Inspection on 13/03/07 for Davenham

This inspection was carried out on 13th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Davenham 25/10/05

Davenham 14/06/05

Davenham 01/12/04

Davenham 21/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Davenham 148 Graham Road Malvern Worcestershire WR14 2HY Lead Inspector Yvonne South Unannounced Inspection 13th March 2007 09.45 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 Davenham DS0000018647.V288526.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. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Davenham Address 148 Graham Road Malvern Worcestershire WR14 2HY 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) 01684 574385 01684 575491 manager@davenham.fote.org.uk Friends of the Elderly Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37), Physical disability over 65 years of age (1) of places Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection 25th October 2005 Brief Description of the Service: Davenham is a fine imposing Victorian house set in beautiful grounds in Malvern Town, close to local shops and the common. A service is offered to a maximum of 37 people over the age of 65 years who have mild to moderate care needs and one person can be accommodated who has a mobility difficulty necessitating the use of a wheelchair. There are 35 single bedrooms with en-suite or private toilet/bathroom facilities close by and a self contained flat for a couple. Although there are two shaft lifts some rooms can only be reached via some stairs. In addition to the private bedrooms there is a communal drawing room, a library, a dining room, a chapel, seating areas on all floors, kitchenettes and a laundry for service users to use. The house is surrounded by an extensive and famous garden, which it shares with the nursing home called Perrins House, which is owned by the same registered provider, the charity Friends of the Elderly. Mrs Susan Copson the registered manager for Davenham recently resigned her post to take up another role within the organisation. Mrs Clare Berrow has been appointed in her stead and she will soon be submitting her application to the Commission for Social Care Inspection (CSCI) for registration as the home’s new manager. The service providers representative (the responsible individual) who oversees the management of the home, is Lorna Long. The web address is www.fote.org.uk At the time of this inspection the fees for the home were stated to be between £507 and £600. Additional charges were made for hairdressing, chiropody, newspapers, dry cleaning and community transport. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that incorporated information received by the Commission for Social Care Inspection since 12/10/05 and the information obtained during fieldwork on 13.03.07. The fieldwork took place over eight hours during which the inspector spoke to four residents and six staff. Documents were assessed and a partial tour of the premises was also undertaken. Assistance was principally given by Mrs Ella Dugdale the deputy manager. Prior to the fieldwork the home was asked by the Commission for Social Care Inspection (CSCI) to complete and return a pre-inspection questionnaire and to distribute questionnaires to the residents, relatives and health care professionals seeking their opinions of the service. To date 4 responses have been received from residents, 5 from relatives and 4 from health care professionals. The focus of this inspection was on the key National Minimum Standards. What the service does well: What has improved since the last inspection? Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 6 Following the last inspection it was recommended that a detailed analysis should be made available to the home of the responses received to the annual quality questionnaires. This has been done and the documents were freely available on the table outside the dining room. 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. The summary of this inspection report can be made available in other formats on request. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 7 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 Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 8 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): 3. (An intermediate service is not offered by this home. Therefore standard 6 was not assessed.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is provided so that people are able to make a decision regarding their admission to the home. Assessments are made of prospective residents’ needs so that places are only offered if the service can provide the care required. EVIDENCE: The questionnaire responses indicated that people had received the information they needed to help them make a decision regarding their future accommodation and care, and they had received a contract. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 9 This was confirmed through assessment of the documents relating to a resident recently admitted to the home. An assessment of care needs had been undertaken before a place was offered to ensure the service would be able to provide the care required. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 10 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. This judgement has been made using available evidence including a visit to this service. Despite some weaknesses in the documentation staff are well informed so that residents are well cared for and their health needs are met. EVIDENCE: An assessment was made of three sets of care records. It was observed that assessments, care plans and reviews had been undertaken and there was evidence that this had involved the appropriate resident. A document titled ‘Activities of Daily Living’ was also available. This gave a summary of care needs but the detail was thin and in some cases incomplete. Some other weaknesses in documentation were observed. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 11 A system of pre-printed care plans was in use for the most common care needs. Although these were detailed they were general and impersonal. A few additions had been made to some of the care plans in use. However there is a risk of failing to make the plans individual. For example pressure care plans did not describe the special aids that the individual used, continence plans did not describe the aids in use and how stocks were maintained, likes and dislikes were not included. Records of professional visits were well maintained and the questionnaire responses received from health care professional were positive. Comments made included; ‘Very well run’. ‘Never any problems’. A resident stated in the questionnaire response that there was an ‘Excellent medical service’. Daily records were well maintained by care staff and gave details of the life of residents. Reviews of night care plans were very informative. Medication was not assessed in detail as the organisation had recently undertaken an audit of this area of care itself and the home had scored highly. However it was noticed that a resident who wished to manage her own medication when she moved into the home did so without an assessment of her ability and understanding being undertaken for nearly seven weeks. The resident had no lockable facilities for storage in her room. Many residents furnish their own rooms and this can lead to a lack of this facility. This needs to be monitored and addressed by the registered persons. It was observed that residents were treated with dignity and respect. The staff who spoke to the inspector were clear how this was safeguarded in their work. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 12 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. This judgement has been made using available evidence including a visit to this service. Residents have access to stimulating activities and interests should they choose to participate. Links are maintained with family and friends. EVIDENCE: The home employs an activities co-ordinator for 15 hours a week. Although this is not long each day she works a group activity is arranged. In addition she endeavours to spend time with individually residents who do not care for such organised group events. The member of staff was about to undertake a training course in nail care and massage with the National Association for Providers of Activities for Older People (NAPA). Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 13 A resident commented in a questionnaire response; ‘We have an excellent ‘activities co-ordinator’ available for all who need activities. I do her weekly quiz, which I enjoy, though I am not good at it. I have plenty of my own work to get on with as I do most of the organising of the chapel. We have weekly Communion Services. And I am busy with my correspondence. Recently outings had taken place to the ballet and concerts. Many residents did not care to go out in the winter months. However a ‘daffodil trip’ had been arrange to take place in the next few weeks. The inspector was told that as the number of frail residents increased there was a growing reluctance to venture out so it was planned to bring more entertainers into the home. In the better weather more use would be made of the superb gardens. An in-house activity programme was displayed outside the dining room and a supply of library books; standard, large print and audio, were available in the library. Recently the manager’s office had been relocated and the vacated room was now being used for activities such as quizzes and physio exercises, which were proving very popular. The home had its own beautiful chapel and regular services were held for those who wished to participate. Visitors were always welcome and the book indicated that there was a steady stream during the day. The menus demonstrated that a good choice of acceptable meals was offered and the residents told the inspector that they were of good quality and enjoyable. A questionnaire response stated that: ‘I am not keen on fish or bread & butter pudding but there are alternatives one can have’. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse by a sound recruitment and training process. The availability and support residents receive ensures that they are able to raise any concerns they may have. EVIDENCE: A complaints procedure was available and included in the Statement of purpose and Service Users Guide. A copy of these documents was on the table outside the dining room and the inspector was told that each person received a copy when they moved into the home. The questionnaire responses indicated that residents and relatives were aware how to raise their concerns. One respondent stated: ‘As we have residents’ meetings every six weeks things can be sorted out then. There is also a book or the manager’. Those residents who spoke to the inspector confirmed this and assured the inspector that they had no complaints. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 15 The pre-inspection questionnaire, completed and submitted to the CSCI by the acting manager, stated that the home had received no complaints since the previous inspection and the records in the home supported this. No complaints had been received by the CSCI either. The inspector spoke to three staff and they were all aware of the correct action they should take when in receipt of a complaint. Three sets of staff records were assessed and demonstrated that an acceptable recruitment process had been used. References had been taken up and checks had been made with the Criminal records Bureau (CRB) and the Protection of Vulnerable Adults (PoVA) list before any candidate was offered employment. Training records and staff indicated that training had been given to recognise and respond to suspicions of abuse. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 16 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained so that residents live in a beautiful house and have access to beautiful gardens that suit their taste and needs. However some issues are increasing the risks of cross infection and safety. EVIDENCE: A partial tour of the home was conducted. It was generally clean and tidy. In the bath/shower room on the middle floor it was observed that the shower chair was rusty, and a used towel and apron had been left in the room. These were removed. The residents’ laundry was in need of up-grading following the installation of a new washing machine. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 17 Liquid soap, disposable towels and personal protective equipment were available in the communal bathrooms and toilets that were inspected. However there were also several bottles of chemical cleaner that had not been stored securely. These have been attended to. One storeroom had a mattress and a ladder in the way so that the door could not be closed. This room has been reorganised so the door can be closed. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. Residents are protected and their needs are met as a result of good recruitment, training and staffing levels. EVIDENCE: The pre-inspection questionnaire indicated that the home was staffed to meet the needs of the current residents and some questionnaire responses indicated that residents and relatives were in agreement. However other comments included: There is not always enough staff available. Sometimes have to wait. It depends who you tell. I’m a blind person and I get all the help I need. Usually staff are available when you need them but they have to give preference to the most needy. Sometimes you have to wait a little for care. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 19 Sometimes staff are very busy and you have to wait. Three sets of staff records were assessed and demonstrated that the staff had received training in the core care subjects. Additional training had taken place in Dementia care, and interpersonal skills. The pre-inspection questionnaire indicated that 53 of the care staff had National Vocational Qualifications. Documents demonstrated that the recruitment process was acceptable. The pre-inspection questionnaire stated that six staff had left employment since the previous inspection. One of these had had her contract terminated as her attitude and work was unacceptable. When necessary agency staff were used to maintain staffing levels. The preinspection questionnaire indicated that this had rarely happened. In eight weeks only one six-hour shift had needed to be covered by a carer from an agency. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and systems, policies and procedures are implemented so that people in the home receive a good safe service. EVIDENCE: The home was well managed. Staff appeared confident and capable in their work and residents were relaxed and ‘at home’. The acting manager was not on duty during the inspector’s visit but she was ably assisted by the deputy manager. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 21 An application for registration will be submitted to the CSCI by the acting manager in the near future. She is currently studying to achieve the Registered Managers’ Award. Information from residents and relatives was positive. One resident stated: ‘I have been here over seven years and appreciate it more with every passing year. I think it is an excellent home. A relative stated: ‘The home is most excellently managed and the staff are professional, caring and friendly. I am not aware of any complaints or dissatisfaction’. Quality Assurance systems were in place. An internal questionnaire/survey had been undertaken with residents. The results were readily available on the table outside the dining room. The results were generally positive and the comments pleasing. A ‘Key Point Quality Audit’ had been undertaken on 24.01.07, which had resulted in a 96 score. A Medication Audit, undertaken on 25.01.07, scored 89 . It was observed that some residents held money in safekeeping. Records were kept and residents signed for withdrawals. Receipts were kept for all expenditure. It was recommended that receipts also be given for income. The balance of two accounts was checked and were found to be correct. The home appeared well maintained. The pre-inspection questionnaire indicated that systems and equipment were regularly serviced. There had been a problem when a lift broke down and this caused some difficulty for some residents until the fault was repaired. The water system and fire safety equipments and systems were regularly serviced and checked. Regular training was in progress. Training records indicated that staff were appropriately trained in health and safety matters. Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 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 X 2 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 4 X 3 X X 3 Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The residents care plans must set out in detail the action which must be taken by care staff to ensure that all aspects of health, personal and social care needs are met. Residents who manage their own medication must be assessed as regards to ability and understanding and have access to secure storage. Action must be taken to ensure risks to health and safety are addressed. Timescale for action 30/04/07 2 OP9 12 31/03/07 3 OP26 13 31/03/07 Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 24 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 Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Davenham DS0000018647.V288526.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!