person shall undertake supervision of the staff at regular intervals, ensuring that individuals are supported in their training and roles of care. OP9 4 OP9 5. 6. OP12 OP38 7 8 9 OP16 OP26 OP30 10 OP36 Dover Cottage Rest Home DS0000004934.V375231.R01.S.doc Version 5.2 Page 27 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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