Inspection on 05/03/08 for Davers Court

This is the latest available inspection report for this service, carried out on 5th March 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Davers Court 20/02/06

Davers Court 27/09/05

Davers Court 06/01/05

Davers Court 08/09/04

Davers Court 22/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Davers Court Shakers Lane Bury St Edmunds Suffolk IP32 7BN Lead Inspector Mary Jeffries Unannounced Inspection 5th March 2008 09:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Davers Court Address Shakers Lane Bury St Edmunds Suffolk IP32 7BN 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) 01284 352590 01284 352589 Mary.Lambert@socserv.suffolkcc.gov.uk Suffolk County Council Mrs Mary Elizabeth Lambert Care Home 34 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (19) of places Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 Brief Description of the Service: Davers Court is a purpose built home for older people, situated in a quiet road not far from the centre of Bury St Edmunds in Suffolk. It is a single storey building laid out around a central courtyard and has been completely refurbished and adapted to a high standard to provide care for up to 34 residents. All residents who live at the home have their own spacious bedroom, with en suite shower and toilet. The home is divided into four ‘houses’. Rosewood caters for frail older persons. Rowanwood and Pinewood accommodate older persons who have a diagnosis of dementia and consequently have a high level of dependency. Sandalwood and Barnham are designated for short-term rehabilitation and transitional care. Rehabilitation care is for residents who need a six week fixed period of care to equip them to return home. Transitional care is for residents who need care for a temporary, but unspecified length of time to consider whether a home care package, residential care or returning home is the right option for them. Davers Court is owned and managed by Suffolk County Council. Davers Court DS0000037636.V360915.R01.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 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. The inspection was undertaken by one inspector; where the inspector’s activities are described in the text the term “We” is used to describe the inspector, as a representative of the commission. An annual quality assurance assessment (AQAA) was sent to us by the service. Surveys were sent to the home for 12 residents and 12 staff members; five residents and four members of staff returned surveys. The inspection took place on one morning in afternoon in March 2008. The duty manager facilitated the inspection, and other staff participated. The Manager was telephoned afterwards to clarify some matters. Three residents were tracked, one of these was accommodated in Barnham, and had been admitted for rehabilitation, two residents tracked had special needs and lived on Rowan wood and Pinewood respectively. One of these residents had been recently admitted; the records of another resident who had been recently admitted were also inspected. Two other frail elderly residents were spoken with, together, in some detail about life in the home. A District Nurse and a nurse who works for the local intermediate care team who were visiting the home on this occasion were both spoken with individually. Files of the two members of staff recruited in the last year were inspected, and the training record of these and another member of staff were inspected. A number of documents were examined including the homes Statement of Purpose and Service User Guide, residents’ care plans, medication records, training records and records relating to health and safety. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Service User Guide requires some further information to be included, so that prospective residents have all of the information they are entitled to before making a decision to live at the home. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 7 The home consults people by talking with them and involving them. They would benefit from undertaking a survey, and this is now underway. The open atmosphere in the home means that established residents are confident to raise any queries and that they will be taken seriously and listened to. New residents may not initially have this confidence, so it is important that the home checks that they can, if at all possible, read any written information given to them, including the Service User Guide and their care plan. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. Quality in this outcome area is good. Residents can be assured that an appropriate assessment of their needs will be undertaken prior to admission, to ensure that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All five residents who returned a survey stated that they received enough information about the home before they moved in to enable them to decide if it was the right place for them. The AQAA stated that the Statement of Purpose had been updated. The document was on display in the home’s reception. The manager confirmed following the inspection, that the only changes were in the layout and format, and that there are no material changes to the content. The AQAA stated that the Service User’s Guide (SUG) had been updated into a user-friendlier format. A copy was available in all of the residents’ rooms. The SUG was an A3 document. Following the inspection we discussed the size of Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 10 document with the manager, as the print font was mainly in scale 12, which is difficult for those with deteriorating eyesight to read. The manager advised that a carer goes through the document with residents following admission and a larger print document can be run off the computer if it is required. The Service User Guide contained most of the information required, but did not included a breakdown of charges and payment arrangements as is now required. Residents also had a copy of a document entitled,” A guide to charges for care in Suffolk.” This gives the total fee, which is currently £359.00 per week, but does not include the arrangements for payment, how additional items are paid for or whether privately funded residents- who are sometimes admitted, have the same fee. All four of the residents’ records inspected, including those for the two recently admitted residents had pre admission assessments of need, so they can be confident that their care plan, and subsequently their care, will be based on a good knowledge of their needs. The Service User Guide states that prospective residents will be invited to visit the home prior to admission, however it is noted on the AQAA that the majority of residents now come from hospital and do not have the opportunity to return if they are unhappy with the home. This is not ideal. The resident who was receiving rehabilitation had a pre admission assessment completed by a physiotherapist. Details of the resident’s health on discharge from hospital were also on file, and the resident’s care plan was based on this assessment. Residents on Barnham have access to physiotherapists and occupational therapists. A notice on one of the doors on the rehab unit stated that a washing and dressing assessment was to take place at 8am. A resident advised that they were being encouraged and supported to be independent, and confirmed that a social worker had visited to assess what assistance they would require when they returned home. The relatives of another resident who had been staying at the home for rehabilitation were spoken with. They advised that the home had got the resident back on to their feet after a serious fall. They had found the staff very helpful, and spoke of having every confidence in the home. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. Residents can expect staff to have a good and up to date knowledge of their care needs, and to be safeguarded by the home’s medication practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All four residents had care plans. Day and night care plans had been regularly reviewed. Three out of four members of staff who returned surveys stated that they are always given up to date information about the needs of the people they care for. One stated that they usually are. One carer added, that the home has, “ Very up to date care plans, being changed daily if needed.” They thought that they had the right support, experience and knowledge to meet the different needs of people using the service, to varying degrees. A visiting District Nurse was spoken with. They advised; “I’m always very impressed, staff are excellent, always very up to date, ……... They know exactly why the resident is here and have a full grasp of their care plan and ongoing planning.” Staff Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 12 spoken with during the inspection demonstrated a good knowledge of the residents who were tracked. One resident spoken with was worried about the dietary advice that they had been given. They were not confident in it, and explained that they had therefore limited what they had eaten at teatime. Consequently they worried about having not eaten enough to see them through the night without it affecting their health. They said that they had not raised the matter, as they didn’t like to cause a fuss, but said that they had now planned how they would do this as they thought it necessary. The resident was offered the opportunity to look at their plan, with us, which did contain nutritional screening; they advised that they couldn’t read it as it was too small, but commented that they could if it was bigger. The resident said that the staff had gone through the plan with them, but that it was in the evening and they were tired so hadn’t taken it all in. This was subsequently discussed with the manager, who advised that the night care plan may have been discussed with the resident in the evening, but that the home insists that all admissions are achieved by 2.30pm, to allow time to go through their plan with them. Three of the five residents who returned a survey indicated that they always receive the care and support they need, two indicated that they usually do. A nurse who was visiting the home to monitor two residents on long-term medication for dementia advised that both of these residents had improved. They had known one prior to admission, when they were living in sheltered accommodation, and commented specifically that the resident was less sleepy than they had been, The other resident that they were monitoring had shown an improvement in their mental state, which the nurse monitored. Three of the five residents’ surveys indicated that they always receive the medical support they need; two indicated that they usually do. Discussion with residents confirmed that they are able to consult with health professionals whenever required. One commented; “Staff are vigilant in calling doctors/nurses when appropriate.” Care plans inspected included details of General Practitioners, opticians and chiropodists appointments. Only one of the residents tracked had had an accident since December, that being when a cat had scratched them. One of the residents had a history of falls prior to admission. None of the residents tracked had bedsides or any other form of restriction in place. All medications, with the exception of controlled drugs are kept in resident’s own rooms, in a locked cupboard. The administration of lunchtime medication was observed. The carer adopted a sensitive manner, for example they moved to one side of the room but remained vigilant to ensure that a person with dementia had taken their medication. They advised that the person did not like being “watched over.” One resident required a controlled dug at lunchtime; two carers accompanied each other and remained in sight of each other Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 13 throughout this task. The resident requiring the medication was on the telephone when they attended their room; the carers let the resident know they were there, but waited outside for the resident to finish their call. Records for two units were inspected and found to be complete. The carer conducting the medication round advised that a new system of checking medications had been given and signed for had been introduced. They advised that the first task of a senior coming on shift is now to check the recording of medications, including those for prescribed creams, of the departing shift senior and query any omissions at that time. Discussions also confirmed that they are satisfied with the levels of privacy and dignity supported by the care provided. One of the care plans noted that the resident prefers a female to assist with personal care, but would accept a male carer if this is difficult to accommodate at times. All five residents surveys stated that staff listen to the residents and act on what they say. Communication with people with dementia is assisted if carers can relate the residents’ current behaviours and feelings to the residents past life and experiences. One of the residents tracked who suffers from dementia had a life history on their file, the other who had been admitted a couple of years ago did not. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. Residents can expect to enjoy a good quality of daily life with a range of activities available to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents were spoken with about the range of social activities available and life at the home. They were sitting in a communal area talking with a visiting volunteer, who attends the home twice a week. One advised that a member of staff had brought then along to this social occasion (they used a wheelchair), without them having to ask, as they knew it was their routine. They confirmed that routines were relaxed and flexible and tailored to their individual requirements. Both residents were very content, one said, “I feel I’ve landed on my feet here.” When asked what made the home special, they responded, “everything.” One of the residents sad that it was better than being at home, explaining that loneliness was a big feature of living alone in old age. Three of the five residents’ surveys indicated that there are always or usually activities arranged by the home that they can take part in, two indicated that there sometimes are. An activities worker attends the home on Tuesdays and Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 15 Thursdays, and that at other times, care staff do activities with residents. Carpet bowls, baking and Dominoes were advertised as due to take place that week. A member of staff spoken with advised that whenever it was a special day, for example Valentine’s Day. Easter, Mothers’ day, St. David’s day, St. Patrick’s Day, something was made of it, that decorations would be put up and a menu choice would reflect the theme of the day. On Valentine’s Day there had been fresh flowers in the house, and on St Patrick’s Day residents were offered a Guinness. A number of residents had small boxes of chocolates, the worker advised that one had been given to each of the women on mother’s day. Many of the residents had mother’s day cards on display, those spoken with advised that their families were made to feel very welcome. at Davers Court. Two residents joining in this discussion said that there was Holy Communion once a fortnight, and an evening service on the second Sunday of each month. Two forthcoming events were advertised on a notice board in the home, one in June and one in March, provided by outside entertainers, “We’ll meet again…sing some of your favourite songs” and “Singing and dancing to the music of the movies.” These entertainments provide an opportunity to reminisce, which is particularly helpful for residents with dementia. Each unit has the use of a small kitchen area hot and cold drinks are freely available. During the morning the cook was seen to go around the home and speak with residents about the meals that they wanted. One resident noted; “Here’s our chef.” The cook advised that the home had a set of picture menus, and that more work had to be done. Four of the five residents’ surveys indicated that they always like the meals at the home, one that they usually do. The main meal that lunchtime was steak and kidney pudding with jacket potatoes, followed by bread pudding and cream. The main evening meal was fish pie and parsley sauce. Three residents consulted with by the chef all said that they enjoyed their meals. They all requested alternatives; one asked for plaice and chips, one omelette, and the other chicken soup and roll followed by milk jelly. Two asked for alternatives for their teatime meal. The cook advised that the home has a good choice and that residents could have more or less what they wanted. Two residents spoken with advised that they preferred not to have a cup of tea in bed in the morning but were aware of some residents who did. One explained that they liked to get up quite early, and had risen at 7am; the other resident said that they had had a lie in that morning. One of the residents said that most people were in bed by 10pm, but they could stay up later if they wanted to, explaining; “We have all the freedoms of home, we aren’t restricted in any way.” While we were talking a resident with dementia walked up to the book display and took one, the women pointed this out, the volunteer reassured them this was alright and that they were aware they had taken a Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 16 book. This was a positive indication that the rights and need for freedom and independent action are also supported for those with dementia. The residents spoken with confirmed that they could lock their rooms if they want to. Through out the morning staff interactions with residents were seen to support the residents’ dignity. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. Residents can expect to have access to a complaints procedure, and for the home to be responsive to their stated concerns. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints had been received by the home or by us since the last inspection. The complaints procedure was available in the reception of the home and a summary was included in the Service User Guide, which was in each resident’s room. All four staff members who provided a pre inspection survey stated that they knew what to do if a resident or a relative has a concern or a complaint. All five residents surveys received indicated that residents know how to make a complaint. Two stated that they usually know who to speak with of they are not happy; three stated that they always know who to speak with if this is the case. The AQAA indicates that the home tries to pick up on any concerns along the way by listening to people and eliciting their views. Two residents spoken with confirmed that they are always asked their opinion, and felt that it was unlikely they would want to complain. They advised that if they needed to they felt that they could have a word with someone and something would be done. One resident who had only been in the home a short while, as indicated elsewhere in this report, did not feel comfortable in raising a concern. The Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 18 arrangements for complaints are summarised in the Service User Guide which each resident has; it refers them to the County Council procedure, and a leaflet about this is also in their rooms. No safeguarding referrals have been received since the last inspection, and he homes’ AQAA stated that none had been made. A senior member of staff spoken with had a good understanding of the types of abuse residents could incur and were able to advise appropriately the action they would need to take if they suspected abuse. They also advised that all staff had had a session on safeguarding, and that new staff receive this in their induction. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26. Quality in this outcome area is good. Residents can expect to live in a well-maintained and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The reception area is comfortable and inviting and has a range of information available including the last inspection report. There was also a large picture of the manager on duty at the time of the reception, giving their name and stating that they were on duty, so it was clear to any residents, relatives, or visitors who they needed to speak to if they wanted to see somebody who was in charge. Since the last inspection, the home had won an award from the District Council in recognition of high standards in food hygiene. All five residents’ surveys indicated that the home is always fresh and clean. It was found to be so on the morning of the inspection. There is a visitor’s toilet just inside the front door, which was clean and tidy and equipped with paper towels, liquid soap and a Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 20 waste bin. A number of toilets throughout the home were checked and these were also found to be in a good condition. Hot water was tested at a number of outlets including toilets, residents living areas and a resident’s room, and all were found to be at the appropriate temperature. Residents care plans also had bath temperatures recorded in them. Residents are placed in one of the four units, but are free to walk throughout the building. One exit from the special needs unit was alarmed to alert staff that a resident from that unit had left it. Entry through the front door was controlled by a keypad to ensure security of all residents. There is an up to date and maintained fire alarm system including door releases on all doors. No hazards were identified in the home environment at the inspection. The home was clean, comfortable and without odour. Two visiting nurses confirmed that they had not been aware of any unpleasant odours lingering in the home. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. Residents can expect to be cared for by a stable and well trained staff group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A relative visiting the home was spoken with advised that they were very confident in the home and that staff were very good. Two residents spoken with confirmed this; one said that they thought staff were very carefully chosen. Three out of four staff members who returned a survey stated that they thought there were usually enough staff to meet the individual needs of all the people who use the service, one thought that there are sometimes enough staff to do this. Three of the five residents surveys stated that there are always staff available when they need them; two indicated that staff were usually available when they need them. On the morning of the inspection staff went about their business in a calm manner, and call bells were answered promptly. Three out of four staff members who returned a survey stated that their employer had carried out pre employment checks, including CRB (criminal Record bureau) and references; one indicated that they had not, but noted that they had started work very many years ago before these were introduced, and that a CRB check had subsequently been undertaken. The manager on Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 22 duty advised that there had not been many appointments. Two recruitment files for recently appointed staff were examined. They contained all the required documentation, and proper recruitment procedures were demonstrated to have taken place. The three staff who returned surveys who had been recruited more recently all stated that they had received an induction, two though it covered everything very well that they needed to know to do their job when they started, the other thought it mostly did. One noted that they also had undertaken shadow shifts which were “really useful and worth while.” The records of two recently appointed staff evidenced that they had received induction in line with the Skills for Care requirements. The AQAA shows that the home enjoys a low turn over of staff, and that 21 of 29 care staff have NVQ2 or above. All four carers surveys stated that they were given training relevant to their role, which helps them understand and meet the needs of individual residents and up to date with new ways of working. The AQAA states that all staff are appropriately trained in Manual Handling and up dated as required. Three staff files inspected all had recent manual handling training evidenced. A member of staff spoken with also confirmed that their Manual Handling training was up to date. The AQAA notes that all staff are to receive infection control training in the next twelve months. The regular provision of training updates in key areas means that residents can expect staff to be able to support their safety in their working practices. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. Residents can expect to live in a well managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager originally trained as a nurse before moving into the care of older people in residential settings. After working as a deputy manager she became the manager of a care home in 1985 and has been the manager of Davers Court since 1996. She gained the CSS qualification in 1991, later completed the Diploma in the Management of Care Services and has also qualified as a NVQ assessor and manual handling co-ordinator. It has previously been evidenced that they attended a Bradford University Dementia Mapping course. They can therefore be expected to have a good knowledge of the types of communication and interaction that will benefit residents with dementia, and to be able to assess this in the home. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 24 The home enjoys a relaxed and friendly atmosphere, and staff demonstrated a very positive and inclusive approach to caring for residents. There was a pleasant atmosphere at the home on the morning of the inspection. The staff were open, helpful and positive and residents were complementary. One carer returning a survey noted; “Thankfully, we do work closely with our team leader, we help them and they help us; and we talk and support each other where we can.” One carer commented; “….we have a good crew, some good team leaders and a good manager.” The home did not hold any money on behalf of residents. Residents either kept their own money, or purchases were invoiced by the Finance section of the County Council. The system for accounting for invoiced purchases was inspected. Invoices from the chiropodist and a list from the hairdresser of residents who had had their hair done were signed and countersigned by a member of staff before being given to the administrator who signed and recorded these before forwarding them. The procedure safeguards vulnerable residents. Paper work was seen of a quality assurance exercise being undertaken in the home, questionnaires had been sent out and responses were to be in by early May. Regulation 26 visits had been undertaken and were available to view in reception, these were thorough documents. Evidence was seen that the home complies with health and safety requirements. The home’s emergency evacuation plan was seen to be in place. Fire extinguishers were seen to have been serviced in July 2007. Chemicals were seen to be stored appropriately in locked cupboards. A certificate for the five-year electrical installation was seen, dated November 2004. The homes public liability insurance certificate and certificate of Registration were on display. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X 3 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 5(a) Requirement The Service Use Guide must contain all of the information required by regulation so that prospective residents and their relatives have all of the information they require to make an informed decision about whether to choose this home. Timescale for action 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP7 Good Practice Recommendations Residents should routinely be offered a larger version of the Service User Guide. It should be established whether residents are able to read their care plans, or if they need to be provided with a document in a different format or size. Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 27 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 Davers Court DS0000037636.V360915.R01.S.doc Version 5.2 Page 28 - 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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