Inspection on 11/10/05 for Dawn Residential Home

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dawn Residential Home 20/01/09

Dawn Residential Home 05/12/06

Dawn Residential Home 02/03/05

Dawn Residential Home 28/09/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Dawn Residential Home Cott Lane Dartington Totnes TQ9 6HE Lead Inspector Margaret Crowley Announced 11 October 2005 th 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. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dawn Residential Home Address Cott Lane, Dartington, Totnes, Devon, TQ9 6HE 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) 01803 862964 01803 840979 Mr Kenneth Ian Barker Mrs Gillian Moira Barker Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 02/03/05 Brief Description of the Service: Dawn is a detached converted residential property set in an acre of grounds with scenic rural views. It provides care for up to 14 service users who are over the age of 65 years in the category of old age only. Service user accommodation is provided on three floors. There are two lounges and a dining room. There is parking for visitors, and attractive gardens with seating areas and a raised decking area with seating. The home is situated in the small village of Cott, near Totnes. There is an accessible local bus service and a local shop and pub. The first phase of a two phase extension has recently been completed, which has provided five new ground floor en suite rooms, and a bath / shower room, staff sleeping accommodation and laundry facilities.The next phase will include a shaft lift to the first and second floors and a new kitchen. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one day on 11thOctober 2005. A tour of the premises took place, and records were inspected. Feedback questionnaires were received from service users and relatives. Service users were spoken with during the inspection. Staff on duty were observed and spoken with in the course of their daily duties. Discussions took place with Mrs Barker, the proprietor and with Sheila Baker, the deputy manager. What the service does well: What has improved since the last inspection? 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. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 6 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 Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 The admission procedure ensures that service users’ needs are assessed and can be met. EVIDENCE: Prospective service users are provided information to assist them in choosing to live at Dawn. The statement of purpose and service user guide should be revised to show the changes in the premises since the last inspection. The statement of purpose should include the number and sizes of rooms, including communal rooms. When new service users are admitted their needs are assessed prior to admission. The management is clear regarding the level of needs that they are able to meet. New service users were spoken with and were confident that their needs can be met at Dawn. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 8 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) 7,8,9,10 Service users have care plans, which are reviewed and enable their needs to be met. EVIDENCE: Evidence was seen of risk assessments and care plans, which are reviewed regularly. Daily records showed that any concerns are recorded and addressed. Service users said that they are well are cared for by staff who are accessible and attentive. Comments from relatives included “The level of care and concern for the resident is genuine and excellent”. Discussions with staff demonstrated their awareness of service users’ needs, including those of new service users. The home maintains good working relationships with the G.P practices and the district nursing service. The systems for the administration of medication are satisfactory with arrangements in place to ensure that service users’ medication needs are met. Staff who administer medicines have received in-house training, but have not yet received accredited training. Medicines are stored in a locked cupboard in the kitchen. The storage facilities do not meet the recommendations of the recommendations of the Royal Pharmaceutical Society The Administration and Control of Medicines in Care Homes (2003). Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 9 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) 12,13,15 Dawn provides a resource for local older people who require care. Service users contact with the local community is encouraged and visitors are welcomed. EVIDENCE: Routines within the home are flexible to ensure that residents can choose how they spend their time. Some service users like to spend time in their own rooms enjoying their interests, but enjoy time spent talking with staff. Informal activities are provided in the lounge, but there is no set activities programme. The premises have an accessible bus service close by and the more able service users will use this to travel into Totnes. There is an open visiting policy and it was confirmed that visitors are made welcome. There is a varied rotating menu. All service users spoken with praised the quality and quantity of the meals. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 10 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) 16,18 Service users can be confident that procedures are in place to enable them to complain and to protect them from abuse. EVIDENCE: The complaints procedure is displayed so that it is accessible to service users. No complaints have been received since the last inspection. Service users were clear as to whom they would go to if they have concerns. There is an adult protection policy and procedure which is accessible to staff. The home has an adult protection video, which staff view. It is recommended that staff receive the multi-agency training in the protection of vulnerable adults. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 11 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) 19,25,26 Service users are provided with accommodation that warm, comfortable, attractive and clean. EVIDENCE: The premises are furnished and decorated to a good standard. There are comfortable and attractive communal areas within the premises, and outside there are large gardens with a decking area with seating. Service users rooms are personalised. Since the last inspection five additional ground floor rooms have been built which have en suite facilities. These are well furnished and equipped. A bath/shower room has also been provided on the ground floor. The rooms on the second and third floors are currently only suitable for service users who can manage stairs, but a shaft lift is to be provided in the next phase of the improvements. Service users rooms do not all have door locks fitted. The programme to install covers to all radiators and pipe work accessible to service users to prevent the risk of service users sustaining a burn, must be completed, commencing with those of greatest assessed risk. The programme to provide temperature control devices to hot water outlets accessible to service users, to prevent the risk of scalds must be completed. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 12 There is an infection control policy and all areas of the home were hygienic and odour free. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 13 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 Staff are employed in sufficient numbers to meet the current service users needs EVIDENCE: The proprietor said that there are sufficient staff employed to meet service users needs by day and by night. Staff spoken with confirmed this. The staff rota was available for inspection. There are two night staff on duty who sleep in. The proprietor said that this adequately meets the service users needs as none have high levels of needs. There is a good range of experience within the staff group. Several staff have worked at Dawn for a number of years. Five of the 15 care staff have NVQ2 or above and others are currently undergoing the training. In addition there are three qualified nurses who work part time at the home. The deputy manager holds NVQ4 in management and care and is undertaking the registered managers award. Staff spoken with confirmed that they are encouraged to undertake training. They felt well supported by the management. Records were inspected of staff recently employed and provided satisfactory evidence of the recruitment and the induction processes. Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 14 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) 31,32,38 Service users enjoy easy access to the resident proprietors. Service users live in an environment where most health and safety standards are satisfactory. EVIDENCE: Mrs Barker is the registered person and lives in a house within the grounds of the home. Dawn has been a family business for several years, although Mr Barker is now less involved now in the day to day running of the home. Mrs Barker holds NVQ 4 in management, but not in care. Mrs Barker and Mrs Baker the deputy manager ensure that there is an open, positive and inclusive atmosphere within the home. This was evident during the inspection from the interaction of service users with the managers and with staff. Routine health and safety issues are managed satisfactorily. Fire and accident records were inspected. Staff received training in fire safety a year ago and are due to have their training updated. It is recommended that this training occur six-monthly, and more frequently for staff on duty at nighttimes. Door wedges have been in use in some service users’ rooms. This practice must cease and Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 15 only approved hold open devices used. The fire exit from the service user’s room on the first floor must have a suitable safe locking device. COSHH data sheets have been provided for products in use and the home has window restrictions above the ground floor. A Legionella risk assessment has not yet been undertaken. Staff are due to receive training in food hygiene Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 16 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x x x x 2 Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13 Requirement The programme of installing covers to all radiators and pipe work accessible to service users to prevent the risk of service users sustaining a burn must be completed, commencing with those of greatest assessed risk. Previous timescale of 31/06/05 not met The programme to provide temperature control devices to hot water outlets accessible to service users, to prevent the risk of scalds must be completed. Previous timescale of 31/06/05 not met A Legionella risk assessment must be undertaken Fire doors must only be held open by approved hold-open devices The fire exit from the service users room on the first floor must have a suitable safe locking device Timescale for action 11/01/06 2. OP25 13 11/12/05 3. 4. 5. OP38 OP38 OP38 13 13 13 11/12/05 11/10/05 11/11/05 Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 18 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 OP1 Good Practice Recommendations The statement of purpose and service user guide should be revised to show the changes in the premises since the last inspection. The statement of purpose should include the number and sizes of rooms, including communal rooms. Medicines should be stored according to the recommendations of the Royal Pharmaceutical Society The Administration and Control of Medicines in Care Homes (2003). Staff should receive training in the administration of medicines Staff should receive the multi-agency training in the protection of vulnerable adults The registered provider should commence training leading to the registered managers award. 2. OP9 3. 4. 5. OP9 OP18 OP31 Dawn Residential Home D54-D07 S3683 Dawn V237116 111005 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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