Inspection on 14/06/05 for Davenham

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Davenham 13/03/07

Davenham 25/10/05

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 Draft Unannounced 14 June 2005 09:30am 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. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Davenham Address 148 Graham Road Malvern Worcestershire WR14 2HY 01684 574385 01886 575491 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) Friends of the Elderly Susan Patricia Copson Care Home 37 Category(ies) of OP Old Age - 37 registration, with number PD(E) Physical Disability - 1 of places Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The are no registration conditions additional to those listed on the previous page. Date of last inspection 1 December 2004 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 is the registered manager for Davenham. The service provider’s representative (the responsible individual) who oversees the management of the home, is Lorna Long. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over five hours and was the first inspection to take place during the year 1st April 2005 to 31st March 2006. The inspection was conducted with the assistance of the manager and the deputy manager and two service users. A range of policy documents were seen, and samples of care and staff records were inspected What the service does well: What has improved since the last inspection? What they could do better: Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 6 The records are well kept but more detail would be helpful to guide the staff providing the care. When people are prone to fall the risks should be assessed and planned action taken to make life as safe as possible. It is unclear whether the training that is provided for new staff covers all the necessary subjects within the first six months of their employment. This needs to be checked and a systematic foundation programme needs to be available. This was recommended last year but there has been no progress so far. However there is an ongoing programme of training in care subjects in operation. All senior staff are trained to give emergency aid but have not done the fourday ‘First Aid at Work’ course. This training had not been done when inspected last year and has still not been done. The home must carry out an assessment to check that the training they have is sufficient for the needs of the home. Training should be available to help staff understand and care for people with specific disorders such as Parkinson’s disease. 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. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 to 5 Service users have information and opportunities to assist in their choice of home. The home is meeting the needs of the current service users. EVIDENCE: The manager said that the statement of purpose and the service users’ guide had been updated to take account of changes in the staff team and training achievements. The service users confirmed that they had received all the information they had needed prior to coming to the home and on arrival, in order to help them make a decision on their future home. The files of two service users were inspected. One did not have a copy of a contract but the manager explained that this was because it was being changed from a temporary one to a permanent one. The copy that was seen was acceptable. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 9 Both service users had been assessed before they had moved into the home and assessment records were available. Although they could not recall the details both service users recalled seeing someone. They both confirmed that they were very happy with their choice, they had been given time to make up their minds and considered that they were being well cared for. One service user had Parkinson’s disease. This was not posing a problem to the home. However it was recommended that training to understand the disease and how to help those affected was obtained for the staff. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-10 Service users’ personal and health care needs are being met. Medication is well managed and administered safely. Service users are respected and their privacy protected. EVIDENCE: The initial care plan was titled ‘Activities of Daily Living’. The design was very congested and gave little opportunity to record detail. It was recommended that the organisation be asked to adjust the design to provide more space for information, facilities to record the date of admission, the date of the plan and the signatures of the member of staff and service user who had drawn it up. Care must be taken to ensure good copies are obtained from the photocopier or the format could be held on computer and printed off as needed. Service users’ plans were available. The format was easy to follow and there was evidence that the plans had been regularly reviewed. Again it was suggested that more detail would be helpful and although the service users had signed the review forms they had not signed the care plans. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 11 In one instance a risk assessment in relation to falls had not been carried out. It was required that this be done before the end of the week. Health care issues were well recorded and the service users confirmed that they had seen the doctors, district nurses and chiropodists when they had needed them. They were happy for the staff to manage their medication for them. They praised the standard of the meals provided and the range of choice offered. The manager showed the inspector a format for undertaking nutritional assessments that they were about to implement. The home had recently changed to the medication modular dosage system provided by Boots The Chemist. Appropriate training and support was being given. A requirement regarding medication training was made following the previous inspection and this had been met. Medication recording was well managed. Storage was acceptable with the exception of the cupboard for controlled drugs. This also held other medication that needed be removed and stored elsewhere. The Boots pharmacist had identified this and the home was addressing the matter. The inspector was told that an investigation was currently underway regarding an issue concerning controlled drugs. A member of staff had been suspended while inquiries were being made. In the interim Boots had been asked to assemble the controlled drugs in blister packs in future for added security and monitoring. Bedroom doors were fitted with locks and service users had been provided with the keys, staff knocked on doors and waited to be invited to enter, post was delivered unopened. Service users confirmed that they were assisted with tact and sensitivity. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-15 Service users live the lifestyle they preferred. Their rights relating to freedom and choice are respected. A variety of acceptable wholesome meals are enjoyed. EVIDENCE: Service users were observed to be taking advantage of the good weather and were walking in the grounds. Call bell necklaces were available so they could call for help if needed. The majority of the service users were independent in their social activities and interests. People were coming and going throughout the inspection. Visitors were welcomed by staff or the person they had come to see. This year it is the centenary for the ‘Friends of the Elderly’ and to acknowledge this occasion Princess Alexandra had recently visited the home and a visit to St James Palace to meet the Queen was shortly to take place. These events involved both the service users and staff and caused much excitement and pleasure. A wide range of other, more usual, activities in house and in the community also took place. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 13 Religious activities took place in the home and support was provided if necessary for those people who wished to attend a church in the community. When asked what she liked best about the home a service user replied that she was happy that she could go to bed when she liked, watch the television programmes she preferred and her own decisions were respected. A choice of menu was provided and service users said that they were asked to make a selection each day. If there was nothing they fancied other suggestions were made. Service users said that the quality and quantity was excellent. One person said that the difficulty was not to put on weight. It was observed that weights were monitored. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. EVIDENCE: Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 15 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) These standards were not assessed on this occasion. EVIDENCE: Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 16 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) These standards were not assessed on this occasion. EVIDENCE: A recommendation was made following the previous inspection that a more systematic foundation training programme be developed and implemented that clearly demonstrate that the National Training Organisation (NTO) specifications were being met within the first six months of employment. There had been no progress towards meeting this recommendation. It was suggested that research through the Internet to identify the topics required would be useful and the inspector undertook to send some literature on the subject to the manager. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 17 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) These standards were not assessed on this occasion. EVIDENCE: A requirement was made following the previous inspection concerning the availability of staff trained in first aid. The manager said during this inspection that all senior staff had done the course, Emergency Aid in the Work Place, and were not qualified in first aid as specified in the standard. The first aid qualification is a four day First Aid at Work course. Although the requirement has not been met, it will be reworded to suggest that, alternatively, a risk assessment could be undertaken to determine the level of training necessary to meet the needs of the home, health and safety considerations and the requirements of the home’s insurance cover. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 19 Yes 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 8,38 Regulation 12(4c) Risk assessments must be carried out and implemented when necessary. 2. 38 13 A qualified first aider with a current four day First Aid at Work qualification must be on duty at all times. Alternatively the home must draw up a risk assessment that identifies that the level of first aid cover is sufficient to meet the needs of the home and ensure that this level of cover is in place. A copy of the risk assessment must be sent to the Commission for Social Care Inspection. Requirement Timescale for action 21st June 2005 15th September 2005 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 E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 20 1. 4 Staff should receive training in understanding Parkinsons disease and the care of those affected. 2. 7 Consideration should be given to reviewing the format for Activities for Daily Living in order to provide a clear copy with more space, and facilities for entering dates and signatures. 3. 30 A more systematic foundation training programme should be developed and implemented that clearly demonstrates that it meets the NTO specification. This recommendation has been repeated from the previous report. Davenham E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 21 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 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 E52 S18647 Davenham V228737 140605.doc Version 1.30 Page 22 - 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. 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