Care Home: Dovetail House Care Home

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What the care home does well Anyone new to the home is fully assessed to make sure their needs can be met before they move into the home. Staff are shown the assessments and care plans are prepared so that staff will be able to meet their needs straight away. Care plans are prepared in accordance with The Mental Capacity Act 2005. People are encouraged to make decisions they are assessed as being able to, so that they have some control over their lives. People have opportunities to take part in education and employment according to their abilities, so they can learn and develop new skills and are able to take part in activities and local community groups. People are able to keep in contact with their families and have personal relationships and their differing dietary needs are catered for. People receive personal support in a way that respects their privacy and dignity. They attend healthcare appointments and specialist services are used. There is a complaints procedure, which is available for people to use and there are policies and procedures for staff to follow if they suspect anyone is not being properly treated. The home is kept clean and well maintained. Staff know how to prevent the spread of infection. There are sufficient staff on duty and the correct recruitment procedures for appointing new staff are followed including carrying out the necessary checks. Staff are provided with the training they need to do their jobs. There is a suitably qualified and experienced manager in post. This ensures that the home is properly run in the best interest of people living in the home. Regular checks and tests are carried out on the building and equipment, including the fire alarm system to protect people`s health and safety. What has improved since the last inspection? When Medicine Administration Records have to be written out by hand the member of staff doing so signs these, and then witnessed by another member of staff to make sure that they are correct so no drug administration error can occur. All medication is stored safely, securely and under appropriate storage conditions to ensure that medication is not given which has deteriorated and to reduce the risks of misuse and mistakes. Medication is only be administered from containers that have been labelled by the community pharmacy or dispensing doctors according to the instructions on the prescription to ensure that medication is given correctly and safely What the care home could do better: Accurate records must be kept of all medicines administered, including the total of controlled drugs being held. CARE HOME ADULTS 18-65 Dovetail House Care Home Park Avenue Mansfield Nottinghamshire NG18 2AT Lead Inspector Stephen Benson Unannounced Inspection 16th September 2008 09:30 Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dovetail House Care Home Address Park Avenue Mansfield Nottinghamshire NG18 2AT 01623 420690 01623 420699 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) Step Forward (Nottingham) Limited Margaret Ann Webster Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Category of registration is to be Learning Disability which is specific to those who have acquired Brain Injury caused by Trauma or Illness Up to 3 beds allowed to be used for palliative care as a result of a neurological disorder. 17th April 2007 Date of last inspection Brief Description of the Service: Dovetail House is a care home providing personal care and accommodation for 16 younger adults who have a traumatic or acquired brain injury and includes 3 beds that can be used for palliative care. The home provides individual programmes detailing the care to be provided and can provide long or short term care, assessments and rehabilitation programmes. The home also offers a buddy system to support service users who have moved out of the home and those needing support within the community. A day care service is also available. The home is owned by Stepforward (Nottingham Ltd), which is run as a family business. The home is located in a residential area on the outskirts of Mansfield town centre and is close to shops, pubs, the post office and other amenities. The home was opened in 2003 and consists of a former domestic dwelling, which was previously run as a nursing home. The current providers refurbished the building following purchase and prior to opening. .All of the homes bedrooms are single and have en-suite facilities. Bedrooms are located on the ground, first and second floors all of which are served by a passenger lift. The home has good-sized gardens that are well maintained and easily accessible. There is a small car parking area to the front of the property and further parking is available on the road. The manager said on 16/09/08 that the fees for the service are £874 per week with additional charges from £15.17 per hour when one to one support is required. There are additional charges for chiropody, activities, toiletries and transport. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people accommodated and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This was our first visit to the home since 1st April 2008. This inspection involved one inspector; it was unannounced and took place in the daytime, including lunchtime. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed in June 2008. We sent survey forms entitled ‘Have your say about…’ to a sample of people and 3 of these were returned. The main method of inspection used is called ‘case tracking’ which involves looking at the quality of the care received by a number of people living at the home. We also use evidence from our observations; we speak with them about their experience of living at the home; we look at records and talk with staff about their understanding of the people’s needs who they support. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: Anyone new to the home is fully assessed to make sure their needs can be met before they move into the home. Staff are shown the assessments and care plans are prepared so that staff will be able to meet their needs straight away. Care plans are prepared in accordance with The Mental Capacity Act 2005. People are encouraged to make decisions they are assessed as being able to, so that they have some control over their lives. People have opportunities to take part in education and employment according to their abilities, so they can learn and develop new skills and are able to take part in activities and local community groups. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 6 People are able to keep in contact with their families and have personal relationships and their differing dietary needs are catered for. People receive personal support in a way that respects their privacy and dignity. They attend healthcare appointments and specialist services are used. There is a complaints procedure, which is available for people to use and there are policies and procedures for staff to follow if they suspect anyone is not being properly treated. The home is kept clean and well maintained. Staff know how to prevent the spread of infection. There are sufficient staff on duty and the correct recruitment procedures for appointing new staff are followed including carrying out the necessary checks. Staff are provided with the training they need to do their jobs. There is a suitably qualified and experienced manager in post. This ensures that the home is properly run in the best interest of people living in the home. Regular checks and tests are carried out on the building and equipment, including the fire alarm system to protect people’s health and safety. What has improved since the last inspection? What they could do better: 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 Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are fully assessed prior to moving into the home to ensure that their needs can be met. EVIDENCE: Information provided on The Annual Quality Assurance Assessment (AQAA) received in June 2008 stated that there have been 4 people admitted to the home in the last 12 months and there have not been any placement breakdowns. It was stated in the Annual Quality Assurance Assessment ‘We reflect at all times service user preferences and aspirations to empower and give opportunity for autonomy over their futures, having once identified risks or any restrictions that may need to be applied. This is done through discussion and with full participation from the service user.’ Anyone new wanting to come to the home is fully assessed prior to being admitted to ensure that their needs can be met. Assessments are obtained from the placing authority, which may be Social Services or Health Authority and those seen were dated prior to the resident moving to the home. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 10 The manager said that two members of the management team will go to assess any prospective new resident where they are currently staying. The home has their own assessment form to complete to help carry out the assessment. Copies of these assessments were seen on people’ files. If the person has Huntingdon’s Disease a Huntingdon’s Disease specialist nurse also joins in the assessment. Staff said they receive some basic information about people’s needs and their likes and dislikes before they move in so they have a good understanding of what support the person requires and how this should be provided whilst they then complete their own assessment. In our survey forms ‘Have your say’ One person said they received enough information about the home before they moved in so they could decide it was the right place for them and 2 said they did not. One person was asked if someone had come to see them before they moved into the home and said, “Yes” Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use 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 living in the home are involved in planning their care and their assessed needs and personal goals are reflected in their individual plan. People make decisions about their lives with assistance as needed and are supported to take risks as part of an independent lifestyle EVIDENCE: Care files were well-organised and broken down into sections and were indexed for ease of reference. They consisted of risk assessments, care plans and behavioural programmes. It was stated ion each care plan that all actions and decisions are made in accordance with the Mental Capacity Act 2005 – two stage test and best interest principals. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 12 The manager said reviewing plans in light of the Mental Capacity Act had been a major challenge to balance their rights and the treatment needed and had sought the advice of an Independent Mental Capacity Advocate (IMCA). In addition to assessments for activities of daily living there were risk assessments for drugs and alcohol, issues of health and medication, road safety and any risks posed to others. A member of staff was seen discussing a care file with one person and there was a note in care files for people who cannot read stating that care plans and risk assessments are read to the individual on a level they understand. The person said, “Staff often talk about what is in my care plan with me.” The manager said care plans are initially changed as they get to know the person and there is a six week review of them. After that, staff who have been assessed as competent to complete care plans, keep them under review and updated. A member of staff said that he now writes care plans as a designated keyworker having been assessed to be able to do so. A letter was seen from a social worker which included, ‘I have observed that the staff I have dealt with had a good understanding of the importance of good and effective care and support plans with attention to detail and also that they demonstrate a person centred approach.’ In another letter a specialist mental health assessor wrote, ‘Dovetail has implemented, formulated and regularly evaluated appropriate care plans for the service user that I have been involved in. These have been based around their needs and have been holistic in nature.’ The manager said that people are encouraged to make decisions through their care plans and have access to advocates if wanted. There are some areas where people, can make full choices, however there are often restrictions that need to be taken into consideration, for example going out is dependent upon an assessment to their and others safety and smoking regimes are used to help people spread out their cigarettes according to their ability to buy them, so they don’t smoke them all straight away. Staff spoke of accommodating wishes of people and gave the example of organising trips to the theatre for one person who likes to go there. In our survey forms ‘Have your say’ all 3 people said they do what they want during the day, evening and at weekends. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 13 One person had been out shopping and showed some shoes she had bought which she said she had chosen herself. She also chose to purchase from the book club who visits the home. The manager said people are able to take risks where they do not have a detrimental effect upon others or it is not seen to be in their best interests, for example one person tries to eat cigarette ends and is prevented from doing so as far as possible. It was stated in the Annual Quality Assurance Assessment, ‘Service users are encouraged to take control and are supported to take responsible risks.’ There were practices seen to reduce risks to others, such as staggered mealtimes due to some unpredictable behaviour. One person said, “I wouldn’t be very good going out if I didn’t have staff with me.” The manager was seen having a discussion with one person who had left the building without telling staff the previous day. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use 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 decide how they spend their time and make us of the local facilities. People are able to maintain family contact and enter into personal relationships. Their rights are respected and they enjoy their meals and mealtimes EVIDENCE: It was stated in the Annual Quality Assurance Assessment, ‘We work to develop the best outcomes for all our service users through the rehabilitation process which are written into care plans therefore are on an individual basis.’ One person was getting ready to go off to work at a catering project. The person said, “I love my job, I go Mondays, Wednesdays and Fridays, they are really good to me.” Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 15 There is an activities and appointments board in the corridor listing what is happening for the coming week. This included trips out of the home, doing food shopping and preparing meals. The manager said people who are able are supported to find employment or attend a college course. Other people have individual programmes in line with their abilities. Staff said one person had recently given up their job and was looking for another one. Another person was at college today having an assessment for a course they want to do. In a letter sent to the home from a catering project it stated, ‘The overall view we have observed is that the home endeavour to meet the social requirements for each individual.’ One person said, “I did a bricklaying course at college.” The manager said that people are supported to use as many community resources as they wish and people go to the theatre, cinema, discos, pubs, restaurants, hairdressers and swimming pool. Also some people have manicures and massages and attend a women’s group. Everyone has been able to choose a day trip they wanted to go on over the summer and one person was supported and accompanied by staff to go on holiday with her children. Staff said that some people enjoy going to a local gym for a workout. One person said, “I enjoy going out to play snooker” and another said, “I’ve been out to have my hair cut. There was information seen in care files about people’s family and the contact they have with them. People were heard discussing with staff about their families, one was talking about a forthcoming visit and another about buying Christmas presents. The manager said that people usually arrange their own contact with their families, but staff will try to get them to avoid any commitments they have, such as work. Staff said two people go to stay with families at weekends and others come to visit in the home. People can use the payphone to make and receive calls. There are some people who have a mobile phone. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 16 In our survey forms ‘Have your say’ One person wrote, ‘I visit my mum every weekend.’ One person said, “I have a boyfriend, we like to be together.” There are a number of different dietary needs amongst people living in the home and different meals were seen prepared to accommodate this. This included a gluten free diet, soft diet and food easy to swallow. There is a 4 week menu which includes a healthy option dish. The main meal is at lunchtime and dishes include fish in parsley sauce, chilli con carne, sausage and mash with onion gravy. There is a different type of fish on Fridays and a roast dinner on Sundays. A lighter meal is had at tea time with things like jacket potato or ‘something’ on toast. Staff were seen serving lunch in a manner appropriate to each person. One person was reluctant to eat so the meal was taken back to the kitchen to be offered again in a little while, which staff said was not unusual and the person would eat it when he was ready. One person said, “The food is marvellous, we get a choice and have plenty.” Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use 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 receive personal support in the way they prefer and require in order to meet their physical and emotional needs. EVIDENCE: It was stated in the Annual Quality Assurance Assessment, ‘We support service user in the way they prefer and required.’ The manager said that personal care is provided by following the appropriate care plan. This will include any gender preferences, bathing choices and how many staff are required to assist. Staff said that the amount of personal care they provide varies according to each person’s ability. It is essential that staff read care plans before they start to give any personal care so they know what people like and how. Care plans seen for personal care provided this information. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 18 One person said, “Staff remind me of the things I have to do, I have Korsakoff’s so would forget if they didn’t. Care files seen referred to a variety of healthcare professionals being involved with people. The manager spoke of accessing services through the doctor In a letter sent to the home from a local medical practice it said there was ‘an excellent working relationship’ and ‘any visit is always expected and well planned for.’ In another letter from the Nottingham Traumatic Brain Injury Service it said, ‘Attitudes of staff and management are to be commended.’ But also said, ‘on several occasions no communication records were forthcoming.’ One person said, “I’ve got glasses now, I had my eyes tested last year. It was stated in the Annual Quality Assurance Assessment, ‘After our last CSCI inspection regarding safe handling of medication all safety measures to ensure no mistakes were made are in place including a new procedure of laminating medication sheets, with information regarding contra indications for service user specific medication.’ Only senior staff who have been trained in medicine administration, and have been assessed as being competent of doing so by the manager are allowed to give out medication. The member of staff doing so wears a red tabard saying they are not to be disturbed whilst giving out medication, so they can concentrate on the task without being distracted. Staff said they are not allowed to be disturbed when giving out medication and that they stay with people until they have taken their medication. Medicine Administration Records were seen and these were fully completed. These included laminated sheets with information about each medicine, dosage and side effects. The records for controlled drugs were seen and there were some recording errors identified that had not been properly corrected. The senior team leader arranged for staff involved to be provided with further training medication recording. A notification under Regulation 37 (Care Homes Regulations 2002) was sent to us informing us of a medication error in August 2008. The manager described how this was responded to and that the member of staff had been put through the medication training again. There were no adverse effects to people as a result of this. A person said, “they bring me my tablets and make sure I take them.” Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use 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’s views are listened to and acted upon and they are protected from abuse and self harm. EVIDENCE: Information provided on The Annual Quality Assurance Assessment showed that there have been 5 complaints made in the last 12 months. It was stated in the Annual Quality Assurance Assessment that ‘Service users are encouraged to air their views and these are documented and acted on’ and ‘all service users have copies of complaints procedure.’ There have been a number of anonymous complaints made about the home since the last key inspection in April 2007. Some of these were referred back to the provider to investigate and others were looked at as part of random inspections on 16/08/07 and 19/10/07. The complaints record contained details of all the complaints and investigations carried out apart from one, which could not be found. The outcome of these was they were not substantiated apart from one, about the deployment of staff. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 20 A further complaint was received by us and referred to the provider on 26th August 2008, which the provider is currently investigating. The manager said it had been quite demoralising having to deal with the anonymous complaints and believed there was an alternative motive for these. Staff were aware of the complaints procedure and said it was displayed outside the office, where it was seen to be. In our survey forms ‘Have your say’ 3 people said they knew who to speak to if they were not happy. One wrote ‘If I am not happy I speak to Maggie (the manager).’ One person said, “I’ve not had any complaints, I would go to the gaffer if I did” Information provided on The Annual Quality Assurance Assessment showed that there had been 1 safeguarding referrals made and 1 safeguarding investigations have taken place. There has been 1 referrals made to the Protection of Vulnerable Adults list. A further safeguarding adults investigation has commenced since the Annual Quality Assurance Assessment was received. It was stated in the Annual Quality Assurance Assessment that, ‘Majority of staff have been trained in the protection of vulnerable adults procedures and this is ongoing as training courses become available. In house training is also provided.’ There are some people who have a support strap used to control their body movements when helping them to eat. This affects people with Huntingdon’s Disease and one person with autism. This is only done with appropriate professional agreement and was seen included within their care plan. The records seen showed an Independent Mental Capacity Advocate (IMCA) had been involved in devising the plan. The manager showed the Nottingham and Nottinghamshire Safeguarding Adults Policy, Procedure and Guidance for Alerters and Referrers and there is a whistleblowing policy in the policy and procedures file. In our survey forms ‘Have your say’ 3 people said they are treated well be staff. One person said, “I feel quite safe here”. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use 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 live in a homely, comfortable and safe environment, which is kept clean and hygienic. EVIDENCE: A maintenance man is employed to carry out any minor repairs and there is a maintenance book to record any repairs that need doing. All areas of the home are accessible to wheelchair users. All areas of the home were clean, tidy, suitably furnished and well maintained. A handrail has been added by the rear steps to make it easier for people to access the garden. Staff said that building was easily accessible and they were able to carry out their duties without any difficulty. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 22 One person said, “I keep my room clean and tidy”. Information provided on The Annual Quality Assurance Assessment stated that there is a policy at the home for preventing infection and managing infection control. There is a red bag system in place for dealing with soiled laundry and protective clothing is provided. There is a washing machine provided for those who are able, to do their own laundry. Staff said they are due to have training on infection control and always use protective clothing when needed. There are gel hand washes located around the home. In our survey forms ‘Have your say’ 2 people said the home is always fresh and clean and 1 said it sometimes is. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use 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 are supported by competent and qualified staff and supported and protected by the home’s recruitment policy and practices. People’s individual and joint needs are met by appropriately trained staff. EVIDENCE: Information provided on The Annual Quality Assurance Assessment showed that there are 27 care staff and a further 9 support staff employed. Ten care staff have left the home in the last 12 months. There have not been any shifts covered by agency staff in the past three months. It was stated in the Annual Quality Assurance Assessment that ‘We continually assess staffing to ensure safe levels and increase as and when necessary, this may be to ensure appointments / leisure time is optimised and that safety is a priority.’ The senior team leader said she has assessed the current staffing levels to be 7 care staff on in the morning, 5 in the afternoon and 3 at night during the Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 24 week and 6 care staff on during the ay at weekends. The rota showed this level of staffing is provided. Staff said they felt there are enough people on duty and if someone calls in sick they try to arrange cover. One person said, “I think there are enough staff on duty”. Information provided on The Annual Quality Assurance Assessment showed that there are 21 care staff who have National Vocational Qualification level 2 or above and a further 7 working towards one of these. A member of staff said he had National Vocational Qualification level 3. It was recorded on The Annual Quality Assurance Assessment that all people who have worked in the home in the past 12 months had satisfactory pre employment checks. Staff files seen showed that the correct recruitment practices are followed. The home follows their equal opportunities policy in the recruitment of new staff. The general manager showed the staff training records and these showed that staff have either received or are planned to receive the required training. Information provided on The Annual Quality Assurance Assessment stated that a staff induction is provided for new staff and that the home has a staff development programme appropriate for the service they provide. Staff said that they have regular training provided Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a well run home and their views are sought. People’s health, safety and welfare are promoted and protected. EVIDENCE: The manager has appropriate experience for her position and has achieved National Vocational Qualification level 4 in care and management. Day to day management of the home is shared out amongst the management team. In a letter sent to the home by a social worker it said, ’I have observed staff members engaging with the manager and it is clear that the manager has everyday involvement in all aspects of care at the home.’ Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 26 Staff said that they thought the home was well run. People living in the home were seen talking with the manager in a relaxed manner. It was stated in the Annual Quality Assurance Assessment that, ‘To comply with the new mental capacity act, the Manager has attended a course already and is a member of the work stream group for the implementation of Deprivation. Senior members of the team are attending training sessions on both IMCA (Independent Mental Capacity Advocate) and DOL (Deprivation of Liberty) in July 2008. In additional IMCA training was conducted to staff last year by a representative of IMCA last year.’ Letters are sent out periodically seeking the views of other professionals and families about the home. Staff said keyworkers did a survey not long ago, however these were not seen due to time constraints and the manager being involved in another meeting. The manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. It was stated on the Annual Quality Assurance Assessment that equipment is tested or serviced as recommended by the manufacturers or other regulatory body. A sample of these were looked at and found to be correct. It was also stated that there are written assessments on hazardous substances. An inspection of the lift highlighted some essential work that was needed and this has been carried out. Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 4 X X 3 X Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 (2) Requirement Timescale for action 20/09/08 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 Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dovetail House Care Home DS0000043884.V372121.R02.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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