Inspection on 15/12/05 for Dewi-Sant

This inspection was carried out on 15th December 2005.

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 13/12/06

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 Graham Thomas Unannounced Inspection 15th December 2005 9:30 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.V263437.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. Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 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 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.V263437.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include 2 named Service Users in MD(E) Category 60 Date of last inspection 7th June 2005 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. Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection was to monitor progress in respect of previous requirements and recommendations gain service users perceptions of the service they receive. The inspector spoke with eight service users, interviewed four staff and held discussions with the recently Registered Manager. A tour of the building was conducted and the home’s system for the administration of medicines was examined. What the service does well: What has improved since the last inspection? What they could do better: Signing for medication and the use of skin creams in the home needs to be monitored. Training specifically in the areas of mental health and challenging behaviour is recommended. The Registered Manager should complete the development of a system to monitor the quality of the service. Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 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. Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 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.V263437.R01.S.doc Version 5.0 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): 2 Service users are provided with adequately detailed contracts. EVIDENCE: Each service user has a contract provided either by the home or the referring authority. Since the last inspection, contracts have been modified to include the room to be occupied. Dewi Sant DS0000003475.V263437.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): 9 and 10 Service users are adequately protected by the homes policies and procedures concerning medicines. Service users felt that they were treated with due respect by staff and their privacy was properly maintained. EVIDENCE: The home’s systems for the administration of medicines was examined. A monitored dosage system is in operation. Medicines were securely stored with the required additional security for controlled drugs. A dedicated refrigerated facility is available for medicines requiring cold storage. An approved homely remedies list had been obtained and staff guidelines were in place for the use of these medicines. Records were sampled which were found to be up to date and largely in good order. Two witness signatures were found to be missing from the controlled drugs register. This was immediately investigated by the Registered Manager and rectified. Some skin creams in service users’ rooms were found to be unlabelled or with the wrong service users name thus posing a risk of cross-infection. After discussion, the Registered Manager took immediate steps to rectify this shortfall. All bedrooms are lockable. A cordless telephone is available for service users to use for private telephone calls. All service users with whom the inspector spoke Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 Page 10 felt that they were treated with respect by staff and that their dignity was maintained. Dewi Sant DS0000003475.V263437.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): 12 and 13 Service users felt that the lifestyle of the home sufficiently matched their individual needs and expectations. Adequate support is provided to service users to maintain contact with those significant to them. EVIDENCE: Service users confirmed that daily living routines are adequately flexible to accommodate their individual needs. Some service users are independent and go to social clubs in the area, or shopping. One to one staffing is provided for those who require support for shopping trips. Service users confirmed that regular physical activities are held as well as receiving entertainment from local musicians. Also confirmed was the welcome offered to visitors by staff. On the day of inspection a Communion service was being held at the home conducted by a visiting priest. Service users confirmed that they were able to follow their own religious beliefs. Dewi Sant DS0000003475.V263437.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): EVIDENCE: Dewi Sant DS0000003475.V263437.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): 19, 20, 21, 23, 24, 25 Service users at Dewi Sant benefit from a safe, comfortable and clean environment which is generally well maintained. EVIDENCE: Dewi Sant is a three storey property in a residential suburb of Plymouth. Access to all three floors is provided by stair lifts. 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 service users with whom the inspector spoke felt that their rooms were adequately comfortable and met their needs. One bedroom was being redecorated in preparation for the next admission. Toilet and bathroom facilities are accessible from all parts of the home. All bathrooms and toilets have were equipped with soap and clean towels. The Registered Manager stated that, since the last inspection, temperature regulation valves had now been fitted to all baths. The home has two large lounges and a dining room all furnished in a comfortable domestic style. Dewi Sant has a no Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 Page 14 smoking policy inside, however service users 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 Registered Manager stated that the corridor carpet on the first floor is to be replaced early in 2006. The ground floor bathroom was also said to be due for refurbishment at this time. There is a call bell system in place. Call alarms were in reach of those service users confined to bed. The home is heated with electric storage heaters. These are guarded. Dewi Sant DS0000003475.V263437.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): 29 and 30 Recruitment practices, whilst generally adequately robust, do not include sufficient checks for the protection of service users. Service users are supported by a generally well-trained staff group. EVIDENCE: The home’s recruitment procedure includes the completion of an application, a requirement for two references and checks against criminal records and the national list for the protection of vulnerable adults. However the checks acquired in the cases of the most recently recruited staff did not confirm with current national guidance. This requires a fresh check for every new post. Two staff had been accepted on the basis of checks from previous employment which are no longer portable. A staff induction training programme is in place which is certificated by an independent training provider. Most staff have received training in care to at least NVQ level 2. Senior carers are undertaking mentor awards. Staff commented favourably on the Registered Manager’s commitment to training and the opportunities made available since her appointment. Dementia care training has been undertaken by all staff. The home cares for two service users with diagnosed mental health disorders and some service users pose significant levels of verbal and physical challenge. Discussion with staff and observation indicated that they would benefit from further training specifically to support those with mental health needs and challenging behaviour. Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 Page 16 Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 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 and 33 The home is generally well run by a competent Registered Manager. Systems have yet to be fully developed to monitor sufficiently the quality of the service delivered to its users. EVIDENCE: At the time of inspection, the Manager had recently been registered. She has an NVQ level 4 in care and a Registered Managers award. Developments seen during the inspection, the condition of the home and comments of service users and staff indicated that the home is generally well run. The Registered Manager has continued to develop quality assurance measures since the last inspection. Questionnaires completed by service users, minutes of meetings were seen as well as health and safety monitoring forms. There was evidence that suggestions from service users and identified shortfalls had been acted upon. Information about the quality of the service still needs to be summarised and integrated into a coherent quality assurance system which Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 Page 18 demonstrates a clear cycle of information gathering, review, action planning and implementation. Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 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 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 3 3 x 3 3 3 x STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X X Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 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 19 Requirement All staff employed since 26th July 2004 and those employed in future must be subject to a new CRB / POVA check Timescale for action 16/01/05 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. 2. 3 Refer to Standard OP9 OP33 OP30 Good Practice Recommendations The Registered Manager should monitor the labelling of skin creams used in the home and implement regular checking of signatures for medication Work on the home’s quality assurance system should be completed and provide a clear cycle of information gathering, review, action planning and implementation. Training is recommended specifically in mental health and managing challenging behaviour Dewi Sant DS0000003475.V263437.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Ashburton Office 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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