Inspection on 14/09/05 for Blackdown Nursing Home

This inspection was carried out on 14th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Blackdown Nursing Home 16/12/08

Blackdown Nursing Home 05/06/07

Blackdown Nursing Home 10/05/06

Blackdown Nursing Home 26/01/06

Blackdown Nursing Home 19/10/04

Blackdown Nursing Home 28/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Blackdown Blackdown Mary Tavy Nr Tavistock PL19 9QB Lead Inspector Douglas Endean Unannounced 14 September 2005 th 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 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. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Blackdown Nursing Home Address Blackdown, Mary Tavy, Nr Tavistock, Devon, PL19 9QB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01822 810249 01882 810249 Whitchurch Care Ltd. Mrs Maureen Seabrook Care Home 33 Category(ies) of Dementia - over 65 years of age (19), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (19), Old age, not falling within any other category (3), Physical disability over 65 years of age (33) Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Registered for max 3 OP Registered for Max 33 PD(E) Service users 65 years and over Registered for max 19 DE(E) service users 65 years and over Registered for max 19 MD(E) service users 65 years and over Date of last inspection 19/10/04 Brief Description of the Service: Blackdown Nursing Home is a care home that is registered to provide nursing care to a maximum of 33 Service Users male or female, over the age of 65. A maximum of 26 beds may be provided to Service Users who have been assessed as having general nursing needs and a maximum of 19 Service Users who have been assessed as having mental health nursing needs. It is also registered for up to 3 Service Users who have personal care needs only. The manager is a level one trained nurse who heads up the team of other registered nurses, Social Care staff and ancillary staff. Collectively they are able to deal with the various care needs of the current Service User group. Blackdown Nursing Home is arranged on two floors with access to the first floor via a stair lift. A shaft lift is in the process of being built. There are 3 communal areas within the home with an additional conservatory planned. The unit designed for the 19 elderly Service Users with mental health needs (Sunflower) is secured for the protection of the Service Users and benefits from a large day room and extensive views over mainly rural land to Dartmoor. There are large, accessible gardens surrounding the home with some paved areas provided with seating. The home is situated on the edge of Dartmoor in the village of Mary Tavy where there are a number of local amenities. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 15th September 2005 over a period of 2 hours and 45 minutes. In this time the inspector read five client files as a representative sample of how the home now records information on each client. He also looked at the maintenance files, 2 staff files, record of activities, accident records and fire logbook and staff training records. During the tour of the home the inspector spoke to three staff members and three clients. The tour included looking at client’s rooms, the communal spaces and the laundry. What the service does well: 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 contacting your local CSCI office. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. Standard 6 is not applicable to this home. There is a suitable amount of information gathered from a variety of sources for the manager or her deputy to make an informed decision about each prospective admission. EVIDENCE: The inspector looked at the files of five clients chosen at random. Each file showed a clear trail of assessment information that was gathered and used to make an informed decision regarding the suitability of each admission. The information included the Discharge team assessment and nurse referral sheet, a care management care plan and mental health needs assessment. The home then added to that information using its own written assessment that made current the knowledge of such things as mobility, nutritional needs and mental state. The client’s have also had a National Health Services funded nursing care assessment but the home is not given copies of the actual assessment. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 8. The level of information gathered by the staff initially, and during reassessment of the client’s, has enable them to develop well-constructed care plans. EVIDENCE: The clients each have care plans. The inspector looked at a sample of five, each was well constructed and identified needs and made action plans to direct the staff in how to achieve the goals. They were in an easy to understand format. The inspector also saw that each plan is reviewed and there was comments made regularly on the total care plan such as “it meets her needs adequately. The plans had information about activities of daily living including personal care needs such as hygiene, control of body temperature, mobility, work and play, expressing sexuality and sleeping. There was also a client’s comfort guide. The delivery of health care needs was also recorded in the daily continuation sheets and “Significant events and Doctors visits” sheets that gave details of General Practitioner visits and assessments for free nursing care assessments. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 9 There was a record of when the flu injection was last given, a regular review of the Waterlow score, a Prideaux nutritional assessment, manual handling information and a record of Podiatry treatment. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 13. The steps taken by the home to identify the social, spiritual and psychological needs of the clients, and then satisfy them, are good. EVIDENCE: The staff have found out from the client’s and their advocates individual likes and dislikes and recorded these in the comforts guide. Samples of these were seen in five clients records that were sampled during the inspection. The home have a notice board in the entrance area where notices of planned activities were on display along with the timetable for regular events. There is music and movement each week and a guitar player monthly. The Methodist and Church of England ministers visit the home. The staff involve themselves in activities such as sing along and bingo. There is also a hairdressing salon that was in use during the inspection using the services of an experienced hairdresser. All the activities are recorded in the client’s files. The inspector saw evidence of this having taken place with the date, activity and staff that were involved being recorded. The clients’s who are resident at the home are generally not able to access community services on their own. However, they do go out with relatives and friends for such things as a drive and a pub bar meal. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 11 Visiting is welcomed at any reasonable hour and the home has made client’s and their relatives and friends aware if this in the statement of purpose. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18. The arrangements for the protection of client’s from abuse, and the recording and reporting of abuse, are satisfactory. EVIDENCE: The inspector saw the complaints procedure displayed on the notice board in the front entrance. It had all the information clients or visitor to the home would need should they wish to raise an issue including the contact details of the Commission for Social Care Inspection. This information was also held in the statement of purpose and service users guide. Two of the client’s who spoke to the inspector knew who to raise a complaint with if they felt it necessary. There are suitable policies and procedures that cover the issue of abuse including a whistle blowing policy. The inspector saw that the home had a copy of the No Secrets video and also a record of the names of the staff who have see it. There has been vulnerable adults training at the home carried out by an external trainer. The staff are also trained in the understanding of different behaviour from client’s and why it may occur and how to respond. The inspector has investigated one complaint in the last twelve months and this was not substantiated. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 & 26. The residence provides a clean, comfortable environment with some very attractive views that can be enjoyed from inside and outside of the home. The level of well-maintained equipment in the home is sufficient to meet the needs of the clients care needs and this will be further enhanced when the shaft lift is complete. EVIDENCE: The home is located at the end of a village just off the main road to Plymouth and Tavistock and has a long driveway leading to parking at the front of the home. There are nice grounds and views over Dartmoor. At present there is some building work in at the rear of the home with some disturbance to the front edge of the grounds. This work will result in more rooms, more communal space and other services including a shaft lift that is slowly progressing towards completion. The extra communal space will then make the home comply full with the National Minimum Standards. There is regular maintenance at the home carried out by one of the owner’s with specialist equipment such as hoists being serviced under contract. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 14 Evidence of servicing on the hoists was seen during the inspector’s tour of the home. The home is nicely decorated and the client’s have personalised their own rooms to their own taste with items personal to them and in colours that they have chosen where possible. The building does comply with the present fire and environmental health legislation. The home was clean and odour free during the inspection. It has its own laundry that has a large commercial dryer and two large capacity washing machines with sluicing cycles. The floors and walls are washable and not permeable to water. There are policies and procedures in place that deal with hand washing and other infection control issues. There is a new disinfecting mechanical sluice on the first floor. Good practice would suggest that the same facility be also provided on the ground floor to reduce the risk of infection inherent in the procedures dealing with body waste. Hand washing facilities are provided in every Service Users room and in appropriate areas around the home. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. There are good procedures in place for the recruitment of staff to the home who are suitable to work in care. The numbers and skill mix of staff on duty is sufficient to meet the needs of the present client’s that live in the home. EVIDENCE: The inspector saw the duty rotas and they provided evidence of the staffing levels for both care and the ancillary services at the home. There is satisfactory numbers of nursing and social care staff on duty at all times who are supported by the people who work in the kitchen and laundry and in the home on domestic duties. There are two registered nurse nurses on duty during the daytime and one registered nurse on at nights who are supported by varying numbers of social care staff over the 24 hour day. The home has a robust procedure for the recruitment of staff of all grades. The inspector looked at two staff files and found that they had most of the items required by Schedule 2 of the Care Homes Regulations 2001 including two written references. They were missing photographic identification and some form of proof of address to make them complete. In addition to the statutory documents required the files also had copies of the induction program undertaken by the staff member and a copy of the staff handbook. The inspector saw evidence that the staff had been involved in mandatory training that was carried out by external trainers. Training included Fire, Manual Handling and First Aid. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35 & 38. The Management of the home is good and this has resulted in good practices in meeting the care needs and welfare of the client’s that live in the home and the staff who work at the home. EVIDENCE: The inspector saw evidence that the home is seeking the views of client’s and their advocates over three consecutive years regarding their levels of satisfaction with the services offered by the home. The Manager has commenced relatives meetings at the home although it has initially not been well attended. There are regular staff meetings held at the home that are also attended by the Registered Persons and minute’s are taken. The manager told the inspector that the home does not manage the financial affairs of any of the client’s. They do however handle small amounts of pocket money for a small number of the client’s. Clear records were seen that showed Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 17 that the home account well for how that money is spent. There are secure arrangements for the safe keeping of money and valuables. The manager and her deputy ensure that the health, safety and welfare of the client’s and staff are fully considered. The client’s have continual assessments that identify risks to their well being such as falls, pressure sores and nutrition. They then plan to reduce the risks and equipment may be used to achieve this. This same equipment is serviced when necessary, the inspector saw evidence of servicing hoists and other safety equipment. The staff also receive training in how to use the equipment to prevent injury to themselves and the client’s. The home has items of equipment in place to reduce the risk of spread of infection such as a disinfecting sluice, washing machines with a sluicing cycle and hand washing facilities in all bedrooms and other places around the home. The inspector saw evidence that accidents are recorded and care plans reviewed as a response to an accident if necessary. Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 2 x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 Blackdown D54-D07 S29072 Blackdown V240156 140905 Stage 4.doc Version 1.40 Page 19 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 OP29 Regulation 19(1)(i) Requirement The Registered Person should maintain staff records in accordence with Regulation 19 and Schedule 2 including a recent photograph and proof of the employees address. Timescale for action 1/11/05 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. Refer to Standard OP20 Good Practice Recommendations Extra communal space is to be provided to ensure 4.1 sq m per Service User is achieved. 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