Inspection on 08/03/06 for Dewdown House

This inspection was carried out on 8th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dewdown House 25/01/07

Dewdown House 16/08/05

Dewdown House 16/02/05

Dewdown House 25/06/04

Dewdown House 10/02/04

Dewdown House 27/08/03

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

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 Dewdown House 64 Beach Road Weston Super Mare North Somerset BS23 4BE Lead Inspector Juanita Glass Unannounced Inspection 09:30 8th March 2006 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 Dewdown House DS0000008038.V282483.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. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dewdown House Address 64 Beach Road Weston Super Mare North Somerset BS23 4BE 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) 01934 417125 01934 631064 Salvation Army Social Services Major Stephen Karl Symonds Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 Brief Description of the Service: Dewdown House is a purpose built home, situated near the sea front of Weston-Super-Mare. The home provides non-nursing care for forty people aged 65 years and over. The home is close to local amenities and staff assist residents to maintain links with the local community. The accommodation is in single rooms over three floors, there is a lift providing access to all floors. The home maintains a Christian ethos. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a very positive unannounced inspection, which took place in the presence of the deputy manager. Residents spoken to during the inspection spoke highly of the standard of care they received. Most residents were observed to be spending their time as they wished, either in their own rooms, following an activity or sitting in the communal areas of the home. One resident spoke at length about staff and the support she received, she said that although it wasnt her own home she felt she lived a full enough life for her age, she also felt staff had an understanding of her need for privacy and that they were always respectful when they spoke to her, during the day staff were observed to have a very friendly and easy rapport with all the residents. Two requirements were made during this inspection one of which remains outstanding from the last inspection. What the service does well: What has improved since the last inspection? The main improvement following the last inspection is the decor in the building, concerns had been raised concerning the need for redecoration following maintenance carried out to make the building accessible for the disabled. A copy of the fire risk assessment is now available for inspection on request. Preadmission assessments now contain more information providing a clear basis for care plans. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 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. Dewdown House DS0000008038.V282483.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 Dewdown House DS0000008038.V282483.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): 1, 2, 3 and 5. 6 does not apply The home provides adequate information for relatives and residents to make an informed choice before taking up residence. A full preadmission assessment is carried out prior to admission, and a visit to the home can be arranged. All residents have signed contracts or statements of terms and conditions EVIDENCE: The statement of purpose has not been revised since the last inspection however it contains all the required information. The Service user guide is very clear and concise, it has been produced in large print and contains graphics and pictures, the service user guide has been commended in previous reports, copies are made available in each room and residents spoken to said they had seen a copy however didnt refer to it that often. The care records for most recently admitted residents showed that preadmission assessments had been carried out and contained more information enabling a fuller care plan to be completed on admission. All care records also contained signed contracts or statements of terms and conditions. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 9 Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Resident’s personal, social care and health needs are fully met. The homes policies and procedures for the administration of medication meet current requirements, however MAR sheets need to be signed. Residents are treated with respect and their rights to privacy are upheld. The home takes into account residents’ personal preferences at the time of their death. EVIDENCE: Records reviewed provided very clear guidance for staff enabling them to meet the assessed needs of the residents, a key worker system is used and some residents spoken to were aware of the role of their key worker and who they were. Care records showed evidence of resident involvement in agreeing boundaries of care, and regular review. The home enables residents to access healthcare services appropriate to their needs and evidence was seen of appointments with Chiropodist, Dentist, Optician and Out Patient Clinics; District Nurse input is sought when necessary. Residents spoken to said that they received the support they required to see any other health professional, they also stated that staff were always polite and respected their privacy. The home has a very clear policy and procedure for the storage and administration of medication, staff were observed to administer medication in Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 11 the correct manner and showed an awareness of the medication they were using. Following a random audit of medication in the home no errors were found, however it was noted that several handwritten entries on MAR sheets had not been signed, all handwritten entries must be signed by the person making the entry. Dewdown House takes into account residents’ personal and religious preferences when facing terminal care they treat residents, relatives and staff with sensitivity and respect. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Residents are offered a range of meaningful activities and links with their church and local community are maintained. Residents are assisted to exercise choice and control over their lives. Residents receive a wholesome appealing and balanced diet. EVIDENCE: Activities are carried out daily by an allocated carer for that day; these include board games, book club, quizzes and puzzles, flexicise, library and regular organised trips out. Management have recognised the need to look at the types of activities offered and to review them so that they continue to be meaningful to the current resident group. The home holds morning prayers daily and transport is provided on Sundays to take residents to Church, Chapel or Citadel. Residents spoken to said they felt they had adequate activities. Residents were observed throughout the day to be making personal choices as to what they did or what activity they attended, the home still includes residents in meetings such as the health and safety group, so that they have a representative say in the running of the home. The home has a four weekly menu which is displayed in the dining room and residents make their choice at the appropriate mealtime so are not expected to remember a choice made earlier in the day. Resident’s comments on the food provided in the home were all complementary, they were very clear about the Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 13 good standard of food provided and the way in which it was presented. One resident repeated comments he had made at the last two inspections, that his reason for selecting the home when he visited was the way in which the dining room was laid up with coordinating tablecloths and napkins. The menus observed showed that residents are offered a choice of nutritious and wholesome meals. The kitchen is clean and tidy and food was stored appropriately. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a clear and robust complaints procedure. The homes policies and procedures protect residents from abuse. EVIDENCE: The home has a robust complaints procedure, which outlines the process to follow, and directs residents or relatives to the Commission for Social Care Inspection if they are not satisfied with the outcome. The complaints book was available for inspection and up-to-date. It was possible when reading the complaints book to follow the course of a complaint from the beginning to it being resolved and the eventual outcome. Residents and visitors spoken to the said that they felt at ease talking to the manager with any concerns, and felt any comments they made were listened to. The home has a very clear policy for the protection of vulnerable adults and elder abuse, and a clear whistle blowing policy. The No Secrets in Somerset folder, outlining the North Somerset policy and procedure for the Protection of Vulnerable Adults, was available for staff in the office. Staff spoken to knew where they could access the information and were aware of the policies and procedures to follow. A recommendation was made that management staff need to access the Adult Protection training provided by North Somerset Social Services, so that they can keep in touch with local changes. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Residents live in a safe well-maintained environment The home is clean, pleasant and hygienic. EVIDENCE: All areas in Dewdown House are accessible to wheelchair users, one service user advises the home on the needs of those in wheelchairs. Extensive refurbishment has been carried out over the last year providing specialist amenities for disabled residents and visitors. Residents spoken to said that the rooms are adequate to meet their needs and it was evident in most of the rooms visited that residents are surrounded by personal possessions and their own Furniture can be bought in if they wish. The home was clean and tidy and well maintained, it was noted that the areas which were in need of redecoration due to maintenance work had been redecorated and returned to its previous standard. Dewdown House DS0000008038.V282483.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 and 30 The numbers and skill mix of staff on duty are appropriate to meet the needs of the residents. The homes recruitment policies and practices do not meet current requirements. Staff are trained and competent to do their jobs. EVIDENCE: Duty rotas for the past month provided evidence to show that the home is adequately staffed. Staff records reviewed contained all the required information, however it was noted that it was difficult to evidence that a POVA first confirmation had been obtained before a new member of staff commenced work in the home. This was discussed with the deputy manager who confirmed that one start date had been delayed until the POVA 1st was received however other records did not contain the relevant proof. All new staff work supervised until a full CRB is received. Staff in the home have received training appropriate to the needs of the residents; 60 of the current care staff have obtained an NVQ 2 or 3, whilst others are registered on courses. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31, 33, 36 and 38 The manager is qualified, competent and experienced to run the home. The home and organisation takes residents opinions into consideration. All new staff are offered a full induction and all staff receive formal supervision. The implementation of health and safety is satisfactory EVIDENCE: The manager is a registered nurse and has the NVQ 4 in Care Management; he has completed the Registered Managers Award at Bridgwater College. The deputy manager has an Open University Managing Care level 3 and has now completed the NVQ4 in Care Management. A residents survey was carried out in November 2005, most of the residents replied; their main concern at the time was the décor following the refurbishment and up grading done earlier in the year, however the majority of Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 18 comments and observations were positive. Residents also take part in house meetings and the health and safety group. All new staff carry out a full induction to the home and are enrolled at Weston College on the TOPSS Induction which also includes basic first aid, when a place is available. All staff have a supervision contract copies of which were seen in staff records, evidence of regular staff supervision was also seen, and staff confirmed that supervision and appraisal identified training needs and personal development. The implementation of health and safety within the home was satisfactory; since the last inspection the fire risk assessment is accessible to staff. The fire log showed clearly that fire alarm tests are carried out on a regular weekly basis, all other required checks were also being carried out at the appropriate times. The home has a safety action group which continues to include all levels of staff and a resident representative; this group carries out a full audit of the home and advises the manager of any needs identified. COSHH data sheets are complete and reflected chemicals used in the home, and all staff handling food have food hygiene certificates. The kitchen and laundry areas were clean and tidy, and staff showed an awareness of appropriate infection control guidelines. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 20 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. 2 Standard OP29 OP9 Regulation Requirement Timescale for action 08/03/06 19(1)Sch2 New staff must be subject to robust recruitment procedures including CRB/ POVA first check 13 (2) Handwritten MAR sheets must be 08/03/06 signed by the person making the entry. 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 OP18 Good Practice Recommendations Management staff need to access POVA training provided by North Somerset Social Services. Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Dewdown House DS0000008038.V282483.R01.S.doc Version 5.1 Page 22 - 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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