Inspection on 28/11/05 for Defoe Court

This inspection was carried out on 28th November 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

Defoe Court 14/10/08

Defoe Court 19/02/08

Defoe Court 16/05/07

Defoe Court 20/06/06

Defoe Court 06/06/05

Defoe Court 16/12/04

Defoe Court 10/06/04

Defoe Court 05/03/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Defoe Court Defoe Crescent Newton Aycliffe Co Durham DL5 4JP Lead Inspector Belinda Parker Unannounced Inspection 28th November 2005 09:00 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 Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Defoe Court Address Defoe Crescent Newton Aycliffe Co Durham DL5 4JP 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) 01325 316316 01325 316633 Southern Cross Home Properties Limited Mrs Lynn Clark Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (4), Terminally ill (3) of places Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 4 persons above the age of 55 may be accommodated within the category of PD commensurate with the home`s Statement of Purpose. 6th June 2005 Date of last inspection Brief Description of the Service: Defoe Court is a registered care home with nursing. It is owned by Southern Cross Home Properties Ltd and located in a residential area of Newton Aycliffe, close to all local amenities. The home is situated in its own private grounds and provides personal care and accommodation for up to 41 older people. The home is purpose built for older people and is on two floors. Personal accommodation and communal areas are located on both floors. Service areas are located on the ground floor. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 28th November 2005 over a period of 7 hours. During the inspection we spoke to service users and staff. A number of records were examined and we toured the building. 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. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 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 the following standard(s): Standards 1,2,3,4 and 5 (Standard 6 is not applicable) The home has in place a clear admission process to ensure the home has the capacity to meet the individual needs of prospective service users. The home’s Statement of Purpose and Service User guide although adequate is currently being reviewed by the company. To present the services provided by the home in a more user friendly and positive manner thus encouraging prospective service users, the manager has developed a DVD virtual tour of the home. EVIDENCE: The home has in place a Statement of Purpose and Service User Guide. These documents are currently under review by the company. Which will provide prospective service users and the people living in the home with clear and up to date information about the service offered by the home. This information will assist prospective service users and their family to make an informed decision as to whether the individual wishes to move in to the home. The company has reviewed the Terms and Conditions of residency. This document is currently being issued to all service users who live in the home. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 8 Service users or their relatives are asked to sign as to their agreement with the service provision. A comprehensive pre-admission assessment is carried out including a draft admission care plan prior to admission by a prospective service user to the home. The manager said service users, relatives and other health care professionals are involved in the admission assessment process. The manager said the home does not admit any individual for whom they do not have the capacity to meet their needs. It is commendable that the manager has developed a DVD virtual tour of the home which along with information and visits to the home prior to admission. The service users and their family have very good information available to enable them to make an informed decision as to whether the individual wishes to move into the home. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 8,9,10 and 11 Care plans are well maintained providing staff with the information they require to adequately meet the health needs of the people living in the home. The home has failed to improve their procedures for recording handwritten entries on MAR sheets where medication is received into the home. This could potentially put service users at risk. EVIDENCE: Three care plans examined contained evidence to show that the health care needs of service users are being met. An audit of medication recording sheets showed that staff are not adhering to the correct procedure for recording hand written entries when medication is received into the home. This issue is concerning and has been outstanding from the last two inspections. The manager must ensure staff follow the correct procedures to maintain the protection of service users. Service users spoken to were complimentary about the care and respect given to them by staff. Comments included, “ I was very ill recently the staff were marvellous, they wouldn’t let me die. And gave me the will to live”, “ I have Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 10 hearing and sight problems, but the staff always take time to let me know what is going on, I don’t like to miss anything”. A policy and procedure is in place in the event of serious illness or death occurs. The manager said the wishes of the service user and their relatives are respected. Arrangements would be made if requested for relatives to stay overnight with their family member if they so wish. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 13, 14 and 15 It was evident from speaking to service users that visiting arrangements in the home are flexible. Service users have appropriate information to make a decision as to whom they would like to speak on their behalf to make their views known. The dietary needs of service users are met. EVIDENCE: The manager said visitors are welcome at any time. A service user spoken to said her family are always made welcome by the staff. New improved information on advocacy services is now available and displayed in the home. This provides service users with information to assist them in making an informed decision as to maybe an independent person other than their family speaking on their behalf. Service users spoken to during the inspection said the choice of food served in the home is good. One service users commented, “ The staff come round and ask you what you would like for dinner and tea”. Care plans examined contained a nutritional assessment. The manager said dietary advice is sought for service users who have specialist dietary needs. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 17 and 18 The home was able to demonstrate that the rights of service users are protected. The registered manager ensures people living in the home are protected from harm or abuse. EVIDENCE: During the recent general election arrangements where in place for the people living in the home to participate in the electoral process if they so wished. Evidence was available to show that the majority of care staff had attended training on POVA (Protection of Vulnerable Adults). The manager said further training sessions are being arranged to ensure that all staff attend the training to provide them with the knowledge and process to ensure the people living in the home are protected from abuse. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 13 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): Standards 21,23,24,25 and 26 The internal environment provides service users with well-maintained and accessible personal and communal accommodation. The registered manager should ensure the home is kept free of offensive odours for the comfort of the people who live in and visit the home. EVIDENCE: Since the last inspection improvements have been made to bathing facilities for the comfort of service users. On the day of the inspection re-decoration of the home was ongoing. On touring the home it was observed that some new chairs had been purchased, providing comfortable seating for service users. The communal areas are light, bright, accessible and provide the people living in the home with a range of comfortable seating and dining areas. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 14 Service users spoken to during the inspection said they were happy with their bedrooms. One service user showed me the range of personal photographs and ornaments she had. Which she said made her room homely. It was observed during the morning while touring the home that offensive odours where present in specific areas. By afternoon the problem had been addressed. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 15 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): Standards 27 and 30 Staffing numbers and skill mix of qualified/unqualified staff are appropriate to meet the collective needs of the people living in the home. EVIDENCE: Evidence was available to show that the home employs staff with the appropriate skill mix and in adequate numbers to meet the needs of service users. Staff vacancies in the home at this time are minimal and do not affect the delivery of care to service users. Each staff member has a personal training profile. On examination of profiles, all training attended by staff is recorded and a copy of training certificate available. The manager demonstrated that she attends training on a regular basis to maintain and develop her own skills and abilities. Ensuring that the people living in the home and other visitors receive a good service. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 16 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): Standards 31 and 32 The registered manager promotes an open, positive and inclusive atmosphere within the home. EVIDENCE: The manager is a qualified nurse with years experience in working with older people. The manager describes her management style as being open, honest, likes to lead by example and likes to involve staff and service users in the decision making process within the home. Regular meetings are held by the manager to pass on information and get the views of the people who live, work and visit the home. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 17 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 3 3 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 3 x x x x 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x x x x Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP8OP9 Regulation 13 (2) Requirement The registered manager must ensure staff responsible for safe handling of medication sign MAR sheet when medication received into the home for individual service users. To ensure health and safety of service users. (Outstanding from two previous inspections. Immediate requirement issued) Timescale for action 28/11/05 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 OP26 Good Practice Recommendations The registered manager should ensure the home is kept free from offensive odours for the comfort of service users. Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Defoe Court DS0000039763.V255618.R01.S.doc Version 5.0 Page 20 - 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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