Inspection on 20/02/06 for Davers Court

This inspection was carried out on 20th February 2006.

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 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

Davers Court 06/03/07

Davers Court 27/09/05

Davers Court 06/01/05

Davers Court 08/09/04

Davers Court 22/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Davers Court Shakers Lane Bury St Edmunds Suffolk IP32 7BN Lead Inspector John Goodship Unannounced Inspection 20th February 2006 10:00 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 Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 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. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Davers Court Address Shakers Lane Bury St Edmunds Suffolk IP32 7BN 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) 01284 352590 01284 352589 Suffolk County Council Mrs Mary Elizabeth Lambert Care Home 34 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (19) of places Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Davers Court is a purpose built home for older people, situated in a quiet road not far from the centre of Bury St Edmunds in Suffolk. It is a single storey building laid out around a central courtyard and has been completely refurbished and adapted to a high standard to provide care for up to 34 service users. All service users who live at the home have their own spacious bedroom, with en suite shower and toilet. The home is divided into four ‘houses’. Rosewood caters for frail older persons. Rowanwood and Pinewood accommodate older persons who have a diagnosis of dementia and consequently have a high level of dependency. Sandalwood and Barnham are designated for short-term rehabilitation and transitional care. Rehabilitation care is for service users who need a six week fixed period of care to equip them to return home. Transitional care is for service users who need care for a temporary, but unspecified length of time to consider whether a home care package, residential care or returning home is the right option for them. Davers Court is owned and managed by Suffolk County Council. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place in the morning. The manager was present throughout. The main purpose of the visit was to check that requirements and recommendations made following the previous inspection in September 2005 had been actioned. All the key standards have now been assessed at least once within a twelve month period. A tour of the home was made, and several residents were able and happy to speak to the inspector. One visitor arrived with two dogs to see their relative, and they discussed their view of the home with the inspector. What the service does well: What has improved since the last inspection? What they could do better: Although the keeping of care plans in a resident’s room is in line with the philosophy of giving people control over their lives, care must be taken to keep the information in the plans confidential to the resident, and any other person agreed by the resident. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 6 One resident’s room had an unpleasant odour. Staff were not aware of this but did know that the resident may have developed a medical condition which could contribute to the problem. The doctor had been called, but staff should have taken action to eliminate the odour. Staff files must contain copies of all training certificates. 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. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 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 Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 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): 2,3,4. Residents are not admitted to the home unless it is clear that the home can meet their needs. EVIDENCE: The file for the most recently admitted resident was examined. It contained the appropriate pre-admission assessment. As this person had not yet completed the initial 6 weekly trial period during which it is agreed whether the home is suitable for them, no contract had yet been signed. Contracts were present for other residents. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 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): 7,8,9,10. Residents can expect to have their needs set out in an individual plan, and to have their health needs met. Residents have access to their care plans, which are kept in their room. Residents are protected by the home’s procedures for the safe administration of medication. EVIDENCE: The rehabilitation unit benefited from the services of an occupational therapist and a physiotherapist. Staff could also seek advice from these professionals on residents of other units, which increased the ability of the home to monitor and take action to meet the health needs of residents. All residents were weighed on admission, and then monthly. This was confirmed in the care plan of a resident. The home had a chair type weighing machine which catered for non-weight bearing residents. It was noted that care plans were kept in each resident’s room, as they were considered to be ‘their’ plans. This was good practice, to allow residents to access information about themselves, and to help staff record events Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 10 immediately. However this could allow visitors to the room to read them. The home should ensure that residents agree who has access to their care plans to maintain confidentiality. This should be reflected in the home’s Confidentiality Policy. There was a “Keeping Well Unit” attached to the home. It ran a six week programme mainly for people living at home, but a few of the residents attended. This unit had a separate entrance. The manager and a team leader were trained as dementia care mappers. A team leader explained how this approach had helped staff to assess and plan proactively for residents’ behaviour and actions, to set out how staff should manage residents, and helped to inform reviews of care. The medication for each resident was kept in their room in a locked wall cupboard, which was in the same style as other furniture. This system had been adopted to allow any resident, who wished and was able, to be selfmedicating, and also it improved security in that it reduced the possibility of dispensing to the wrong resident, and meant that each administration only used one set of medication at a time. MAR (medication administration record) charts were also kept in these cupboards. Most of the residents in the rehabilitation (rehab) unit were able to selfmedicate as this would be part of the rehab plan to enable them to move into self-caring accommodation. The inspector spoke to one resident in the rehab unit, who described how they managed their medication, and how the staff monitored them regularly. This person also self-administered oxygen from a cylinder in the room. Proper security for this cylinder was in place and the required notice placed on the room door for fire access information. The previous report had recommended that the home review the timing of medication at meal times. The manager reported that this had been done, and she had explained to some residents that staff could not complete the process until they had seen the resident take the medication. The manager confirmed that residents could ask to take their medication after the meal unless there was a medical reason otherwise. Some residents were seen to be given medication at lunchtime, and were quite content to take it. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 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): 12,14. Residents can choose how and where they spend their time. They can expect to be consulted about their preferences for daily activities. EVIDENCE: Although residents were placed in one of the four units, they were free to walk throughout the building. One exit from the special needs unit was alarmed to alert staff that a resident from that unit had left it. One person from that unit was seen to be walking round the building but under the supervision of the staff. Entry through the front door was controlled by a keypad to ensure security of all residents. Following the comments of some residents at the last inspection, the home had undertaken a survey of their wishes about suitable activities which could be put on. An activities worker comes in one day a week; at other times care staff are responsible for activities on the units. The survey had led to a Tai Chi session, cooking (which staff said was very popular), and reminiscence quizzes. The home was also visited by the Pat a Pet scheme, carpet bowls were scheduled, and gardening took place in the right weather. The manager showed the inspector a questionnaire that had just been circulated, asking what residents would like to do to celebrate the Queen’s 80th birthday. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 12 The inspector spoke to two residents who were sitting in the lobby. They said they sat there a couple of times a week to “keep an eye on who was coming in”. They were sitting with a volunteer who joined them regularly for conversation. This person was an official volunteer with a name badge. They also had a relative in the home. Other residents were sitting in the lounge areas of their units. They all chatted to the inspector and said they normally sat where they were. They said they were well-cared for, and content with their accommodation. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 13 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. Residents can be confident that their views and concerns will be listened to. EVIDENCE: The home had received no complaints since the previous inspection nor had the Commission for Social Care Inspection. A visitor said that if they had any concern about the care of their relation they would raise it with any of the staff, but the need had never arisen. They said that the staff were always friendly and helpful. “I can’t think of any one of them that is not pleasant and cheerful”. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 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): 25,26. Residents live in a secure environment with freedom of movement within the building. Residents live in a clean and pleasant purpose-built home which is a comfortable and, because it is divided into small units, a homely place. EVIDENCE: Although residents were placed in one of the four units, they were free to walk throughout the building. One exit from the special needs unit was alarmed to alert staff that a resident from that unit had left it. One person from this unit was seen to be walking round the building but staff were aware of this. The front door was operated by a keypad to ensure security of all residents. Two staff had completed a distance learning course on Infection Control run by a local college. Action had been taken to implement the recommendation from the previous report concerning the need to include domestic and laundry arrangements in the Cross-infection policy. It was noticed that dirty laundry was moved to the laundry room in clearly marked closed wheelie bins. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 15 One resident’s room had an unpleasant odour, although the visitor in that room did not mention it during a discussion of their relative’s care. When it was queried afterwards with a team leader, they said that they believed the resident had an infection, and they were waiting for the doctor to call to check this. This was the only area where there was any suggestion of an unpleasant smell. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 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): 27,29,30. Residents can expect to be cared for by a stable and competent staff group, who have received appropriate training, and have been recruited safely. EVIDENCE: Staffing levels had been examined at the previous inspection and found to be appropriate. There were two carer vacancies at this inspection but two people were about to be employed. All pre-employment checks had been undertaken and the required information was in the files. The manager commented that one person’s start date had been delayed due to the policy of one previous employer not to give references. The recruitment file for the newest member of staff was examined. It contained all the required documentation, except a copy of the person’s NVQ 2 Certificate which they had achieved with a previous employer. The member of staff confirmed to the inspector that they had this qualification. The manager agreed to place a copy of the certificate in the file. This person was on duty during the inspection and appeared to have a friendly relationship with residents. They confirmed aspects of their previous experience, and commented that, as a relief carer, they were moved around the units as required. They did not find this a problem. The training register was examined and contained information on the training events that staff had attended and the ones scheduled. In particular, fire training, and moving and handling, refresher sessions had now been completed Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 17 for all staff. The manager reported that a day and night team leader had been designated to be responsible for ensuring that training is accessed by staff. Recent training included a Person-centred Dementia Care workbook based modular course run by a local college. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 18 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): 32,33,36,37,38. Residents benefit from a well run home. This is evident from the interest and commitment of staff. Residents are protected by the proper completion of all documentation, with a regular audit of care plans to ensure residents’ needs are being met. This process is incorporated into staff supervision where appropriate. Residents’ safety is now better protected with alarm-linked door closers and an up-to-date fire risk assessment. EVIDENCE: There was evidence that regular supervision sessions for staff were being undertaken regularly. As part of the quality assurance process, the manager reported that she asked the senior staff to bring a selection of care plans to each session, which were examined for completeness and for being up-to-date. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 19 Staff meetings were held once a month, including specific meetings for night staff. The home did not hold any money on behalf of residents. Residents either kept their own money, or purchases were invoiced by the Finance section of the County Council. All residents’ room doors had recently been fitted with automatic door closers linked to the fire alarm. These allowed the door to be held open at any point in its swing, as residents chose. The fire risk assessment had been fully completed. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 20 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 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 3 3 3 3 3 Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 21 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 OP29 Regulation 19, Schedule 2(5) Timescale for action The registered person must keep 28/02/06 documentary evidence of any relevant qualifications and training of staff. Requirement 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 2 Refer to Standard OP10 OP26 Good Practice Recommendations The registered person should ensure that the practice of keeping personal care plans in the resident’s room maintains their privacy and confidentiality. The registered person should ensure that staff deal with unpleasant odours quickly and sensitively. Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Davers Court DS0000037636.V284113.R01.S.doc Version 5.1 Page 23 - 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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