CARE HOMES FOR OLDER PEOPLE
Davenham 148 Graham Road Malvern Worcestershire WR14 2HY Lead Inspector
Unannounced Inspection 25th October 2005 2.15pm 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.V251205.R01.S.doc Version 5.0 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.V251205.R01.S.doc Version 5.0 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 01886 575491 Friends of the Elderly Susan Patricia Copson 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.V251205.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th June 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, a hairdressing salon, an activities room, 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 DS0000018647.V251205.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over two hours from 2.15pm until 4.15pm. The inspector was assisted by the registered manager and also spoke to four residents and two visitors. The focus of the inspection was on the requirements and recommendations that had been made following the previous inspection and standards concerned with protection and rights, infection control and staffing A service questionnaire was completed by the home prior to this inspection and returned to the Commission for Social Care Inspection. The manager was asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. Thirty-one responses were received. What the service does well: What has improved since the last inspection?
Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 6 Since the last inspection a second shaft lift has been installed and brought into use. The dining room and adjacent corridor have been redecorated and the lighting improved. A new en-suite is being installed in one bedroom and those in two other rooms are being upgraded, as is a communal bathroom. The office has been moved to a room overlooking the car park and the front door. The activities organiser now uses the large room that has been vacated and the residents are able to enjoy a wide range of activities and events there. Following the last inspection the home was asked to make improvements in two areas of care recording and three recommendations were made. These have all been complied with. In response to suggestions from the residents handrails have been installed along the garden paths and a safety rail placed around the pond. 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. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 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.V251205.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These standards were not assessed during this inspection. However a recommendation had been made that staff should receive training to understand Parkinson’s disease and the care of those affected. The manager said that a training file was now available to staff with information on many topics and conditions that residents may be troubled by. These included Parkinson’s disease. Additional training took place in the home. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 9 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 the following standard(s): EVIDENCE: These standards were not assessed during this inspection. However a requirement and a recommendation was made following the previous inspection. These were that risk assessments should be carried out and implemented when necessary and 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. The manager said that communication and monitoring had been improved. Concerns and needs were usually identified during staff handovers and in the message book. Either she or the deputy attended and monitored both every day. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 10 The format for the ‘Activities of Daily Living’ document had not yet been reviewed. However the Head Office had been made aware of the recommendation and the manager expected that when the format was reviewed improvements would be made. Currently staff were encouraged to include as much detail as they could and always to date and sign their entries. The manager and the deputy regularly monitored the recordings. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 11 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 the following standard(s): EVIDENCE: These standards were not assessed during this inspection. However the residents and visitors told the inspector that the quality of care and range of choice was excellent. It was observed that there was freedom of movement through the home and respect for individuals and their private rooms. Recently the office had been relocated and the old room, which overlooks the gardens, was now used as an activities room. Residents were supported to pursue a range of activities and interests. Most residents told the inspector personally and in the questionnaires that the quality and choice of food was very good. However there were three people who were unhappy. The manager was aware of their concerns and the staff were working with them individually to address the issues they raised. One resident had expressed her disappointment that the home did not grow more of their own fruit so trees had been planted in the garden. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 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 the following standard(s): 16, 17, 18. The residents’ are able to raise concerns and be confident that they will receive a response. There are systems in place that ensure residents’ legal rights are protected. EVIDENCE: Every resident had received a copy of the complaint procedure in the homes brochure when they moved into the home. Copies were displayed in the home and the manager confirmed that she spoke to each resident to ensure they continued to be aware how to raise their concerns. Residents told the inspector that they had no complaints and the care they received was excellent. Nonetheless three questionnaire respondents said they were unaware how to make a complaint. The manager will address this. The current residents do not need advocacy services but information is readily available in the home. All residents were entered on the electoral role and the manager said that there was great interest at election times. All recruited staff were subject to a check of the POVA registered by the Criminal Register Bureau. If concerns arose appropriate action was taken. Staff were supported to understand and cope with anger, rudeness and unpleasantness from some residents.
Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 13 Appropriate policies and procedures were available and implemented to provide safe storage for valuables, advice for residents on personal insurance, the making of wills and the giving of gifts. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19 The premises and facilities are safe, well maintained and meet the needs of the residents in the home. Systems are in place to reduce the risks of cross infection. EVIDENCE: A short tour of the home demonstrated that improvements continued to be made. The manager said that budget approval had been granted to improve the area by the laundry and staff room in the New Year. It is acknowledge that the needs of residents take priority but it is good that the needs of staff are also respected. The cleanliness of the home was a credit to the staff concerned. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 15 Infection control measures were in place. The laundry facilities were good and well managed, personal protective equipment was readily available, clinical waste disposal was available and liquid soap, disposable towels and washing facilities were appropriately placed. Sluice facilities are provided. The manager confirmed that all staff received training. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Sufficient suitable staff are recruited and trained to meet the needs of the service. EVIDENCE: The duty roster indicated that one senior and three care assistants were on duty every day shift and at night there were two waking staff on duty. The manager said that staff were very good at covering vacant shifts when the need arose. Staff were very supportive to each other and the home. There had been no new staff appointed since the last inspection and there were currently vacancies for a domestic and an administrator. There was a sound recruitment procedure in use. The home had not previously had an administrator on the team. However with the increase in paper work this was now acknowledged as necessary and would free up the manager and deputy to devote more time to the management of the service. Positive comments received from residents and visitors have been recorded in the summary. Less positive comments included; ‘Neither of the two managers are on duty at weekends. However a senior carer is always in charge. All staff do their best to be two places at the same time, sometimes the stress shows. Staff sometimes seem rather busy. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 Systems are in place to monitor the standard of the service, identify and address concerns and initiate improvements in the best interests of the residents. Residents’ financial interests are safeguarded by the policies and procedures in use. EVIDENCE: The home undertakes an annual quality audit and is subject to a monthly inspection visit by a person appointed by the provider. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 18 ‘Clinics’ are held with the residents to discuss up grading projects in the home and discuss ideas and suggestions they may have to improve the facilities. The residents had suggested hand rails be installed along the garden paths and this had been done. Safety rails had also been erected around the pond. The providers ask the residents to complete a questionnaire each year. These were sent unseen to the Head Office. Unfortunately the home receives very limited feed back so they are deprived of an opportunity to identify opportunities to where the service could be improved and to provide residents with an analysis of their views. The Service Users Guide (standard 1.2) requires that service users’ views be included. An analysis of the annual survey would ensure the views included were up to date. There have been ongoing discussions with the provider and the Commission for Social Care Inspection regarding first aid training and the requirements of the legislation, standards and needs of the home. A requirement was made in the previous inspection and subsequently a risk assessment was sent to the Commission for Social Care Inspection. First aid training requirements will be reassessed in the future in light of any changes to the National Minimum Standards, which are currently being reviewed. The fire log was not checked. However the manager said that training had taken place the previous day. From her descriptions it was apparent that this was a regular event and staff were imaginatively challenged by different training scenarios, which avoided the risk of complacency developing. Checks of the fire detection systems and equipment were regularly carried out. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 19 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action 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 OP33 Good Practice Recommendations It is recommended that a detailed analysis is made available to the home of the responses received to the annual quality questionnaires. Davenham DS0000018647.V251205.R01.S.doc Version 5.0 Page 21 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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