Inspection on 06/03/07 for Davers Court

This inspection was carried out on 6th March 2007.

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 20/02/06

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 Mary Jeffries Key Unannounced Inspection 6th March 2007 11:00 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 DS0000037636.V307419.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000037636.V307419.R01.S.doc Version 5.2 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 caren.sandle@socserv.suffolkcc.gov.uk 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 DS0000037636.V307419.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 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 residents. All residents 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 residents who need a six week fixed period of care to equip them to return home. Transitional care is for residents 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. The current scale of charges is £331 per week for very dependent residents to £385.00 per week for residents with dementia. Hairdressing, private chiropody, newspapers and toiletries are not included in this price. DS0000037636.V307419.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. The inspection took place during one day in March, and lasted 8hrs. It was facilitated by the Registered Manager, care staff and domestic staff contributed. A tour of the home was made, and the majority of residents were met. Three residents were tracked. A group of residents on the frail elderly unit were spoken briefly, one in more depth and residents on the special needs units were observed. A pre inspection questionnaire was completed by the home during the year. There were four vacancies in the home at the time of the inspection, two in the intermediate treatment unit and two transitional places. One resident was in hospital. What the service does well: What has improved since the last inspection? There was only one requirement made at the last inspection, that being that documentary evidence of staff qualifications were kept on file. These were in place for manual handling and for recently appointed staff. DS0000037636.V307419.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000037636.V307419.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000037636.V307419.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that they will not be admitted to the home unless it is confident and clear that their needs can be met. EVIDENCE: The home stated in its pre inspection questionnaire that there had been no changes to the Statement of Purpose. CSCI have not subsequently been notified of any changes. The home provides both ‘rehabilitation care’ and ‘transitional care’ in Barnham House and Sandalwood House respectively. The rehabilitation care was for residents who needed a six-week fixed period of care to equip them to return home. This was often following hospital operations. One resident had been in the home for approximately a year, this was due to delays in the works being carried out to make their home suitable. They were unhappy about this, as they did not need to be in a home, but very satisfied that the home was very pleasant and assisting appropriately. DS0000037636.V307419.R01.S.doc Version 5.2 Page 9 Intermediate care consists of a structured programme of care, provided for a limited period of time, it assists a resident to maintain or regain the ability to live in his home. This is provided in one unit, with specialised facilities, equipment and staff. Files of the home’s two most recently admitted residents were examined. The contained Compass Social Care assessments and there was evidence that they had been assessed by the home prior to admission. In one there was a stars assessment on file, on the other discharge notes from a nursing home. One of these recently admitted residents had not yet completed the initial 6 weekly trial period during which it is agreed whether the home is suitable for them. There was a contract on file, but it had not yet been signed, as the six weekly review had been postponed to provide for a poorly close relative to attend. Resident files also contained a Service User Guide and a complaints information booklet. Two Occupational Therapists visiting the home on the day of the inspection advised how they contributed to the pre admission assessment for prospective residents to the Intermediate care unit, but were clear that the individuals also had to meet the home’s criteria, and the homes Registered Manager was ultimately responsible for accepting an admission. The home was successfully able to meet different types of resident need that were clearly delineated in the separate houses. The Registered Manager and senior staff were very clear about what particular needs could be accommodated at the home and this was reflected throughout written documentation. The Registered Manager stated that residents could only be admitted to these houses on Monday to Thursday and before 2 p.m. This protocol had been agreed with Suffolk County Council and the local Primary Care Trust and was to avoid emergency and unplanned placements where possible. DS0000037636.V307419.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a full care plan, based on their assessment, but may not be assured it will be fully reviewed in line with the standard so that all current needs are identified and addressed at the earliest opportunity. Residents can expect their health needs to be well met and can have a high degree of confidence that the correct medicine will be administered to them, but cannot be assured that medication will always be given in a timely way. EVIDENCE: The rehabilitation unit benefited from the services of an occupational therapist (OT) 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. An OT spoken with gave an example of a resident who was slipping out of their chair; they were able to suggest a one-way slip draw sheet which solved the problem. DS0000037636.V307419.R01.S.doc Version 5.2 Page 11 The files contained good personal information about residents, life histories, personal care preferences and records, other preferences such as diet and daily routines, detailed night care arrangements, leisure preferences. Contemporaneous care notes were written by care staff very regularly. Those for the residents tracked were appropriate, informative and professional. The care plans were reviewed by key workers on a monthly basis, following a full review six weeks after admission. One plan looked at had no record of a daytime monthly review for several months, since a main review in August 2006. Since then this resident had been into hospital twice, and had had a seizure. Regular monthly nighttime care reviews were on file. Another resident had no daytime review for the month of February, following their monthly review on 10th January 2007. The resident had four entries in the accident book in January, although these events had not caused injury, the resident had been found on the floor on these occasions. At the March review the need for a full review had been identified, and a new risk assessment put in place. Care plans and discussion with staff indicated that the health needs of residents are carefully assessed and monitored, and appropriate intervention is sought at an early stage when problems arise. Records of GP visits and visits from other healthcare professionals, including District Nurses, and Chiropodist were kept. Each resident’s care records contained a manual handling risk assessment, a nutritional assessment, weight monitoring chart and a continence care assessment. The medication for each resident was kept in their room in a locked wall cupboard, which was in the same style as other furniture. Inside the cupboard there was a photograph of the resident. This system allows any resident, who wished and was able, to be self-medicating, and since each administration only used one set of medication at a time, the risk of error is reduced. MAR (medication administration record) charts were also kept in these cupboards. The team leader administering medication advised that there was only one resident on the ordinary units who administered their medication at the present time. The team leader asked each resident’s permission to enter into their room to get their medicines. Medicines were seen to be popped from blister packs into a single medicine pot, and taken, to one resident at a time. Residents were at lunch and had a drink available. The team leader demonstrated a good manner with residents and watched whilst the medicine was taken. However, this invariably meant that the majority of residents were asked to take their tablets mid way through their meal. None objected to this on this occasion. The team leader asked another carer to ensure that one resident took their medication which was soluble, and would reasonably take some time. They advised that they were able to do this as the carer they had asked had also had medication DS0000037636.V307419.R01.S.doc Version 5.2 Page 12 training. Otherwise, medication was signed for by the team leader after they had witnessed it being taken. Half of the medicine administration records, (MAR) sheets were seen, and were generally well completed, without gaps or errors. However, one resident was given their morning medications at lunchtime, 13:20 hrs. The team leader advised that this resident had got up later than usual, and that during the later morning they had been involved in an admission and booking in medication. The care records showed that this resident had risen at 10 o’clock, almost three and a half hours before they were given their morning medication. Medicinal creams were applied by care staff. These were kept in the locked cupboards on the dementia care units, unless they required refrigeration. Separate treatment sheets were kept within residents care plans. An example of this was requested, and the file of the next resident who had creams prescribed was reviewed. This resident had a cream prescribed to be applied twice a day. Since the beginning of the treatment sheet there were two gaps, one of three days, and on several other days the cream was only recorded as having been applied once. Relationships between residents and staff were seen to be warm and friendly, with carers providing support and assistance in a positive, respectful and sensitive manner. During the day, none of the residents on the special needs unit were seen to be in any distress, though they were alert to their surroundings. The home keeps a folder of cards received from relatives. One received in February 2007 stated, “ My mother is very grateful for all of the care and attention you gave her during her recent stay with you. She found the home facilities to be excellent, and much appreciated the caring and professional care which was provided.” DS0000037636.V307419.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to enjoy a good quality of life, and to enjoy choice and control over their lives. Residents can expect that their independence will be encouraged. EVIDENCE: An activities worker comes in one day a week. The activities worker was in the home on the day of the inspection, and a musical session was held during the afternoon. At other times care staff are responsible for activities on the units One resident with special needs used to work for a national newspaper, during the day they spend time checking headlines in a news paper and a member of care staff was seen to be taking an interest in this with the resident. Residents are also able to attend exercise sessions that are organised by the health care staff on the intermediate care unit. An outing for six residents with one to one staffing on a boat was being organised for the summer, in addition to a trip to Felixstowe and to the Abbey Gardens. DS0000037636.V307419.R01.S.doc Version 5.2 Page 14 Several residents spoken with said they could have visitors whenever they liked, and that staff made them feel welcomed. A quality assurance exercise had taken place on food which reminded residents that there friend or relatives could have a meal – at a cost – at the home with them. One relative was at the home during the mid day period and was assisting with the residents mid day meal and feeding in a quiet separate areas. The resident’s care plan noted that this arrangement had been agreed. Whilst breakfast starts at 9am, care staff advised that if someone gets up earlier than this and wants something they can have it. Residents described a range of choices that they have for breakfast. A number of residents had had a cooked breakfast on the day of the inspection, these choices were recorded by the kitchen staff; some had had sausages, some had had bacon and eggs. Snacks were available at all times, including fresh fruit. Residents confirmed that it was enjoyable, and that they had a range of other choices which the kitchen staff had discussed with them. The menu was attractively laid out in print form, with the choices available. Meals are delivered from the kitchen in heated trolleys, and kitchen staff are on hand to serve the food and hear first hand any comments residents may have. Serving dishes are placed on the table to allow residents to serve themselves. The main midday meal served on the day of the inspection was ham, and fresh vegetables. Tables were nicely laid and the food was well presented and looked attractive. The mealtime was seen to be relaxed and comfortable. The questionnaire on food did not include any enquiry into resident’s views on the timing of medication rounds coinciding with meal times. Residents spoken with confirmed that they had considerable choice in their daily lives. One said, “it’s just home, our home. We can do what we like.” One person from the special needs unit was seen to be walking round the building most of the day quite happily, plumping up cushions at times, having coffee with two members of staff at another time, and visiting the Registered Manager later in the day. During the morning some residents were in communal lounge areas, some were up and dressed but in their rooms. One resident tracked had not wanted to get up early as is their usual preference, and had risen late, at 10am. This choice however was not supported by the medication arrangements on the day of the inspection – see standard 9. Hairdressing facilities were available for residents who wished to have their hair done on site. DS0000037636.V307419.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have access to a good complaints procedure and they can expect to have a high degree of satisfaction with the service, based on the attentiveness and responsiveness of staff to respond to any concerns they may have. EVIDENCE: The home uses the Social Care Services complaints procedure, and copies of this were available in the entrance hall, and were provided to all new residents. The Registered Manager advised that the home had received no complaints since the previous inspection nor had the Commission for Social Care Inspection. The Pre inspection questionnaire, which had been completed sometime earlier by an acting manager indicated that two complaints had been received. At the time of the inspection the Registered Manager did not know what these were. The Registered Manager thought they might relate to one resident who had reason to be unhappy with slow progress Social Care and Housing had made on getting their accommodation ready for them to return home. This resident was spoken with, they confirmed that they had no complaints about Davers Court, but had complained about other parties perceived lack of action which had led them to remaining at Davers Court unnecessarily. The Registered Manager subsequently confirmed that two complaints made by this resident through Customer First had been entered on the PIQ, but that they had transpired not to be complaints about the home. DS0000037636.V307419.R01.S.doc Version 5.2 Page 16 Two residents spoken with said that they felt they could say if they weren’t happy with anything to any of the staff, but could ask to see the Registered Manager. They indicated that they felt it was very unlikely that they would ever need to. The home uses the Social Care Services Protection of Vulnerable Adults (PoVA) policy. A senior member of staff spoken with, who is sometimes the senior person on duty was aware of there was a policy and was able to talk about the range of types of abuse residents were vulnerable to. However, they said that had not had training in POVA. When asked what action they would take if they suspected abuse advised they would immediately report it to management and take it from there. All new staff had training around PoVA in their induction, and those that have completed NVQ have done a unit on it. The homes Registered Manager had evidence of in house training in 2003. Locally agreed procedures have changed in that period. The Registered Manager advised that staff had been instructed on the changes. Immediately following the inspection the Registered Manager emailed the commission to confirm that they had located a document signed by staff to confirm they had received written information about the changes to local interagency procedures, and that refresher training was commencing for all staff. The health workers were not employed by the home, but the Registered Manager had obtained copies of the Criminal Record Bureau checks. DS0000037636.V307419.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in an environment that facilitates their lives, is homely, comfortable and well maintained, but cannot be assured that all risks in the environment will be identified and monitored. EVIDENCE: The home is attractive, well designed to meet residents’ needs, decorated and well maintained. Outside of the front door, bowls of spring bulbs added a homely touch. Several well-tended and pleasant secure gardens are available for the use of residents, and communal areas offered good views over the gardens. Residents are placed in one of the four units, but are 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. Entry through the front door was controlled by a keypad to ensure security of all residents. DS0000037636.V307419.R01.S.doc Version 5.2 Page 18 The home provides more than double the recommended communal space per resident. Communal space consists of at least one lounge and one dining room on each house as well as a choice of conservatories and other general communal areas. A good level of storage space was available at the home to store heavy equipment such as wheelchairs, hoists and cleaning machines. The environment was well designed with several adaptations that were suitable for the care of the residents. Floor lights were fitted in the corridors to ensure lighting levels could be kept low, yet safe at night. All residents’ rooms are single rooms. Individual rooms on the special needs unit had identifying pictures, for example one resident who used to be a farm worker had a cow on their door. Individual rooms were furnished to a good standard, personalised, and attractive. In these, and in communal areas there were appropriate adaptations, for example blocks to raise the height of chairs. Two separate lockable storage facilities were provided in each of the bedrooms, one for medications and one for personal effects. A fully operational call bell system was in place with different rings for a standard call for assistance and an emergency. In addition to the baths in the bathrooms on each unit, individual rooms all have en-suites which include assisted shower facilities. In a number of the rooms on the special needs unit the beds were seen to face these en-suites; this is good practice as it is helpful in reminding residents to use the facility. There were also assisted lavatories near to communal areas. Each unit has it’s own kitchen area. On the special needs units the cooker hobs have an override switch located in a high cupboard so that staff can make these unusable at night. Hot water temperatures were taken at three baths and two bathroom sinks and were all found to be just below 43 degrees. Hot water temperatures were taken at two of the sinks in the kitchen / sitting room areas of the special needs units and these were found to be excessive. On Pinewood the temperature was 49.8 degrees Celsius, On Rowan Wood 46 degrees Celsius. This was brought to the attention of the Registered Manager and they arranged for the handy person to adjust these during the day. They were tested later in the day and found to be below 43 degrees. The handy person advised that although hot water temperatures were monitored at all other hot water outlets they had not monitored hot water at these sinks. The home was, with one exception, found to be very clean. One resident’s room had an unpleasant odour. A member of staff advised that the resident was not in their room at that time but had given permission for the carer to enter to obtain their medication. The carer advised that the resident had a catheter, and that it had been arranged for the carpet to be cleaned that afternoon. The en suite bathroom was odour free. DS0000037636.V307419.R01.S.doc Version 5.2 Page 19 The homes kitchen was well organised and very clean. Appropriate records of fridge and freezer temperatures were seen to be maintained. Coloured coded chopping boards were stored on an appropriate rack. The laundry was seen to be very clean and orderly, and mops were stored appropriately within it. Appropriate sluice and laundry facilities were in place, complying with all relevant legislation. Clear instructions on how to use facilities were available for staff. Red bags that seal soiled laundry at source, enable safe transportation of the laundry and are then placed directly in the washing machine were used for all types of soiled laundry. Dirty laundry was moved to the laundry room in clearly marked closed wheelie bins. The home has a smoking room, and the Registered Manager advised that this will comply with the forthcoming regulations. The room is a veranda type room, and staff can observe without entering, it has a self-closing door, and good ventilation. The room has several large green plants. DS0000037636.V307419.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by properly recruited staff, and to be in safe hands. EVIDENCE: Residents spoken with users stated that the “staff are very pleasant” and “you only have to ask or mention something and they will do their best to make sure it is done.” Scrutiny of staffing rosters and discussion with the Registered Manager staff indicated that the staffing levels at the home were based on five care staff being on duty at all times during the day, with each care staff member specifically designated to each house. The staffing structure was that each of the five units had one carer between 7.00 am and 10pm, and that a floating worker was employed between the two units catering for residents with dementia, between 7.30 am and 10 pm, with a half hour overlap between these two shifts at mid day. Staffing levels at night were two care staff and one team leader. Ancillary staff were employed in sufficient numbers to achieve positive outcomes. The Registered Manager was supernumerary to all of these staff. Throughout the day, call bells were heard to be answered promptly, and staff appeared unhurried and attentive to residents. DS0000037636.V307419.R01.S.doc Version 5.2 Page 21 The Pre Inspection Questionnaire (PIQ) provided by the home indicated that 50 of care staff had NVQ. Two staff who held NVQs had left since this questionnaire had been provided, two other carers had achieved theirs, and two more were undertaking NVQs. The PIQ also stated that Manual handling updates, risk assessment updates, food hygiene refresher course, and fire training had been provided. Also, infection control training, Unisafe training, and Medication training. The training register was examined, but was found not to be up to date and did not include dementia training. The Registered Manager advised that some staff had received training included a Person-centred Dementia Care workbook based modular course run by a local college, and a member of staff separately confirmed this. The cook advised that the kitchen staff discuss menus and choices with residents, and that they are able to have dementia training; the cook advised that they had enlisted for this but not yet received it. Manual handling training certificates were found on a sample of staff files selected. The recruitment files for the most recently appointed staff were examined. They contained all the required documentation, and proper recruitment procedures were demonstrated to have taken place. One resident spoken with had recently been involved with the interview process for new carers. They confirmed that they had played a full part in both the interviews and the decision-making process, and had the opportunity to decide what question they wanted to put to the interviewees. Two recently appointed staff had received induction in line with the Skills for Care requirements. DS0000037636.V307419.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a well ordered and well maintained caring and friendly home which has an open atmosphere. They can expect most matters affecting their comfort and well being to be dealt with fully. Residents cannot be assured systems are adequately monitored or flexible enough to ensure all important needs and risks will be responded to. EVIDENCE: The Registered Manager originally trained as a nurse before moving into the care of older people in residential settings. After working as a deputy manager she became the manager of a care home in 1985 and has been the manager of Davers Court since 1996. She gained the CSS qualification in 1991, later completed the Diploma in the Management of Care Services and has also qualified as a NVQ assessor and manual handling co-ordinator. They had a DS0000037636.V307419.R01.S.doc Version 5.2 Page 23 certificate displayed showing their attendance at the Bradford Dementia Mapping course. The Registered Manager had been on secondment away from the home for nine months between the beginning of April 2006 and up until December 2006. During this time a Senior Team Leader had deputised. The Registered Manager advised that they were focusing on consolidation, after the period away. The home enjoys a relaxed and friendly atmosphere, and staff demonstrated a very positive and inclusive approach to caring for residents. There was a pleasant atmosphere at the home on the day of the inspection. The Registered Manager and the staff were open, helpful and positive and residents were complementary. The home had a bi monthly newsletter which had useful information, including welcomes to new residents and notices if the death of residents. A recent quality assurance exercise was undertaken in respect of meal times; high degrees of satisfaction were found. 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. The system for accounting for invoiced purchases was inspected. Invoices from the chiropodist and a list from the hairdresser of residents who had had their hair done were signed and given to the administrator who signed and recorded these before forwarding them. Whilst there were two signatures the procedure did not safeguard vulnerable residents. Property lists were contained within files inspected. A member of staff spoken with advised that supervision took place frequently, sometimes monthly, but no longer than two monthly. Staff files looked at showed that supervision was generally taking place on this basis, however a relief member of care staff who had been employed in October 2006, had no record of supervision following induction. The Registered Manager subsequently provided information that detailed this relief worker’s hours of duty; of 9 shifts worked, 3 were training, 4 were shadow shifts and 2 only were actually completed working on a shift. A current, up to date certificate demonstrating appropriate Employers Liability Insurance for the business was on display outside the main office. The home’s Registration Certificate and notice of the Inspection were displayed. The Statement of Purpose, Service User’s Guide and last Inspection report were available in reception. A risk assessment of the process of food provision was in place. The home’s current five-year electrical certificate was seen. Evidence was seen that all hoists had been regularly serviced. All residents’ room doors had DS0000037636.V307419.R01.S.doc Version 5.2 Page 24 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. A fire safety audit had been undertaken by the Fire and Rescue service in August 2006 and the outcome was considered to be satisfactory. DS0000037636.V307419.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 2 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 3 X 3 X 2 3 X 2 DS0000037636.V307419.R01.S.doc Version 5.2 Page 26 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. 2. 3. 4. Standard OP7 OP9 OP9 OP25 OP38 Regulation 15 13(2) 13(2) 13 (4)(a)(c) 13(6) Requirement Care plans must be fully regularly reviewed in line with the standard. Medication must be given at or as close as possible to the prescribed times. Medicinal creams must be applied as per prescription and records must evidence this. Hot water at all outlets accessible to residents must be monitored and maintained at 43 degrees Celsius. Invoices for goods and services obtained on behalf of residents with special needs must be countersigned by a member of staff who can validate that they have been received. Timescale for action 31/03/07 16/03/07 16/03/07 12/03/07 5. OP35 20/03/07 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 Good Practice Recommendations DS0000037636.V307419.R01.S.doc Version 5.2 Page 27 1. Standard OP9 2. OP15 3. 4. 5. OP18 OP26 OP30 Residents should be asked specifically whether they want to take up the option of having their medications after their meal, unless there is a medical reason otherwise, and this should be recorded. Picture menus should be available fro residents with dementia, and the photograph for the main choice displayed so that residents can enjoy anticipating a specific meal. An update of in house Protection of Vulnerable Adults training, including current local inter agency procedures should be available to any staff requiring this training. The registered person should ensure that staff deal with unpleasant odours quickly and sensitively. A training analysis and plan should be produced for all training other than NVQs. DS0000037636.V307419.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000037636.V307419.R01.S.doc Version 5.2 Page 29 - 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. 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