CARE HOMES FOR OLDER PEOPLE
Davenport Manor 170 Bramhall Lane Davenport Stockport SK3 8SB Lead Inspector
Kathleen Mcall Unannounced 8 September 2005: 13:15 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. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Davenport Manor Address 170 Bramhall Lane, Davenport, Stockport, SK3 8SB 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) 0161-483-4598 0161-483-4598 Davenport Manor Nursing Home Limited Mrs W Drabble CRH - Care Home 34 Category(ies) of DE - Dementia (34) registration, with number MD(E) - Mental Disorder over 65 (10) of places OP - Old Age (34) nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: The home is registered for a maximum of 34 service users, to include up to 34 service users in the category of OP (old age not falling within any other category; up to ten service users in the category of MD(E) (mental disorder, excluding learning disability or dementia - over 65 years of age); up to 34 service users in the category of DE (dementia - under 65 years of age). The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 3 March 2005 Brief Description of the Service: Davenport Manor is one of three residential care homes owned by the Davenport Manor Nursing Group. The registered providers are Mr Kieran Patel and Mr Dilip Patel. Mrs Wendy Drabble is the registered manager. Davenport Manor is registered to provide care for up to 34 older people or older people with dementia over the age of 65 years, and up to 10 residents with a diagnosis of mental disorder. Davenport Manor provides permanent residential care services, respite and short-stay services. The home has 28 single rooms, 17 with en-suite facilities, and six shared rooms. Currently, only one of the shared rooms is jointly occupied. There are three lounge/dining rooms. The home has a passenger lift to assist service users to the first floor. A large, fully enclosed garden is situated at the rear of the building and there is ample car parking facilities at the front of the house. Davenport Manor is situated in the Davenport area of Stockport. Local shops, churches, post office, surgeries and a newsagent are close by. There is a regular bus service and Davenport railway station is approximately a quarter of a mile away. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over the course of a day. The registered manager accompanied the inspector throughout the inspection process. Care plans, assessment documentation, medicines and their storage were examined. The inspector spoke with a number of residents in the home and several members of staff. What the service does well: What has improved since the last inspection?
Since the last inspection the home has improved its procedures around completing risk assessments on residents. Also the home has now purchased a number of dishes with separate moulds for those residents who require pureed food, thus improving the appearance and flavour for these residents. A number of residents’ bedrooms had been improved since the last inspection. Carpets, curtains and beds had been replaced. A new assisted bath has also been provided in the home, this was said to be popular with residents.
nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 6 All hoists and lifting equipment used in the home is now regularly maintained and an up to date certificate for each piece of equipment was made available for inspection. Previously Davenport Manor had a problem with rainwater seeping into the basement area of the home; this presented a risk to staff using the laundry area. Since the last inspection the registered manager has successfully resolved this problem. 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. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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 nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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) 2, 3 and 4. Service users had been issued with a written contract. Arrangements were in place that ensured service users care needs were fully assessed before admission. EVIDENCE: The service User contract was revised earlier this year and all service users had a contract, which detailed the terms and conditions of their stay. There had been several new admissions to the home since the last inspection. Service users were assessed prior to their admission to the home; no service users were admitted to the home without their care needs having been assessed. Assessments were obtained from social workers and health professionals if they had been involved in the admission. Those files of service users recently admitted to the care home were examined and contained up to date assessment documentation held in respect of each person. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 9 Service users told the inspector that they were quite satisfied with the way in which the home met their care needs. Care staff demonstrated a good understanding of service users care needs. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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, 8, 9 and 10. Care plans do not accurately reflect how a service users needs were met. Service users were treated with respect and dignity at all times. EVIDENCE: nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 11 All service users had a care plan. However care plans did not include all aspects of a service users care needs and how care staff were meeting these needs for example care plans did not always state how the home was meeting a service users social care needs, neither did they indicate if care staff were assisting service users with medication. Davenport Manor is registered for service users with dementia and for service users who may have a mental illness, whilst this information was included on the care plan, care plans did not state how these area of need were being met. Risk assessments had been undertaken and care plans were cross-referenced to indicate to staff that a risk assessment had been completed. Risk assessments, moving and handling assessments, weight charts and preadmission assessment information was stored in one accessible folder. Care plans were reviewed on a monthly basis and any changes needed were made. Davenport Manor had specialist equipment in place to meet the needs of service users living there. GP’s and district nurses were regular visitors to the home. The home had recently updated the medication policy to include all aspects of medication storage and administration. Medication was provided in the monitored dose system, this was stored appropriately. On examination of medication records it was found that on a number of occasions medication details had been handwritten. These were of variable quality, some had not been signed or dated and the quantity was not indicated, neither had they been validated by an additional member of staff. The home had a secure dedicated refrigerator for the storage of medication requiring refrigeration; the temperature of this refrigerator was monitored and recorded on a daily basis. Service users were identified prior to medication administration by the use of photographs attached to the medication administration records, however a significant number of medication records did not have a photograph of the service user. Service users told the inspector that staff treated them well and they were very satisfied with the care they received. One service user said he had no need to complain and that care staff did well for him given his poor health. Care staffr approach towards service users was respectful, sensitive and caring. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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, 13 14 and 15. Not all service users recreational interests and needs were met. Service users were able to exercise choice and control. Mealtime arrangements were well managed and satisfied the majority of service users expectations. EVIDENCE: Davenport Manor offered a flexible routine to service users. Staff encouraged service users to make choices as to how they spent their time, whether they wished to join in activities or not, what they ate and what clothes they chose to wear. The deputy manager was responsible for arranging activities and a number of trips and other events had been arranged throughout the year, such as a trip to Blackpool, a summer fair and a planned trip to Knowsley Safari Park. These trips and events were popular with service users, who told the inspector that they had enjoyed them. Some service users didn’t like the coach trips and chose not to take part. Whilst the home had a structured activities programme at the time of the inspection no activities were taking place. One carer invited a service user to complete a jigsaw; the service user later told the inspector that she had enjoyed this. Other service users were observed to be sitting in one of the three lounge areas, sleeping or watching TV. A number of service users told the inspector that they were quite satisfied with this however several others said that they would like to see more organised activities taking place on a
nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 13 regular basis. Davenport Manor is registered to provide care services for up to 34 service users with a diagnosis of dementia, at the time of the inspection there was no evidence of any specific activities being undertaken with these service users. Service users have the choice of sitting in three lounges and some service users told the inspector that they did not want to move to the main lounge where activities usually happen. Visitors were made welcome at the home and service users kept in touch with family and friends. Meals were served at regular intervals and were usually taken in the dining room areas. The lunchtime meal was the main meal of the day and the teatime meal was lighter with a hot and cold option. Service users told the inspector that they had enjoyed their lunch and that the meals provided were very good and that a wide choice was available. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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) 16 and 18. Service users felt confident that their complaints would be taken seriously and acted upon. Staff had undertaken appropriate training in adult protection, which ensured the protection of service users. EVIDENCE: The home had a detailed complaints policy and procedure; there had been no complaints since the last inspection. Service users with whom the inspector spoke said that they knew who to complain to if they had a problem and all felt confident that the problem would be resolved in a satisfactory manner. One service user added that they had never needed to complain and were very satisfied with the care that they received. The home had a procedure for responding to allegations of abuse. All staff on duty at the time of the inspection had completed training in adult protection, as had all long-term permanent members of staff. The home had recently employed a number of new staff and as part of their induction programme adult protection is looked at. The registered manager also had plans to put these members of staff forward for further in depth adult protection training. The inspector met with a newly appointed member of staff who had recently completed her induction. She demonstrated a good understanding of the issues around adult protection and was clear about her responsibility with regard to reporting abuse and poor practice. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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) 19, 21, 24 and 26. The home was well maintained and provided comfortable living accommodation for service users. EVIDENCE: A number of service users rooms were seen, these were also furnished and equipped to a comfortable standard, many had been personalised by the occupants. Since the last inspection the registered manager had replaced carpets, furniture and curtains in several bedrooms to improve standards within the home. Bathing facilities had also improved and a new assisted bath had been fitted in the home, staff reported that this was popular with service users. The home was clean, tidy, bright and airy throughout and was free from any unpleasant odours. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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) 27, 28, 29 and 30. The home was sufficiently staffed with a staff group that was trained to undertake their duties, and recruitment procedure ensured that service users were protected. EVIDENCE: At the time of the inspection the home was sufficiently staffed to meet the needs of service users. A staff rota showing which staff was on duty and in what capacity was kept at the home. Agency staff were used periodically, the inspector had a discussion with an agency staff member, who told her that she had worked at the home previously and was familiar with routines and service users at the home. Staff appeared to have a positive relationship with the service users. Six new members of staff had commenced employment at the home since the last inspection; the registered manager had followed appropriate recruitment procedures with regard to newly appointed staff. Care staff on duty at the time of the inspection confirmed that they had undertaken further training to assist them in their role as carers. The registered manager informed the inspector that all new staff completed a period of induction at the commencement of their employment with the Skills for Care council. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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) 31, 35 and 38. A competent and trained manager runs the home. the home were addressed. EVIDENCE: The registered manager, Mrs Wendy Drabble has over twenty years experience of working in the residential care profession and is a registered nurse. She holds an NVQ Level 4 qualification in Management and Care and holds the Registered Managers Award. Mrs Drabble had undertaken periodic training to up date her knowledge and skills. Service users are encouraged to handle their own finances or with support from family or representatives. Small amounts of cash were kept for individual service users for day-to-day expenses ie. hairdressing costs. All service users had a secure facility in their bedrooms for personal items, although service users were encouraged to leave anything of great value with their relatives or friends.
nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 18 Health and safety issues at Staff had updated their training in safe handling and moving procedures, fire safety, food hygiene and health and safety. The home maintained records in respect of fire safety at the home. Certificates confirming the maintenance of the bath hoist, electrical and gas supplies to the home were seen on inspection. The home records information in respect of falls and accidents by service users. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 x x 3 nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 20 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 OP 7 Regulation 15(1) Requirement The registered manager must ensure that care plans cover all aspects of health, personal and social care needs of service users. The registered manager must ensure that a photograph is kept of each service user living at the home and that these are placed on the medication administration records to ensure identification of the service user and maintain safe administration of medication. The registered manager must ensure that handwritten medication details on the medication adminstration records are accurate, signed, dated and the details are validated by an additional member of staff. The registered manager must provide a range of activities that meet the needs of all service users at Davenport Manor. Timescale for action 8th October 2005. 2. OP 9 17(1)(a) Schedule 3 8th October 2005. 3. OP 9 13(2) 8th September 2005. 4. OP 12 16(2)(n) 8th January 2005. nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 21 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 Good Practice Recommendations nn F54 F04 davenport manor U s8551 v248145 080905 stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 2nd Floor Heritage Wharf Portland Place Ashton under Lyne, OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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