Archived: Dovecote Manor

Dovecote Manor provides accommodation, personal care and support for up to 30 older people. There were 25 people accommodated at the time of the inspection.

People’s experience of using this service:

There was a positive atmosphere in the home which we found to be homily and well run. People living in the home interacted freely and staff were seen to be caring and supportive.

The assessment and planning of people’s care was individualised. We found care records that supported people were completed and reviewed with the person’s input.

Systems were in place to monitor medication so that people received their medicines safely.

We were given positive feedback from the people we spoke with who were living at Dovecote Manor. They told us they enjoyed living at the home and their quality of life was good. People said they were well cared for. People were listened to and had the support they needed to express their needs and wishes. People could make decisions and choices.

All the people we spoke with told us they felt safe and well supported. One person said, “The staff are excellent – efficient, considerate, knowledgeable and patient.” Another person commented, “The staff are very good and look after you well.”

The home was staffed appropriately and consistently. Staff could explain each person’s care needs and how they communicated these needs. People told us that staff had the skills and approach needed to ensure they were receiving the right care.

Care was organised, so any risks were assessed and plans put in place to maximise people’s independence whilst help ensure people’s safety.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported.

Arrangements were in place for checking the environment to ensure it was safe. We found the environment safe and well maintained.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed.

We saw people’s dietary needs were managed with reference to individual needs and choice. Meal times provided a good social occasion.

The registered manager could evidence a series of quality assurance processes and audits carried out internally and externally by staff and from visiting senior managers for the provider. These were effective in managing the home and were based on getting feedback from the people living there.

Rating at last inspection:

This service had previously been inspected in November 2016 and rated as good. The report was published on 21 December 2016.

Why we inspected:

This was a planned comprehensive inspection. There were no previous concerns about the service. The service continued to be rated as providing Good care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This was an unannounced inspection which took place on 16 November 2016. The service was last inspected in October 2015 and at that time we found breaches of regulations with respect to: People living in the home were not protected against the risks associated with unsafe or unsuitable premises because of inadequate safety equipment on staircases; people were not protected against the risks associated with security and confidentiality because records were not stored securely; quality assurance systems did not identify risks and omissions in care files and people’s personal preferences were not met.

Following the inspection the provider sent us an action plan which told us how the regulations would be met. This inspection was a comprehensive inspection, during which we reviewed the previous breaches. We found all of the breaches had been met and the home was operating safely.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found the home supported people to provide effective outcomes for their health and wellbeing. We saw there was effective referral and liaison with health care professionals when needed to support people.

We looked at how staff were recruited and the processes to ensure staff were suitable to work with vulnerable people. We saw required checks had been made to help ensure staff employed were ‘fit’ to work with vulnerable people.

We found there were sufficient staff on duty to meet people’s care needs.

Care was organised so any risks were assessed and plans put in place to maximise people’s independence whilst help ensure people’s safety.

We saw there were good systems in place to monitor medication safety and that nursing staff were supported with updates to help ensure their competency so that people received their medicines safely.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. Training records confirmed staff had undertaken safeguarding training. All of the staff we spoke with were clear about the need to report any concerns they had.

We made a recommendation regarding the induction training for staff. The provider needs to develop the induction training to include the ‘Care Certificate’ which is the governments blue print for ensuring effective induction for new care staff.

Arrangements were in place for checking the environment to ensure it was safe. For example, health and safety checks were completed on a regular basis so hazards could be identified. Planned development / maintenance was assessed and planned well so that people were living in a comfortable environment.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person’s mental capacity was made.

When necessary, referrals had been made to support people on a Deprivation of Liberty [DoLS] authorisation. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. The applications were being monitored by the registered manager of the home.

We saw people’s dietary needs were managed with reference to individual preferences and choice. Meal time was seen to be a relaxed and sociable occasion.

People we spoke with said they were happy living at Dovecote Manor. Staff interacted well with people living at the home and they showed a caring nature with appropriate interventions to support people. People told us their privacy was respected and staff were careful to ensure people’s dignity was maintained. Staff were able to explain each person’s care needs on an individual basis and how they communicated these needs.

People we spoke with and their relatives felt staff had the skills and approach needed to ensure people were receiving the right care.

People felt involved in their care and there was evidence in the care files to show how people had been included.

Social activities were organised in the home. People told us they could take part in a variety of social events which were held.

We saw a complaints procedure was in place and people, including relatives, we spoke with were aware of how they could complain. We saw there were good records of complaints made and the manager had provided a response to these.

The registered manager was able to evidence a range of quality assurance processes and audits carried out internally at the home. We found supporting management systems fractured and inconsistent but the standards in the service had been maintained and monitored well by the registered manager.

The registered manager was aware of their responsibility to notify us [The CQC] of any notifiable incidents in the home.

We spoke with six people living in the home and two relatives on the day of our visit. They spoke positively about the care provided and told us staff were 'attentive' and 'caring'.

The manager was identified as the appointed infection control lead for the home to ensure effective controls and checks were in place. The home carried out monthly audits regarding laundry, kitchen, room cleaning and infection control standards. We looked at the last two audits from June and July 2013 which indicated standards were being maintained.

People we spoke with told us that staffing levels were good and that they did not have to wait long for call bells to be answered if they needed assistance.

The home had accurate and up to date records related to the running of the home which assisted in maintaining a safe environment for people and staff to live and work in.