Inspection on 13/12/06 for Dewi-Sant

This inspection was carried out on 13th December 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dewi-Sant 23/07/10

Dewi-Sant 07/05/10

Dewi-Sant 18/03/09

Dewi-Sant 15/12/05

Dewi-Sant 07/06/05

Dewi-Sant 25/11/04

Dewi-Sant 29/06/04

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 Dewi Sant 32 Eggbuckland Road Mannamead Plymouth Devon PL3 5HG Lead Inspector Jane Gurnell Unannounced Inspection 13th December 2006 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 Dewi Sant DS0000003475.V290571.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. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dewi Sant Address 32 Eggbuckland Road Mannamead Plymouth Devon PL3 5HG 01752 664923 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) Mannarest Limited Mrs Jennie Dawn Preston Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34) of places Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include 2 named Service Users in MD(E) Category 60 Date of last inspection 15/12/05 Brief Description of the Service: Dewi Sant is a large older building located close to the centre of Mutley Plain shopping centre, and near the city centre of Plymouth. Although close to shops and services, the home is quiet inside, and has a pleasant enclosed garden. The accommodation is provided on three floors, with a stair lift provided to reach the upper floors for service users with mobility limitations. Because of the layout of the home it is not suitable for wheelchair users. Dewi Sant has two large lounges, and a conservatory and dining room on the ground floor. The home has four bathrooms, one with a bath hoist, and three with bath seats. There are eight toilets in the home. Dewi Sant is registered to provide care for a maximum of thirty four service users over the age of 64 years for reason of old age and dementia. Information relating to the services provided at Dewi Sant can be obtained directly form the home. The current weekly fees range from £273 to £330. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken on 12th December over the lunchtime and early afternoon period. Prior to the inspection, the Commission had sent surveys to the home to allow those residents who are able to comment directly to the Commission regarding their experiences and the quality of the services provided. Those surveys returned commented favourably about the home. The inspector made a tour of the building, spoke to residents and staff, and examined care plans, staff files and the home’s quality assurance documentation. The Registered Manager, Mrs Preston was available and she and her staff team assisted the inspector throughout the inspection. This inspection also contains information from a random inspection made to Dewi Sant on 7th June 2006 following an anonymous complaint received by the Commission in relation to the welfare of 2 residents. The complaint was not upheld and no breaches in the Care Homes Regulations were identified. The results of the inspection will be discussed in the section of this report for Health and Personal Care. What the service does well: What has improved since the last inspection? What they could do better: Advice was given to include a description of what each resident was able to do for him- or herself to prevent the loss of skills and ensure staff are fully aware of each resident’s abilities. A requirement was made to ensure 2 written references are obtained for each employee prior to the commencement of employment to provide evidence of their past work performance, their good character and suitability to work in a care home. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 6 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. Dewi Sant DS0000003475.V290571.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 Dewi Sant DS0000003475.V290571.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): 1, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments ensure that the prospective resident’s needs are known prior to admission and that Dewi Sant is able to provide an appropriate service. EVIDENCE: One newly admitted resident explained how she had been able to visit the home prior to making a decision to move in and had been given information about the home to assist her with her decision. She said that she had been made very welcome and had settled in well. A pre-admission assessment was available for this resident indicating that the Registered Manager had assessed her care needs before offering her a place at Dewi Sant. The pre-admission assessments have been developed further to ensure the religious and cultural needs of prospective residents are addressed and allows for discussion to ensure these are known and can be met. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 9 A resident who had responded using the written surveys, said that her daughter had consulted with the home at length about her needs and had been given the opportunity to discuss her admission with a Community Mental Health Nurse prior to making a decision to move into the home. This demonstrates the Registered Manager’s commitment to assisting prospective residents to make an informed choice over the suitability of the care home. Dewi Sant DS0000003475.V290571.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, 11. 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 staff will treat them with respect and their health and personal care needs will be met. EVIDENCE: The inspector reviewed in detail the care plans of 4 residents. Care plans are the documents that describe each resident’s health, personal, psychological and social care needs and the action required by staff to meet those needs in a consistent manner. The Registered Manager was in the process of updating the care plans to include a more detailed description of the residents’ needs. Advice was given to include a description of what each resident was able to do for him- or herself to prevent the loss of skills and ensure staff are fully aware of each resident’s abilities. Those residents consulted either in person on the day of the inspection, or prior to the inspection with the surveys, confirmed that their needs are met and they are satisfied with the quality of the service at the home. One resident said “attention is paid to every detail”, another that “every effort is made to maintain a high standard of care”. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 11 Medication is stored safely and the administration records were well maintained and accurate. Those staff responsible for the administration of medication have received training from the local pharmacist ensuring they are aware of safe medication practices. In June 2006 the Commission received an anonymous complaint regarding the welfare of 2 residents and alleging that manual handling practices were unsafe. On 7th June the Commission undertook a random inspection of the care home to look at the particular issues raised. As part of this inspection, the inspector spoke with the two service users involved, reviewed their care plans, and consulted with the District Nurse and Social Worker involved with their care: both of who spoke favourably of the care and support provided at Dewi Sant. The inspector concluded that the complaint was not upheld and there had been no breaches in the Care Homes Regulations 2001. The care of these residents was well documented and the inspector determined that their needs were being met. Plymouth City Council’s Environmental Health Department had also received a copy of the complaint and the Environmental Health Officer joined the Commission’s inspector at the inspection. It was identified by the Environmental Health Officer that a slope created by placing ramps to enable wheelchair access over the 4 stairs to one of the bedrooms was too steep and placed both staff and the resident at risk of injury. The Registered Manager offered the resident a different room and the matter was resolved. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 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. 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. Social activities are managed well and provide interest for the residents. Meals are nutritious and varied. EVIDENCE: Those residents who are able are encouraged to continue with their interests and hobbies outside of the home. The majority of the residents however have dementia that affects their ability to socialise independently. The Registered Manager organises regular social activities to provide interest and stimulation for the residents. Family and friends are made welcome and can visit at all reasonable times of the day. One resident said that her daughter visits regularly and is made very welcome. Her daughter is kept fully informed and the staff liaise with her frequently. At the time of the inspection the inspector was able to observe the lunchtime meal. There are 2 “sittings” for meals at the home to ensure everyone has the time and support they need to enjoy their meal in comfort and to prevent the dining room from becoming over crowded with staff assisting those who need extra help. The inspector witnessed residents being assisted to eat their meal in an unhurried and pleasant manner. One resident said “the quality and quantity of the food is always good”. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 and relatives can be confident that their concerns will be listened to, taken seriously and acted upon. The home’s vulnerable adults procedure is robust and will ensure the protection of residents. EVIDENCE: Those residents consulted said the Registered Manager and her staff team were very approachable and felt confident their concerns would be dealt with promptly and to their satisfaction. The complaints procedure is displayed in the main hallway making it easily accessible to residents, relatives and other visitors to the home. The Commission received an anonymous complaint about the welfare of 2 residents, which has been discussed under the section for Health and Personal Care. At the time of the random inspection in June, the Deputy Manager and her staff team fully co-operated with the Commission demonstrating their professional approach to dealing with complaints and concerns. The Registered Manager is aware of Plymouth City Council’s procedure for reporting suspected abuse and her responsibility should she suspect a resident is at risk. Care staff have received training in the protection of vulnerable adults making them aware of the symptoms of abuse and their responsibilities. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Dewi Sant provides a safe and pleasant home for its residents. EVIDENCE: On inspection, both the interior and exterior of the premises were in a generally good state of repair and well maintained. The home has 34 bedrooms all of which are single. All bedrooms were pleasantly decorated and have been personalised by the service users. All the residents with whom the inspector spoke felt that their rooms were adequately comfortable and met their needs. Toilet and bathroom facilities are accessible from all parts of the home. Temperature regulation valves had been fitted to all baths to reduce the risk of scalds. The home has two large lounge rooms and a dining room all furnished in a comfortable domestic style. Dewi Sant has a no smoking policy inside, however residents may smoke outside if they wish. Cleaning was in progress during the inspection and a high standard of cleanliness was observed throughout. All part of the home were free from offensive odours. The home is heated with electric storage heaters that are guarded to reduce the risk of burns. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practices do not include sufficient checks for the protection of residents. Residents are supported by a generally well-trained staff group. EVIDENCE: Residents said the staff are very kind and caring. They said they are assisted promptly which indicates that there are sufficient staff employed to meet the needs of those currently living in the home. One resident said that there are “always members of staff in the main areas of the home available to help and on hand for any problems”. At the time of the inspection there were 5 care staff on duty, 2 catering staff and 2 domestic and laundry staff as well as the Registered Manager. The inspector examined the personnel files of 4 staff members. All were found to have a Criminal Record Bureau disclosure, the necessary check to ensure as far as possible only suitable staff are employed at the home. Of the 4 files examined, 2 contained no written references and the other 2 held one reference: all staff must have 2 written references prior to the commencement of their employment to provide evidence of their past work performance, their good character and suitability to work in a care home. The Registered Manager explained that Mannarest Ltd’s administrator oversees the employment checks for each employee and that the references may be held in her office. The Registered Manager was advised to keep documentation relating to each Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 16 employee in one place for easy access and to allow an audit trail of the home’s recruitment practices. Records were available of the training undertaken by the care staff. The home uses a distance learning training provider to ensure staff are kept up to date in their statutory training, such as first aid and manual handling, and issues relating to the care needs of their residents, such as dementia care. The majority of staff have a National Vocational Qualification and a number of staff have recently completed a training course in the needs of people who suffer from anxiety and depression, which is common amongst older people and those with dementia, demonstrating the Registered Manager’s commitment to ensuring her staff team have the knowledge and skills to care for older people with complex needs. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well run by a competent Registered Manager. EVIDENCE: From discussions with the residents, staff and the Registered Manager it was evident that home is well run. Mrs Preston has demonstrating her skills and commitment to the welfare of the residents and staff throughout this and previous inspections. Evidence was available that Mrs Preston consults with residents, relatives and staff every few months to assess the quality of the services being provided: the results of written surveys, housing-keeping and maintenance audits as well as meeting minutes were available for inspection and indicated the Registered Manager and staff’s commitment to providing high quality care to the residents. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 18 Staff said they are well supported in their role and receive supervision from the Registered Manager to assess their work performance, identify any particular difficulties and to plan their forthcoming training. Documentation relating to the servicing of equipment, such as the stair lifts and the fire alarm system, was available and provided evidence that equipment is maintained in safe working order. Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation Reg. 19 (1)(b) Schedule 2(3) Requirement (1) The registered person shall not employ a person to work at the care home unless— (b) subject to paragraphs (6), (8) and (9), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. Schedule 2(3) Two written references, including, where applicable, a reference relating to the person’s last period of employment, which involved work with children or vulnerable adults, of not less than three months duration. This relates to the employment of staff without obtaining 2 written references. Timescale for action 31/01/07 Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 21 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 Standard Good Practice Recommendations Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Dewi Sant DS0000003475.V290571.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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