Inspection on 07/06/05 for Dewi-Sant

This inspection was carried out on 7th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 15/12/05

Dewi-Sant 25/11/04

Dewi-Sant 29/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

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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 PL3 5HG Lead Inspector Tina Maddison Announced 7 June 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dewi Sant Address 32 Eggbuckland Road, Mannamead, Plymouth PL3 5HG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 664923 Mannarest Limited Christine Hanwell 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 D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include 2 named Service Users in MD(E) Category 60 Date of last inspection 25th November 2005 Brief Description of the Service: Dewisant 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 residents with mobility limitations. Because of the layout of the home it is not suitable for wheelchair users. Dewisant 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. Dewisant 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 D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection began at 9.45 am and ended at 4.00pm. During the inspection a meal was sampled, and a tour of the home was conducted. A pre inspection questionnaire was received from the Manager prior to the inspection. Comment cards were received from six relatives, and during the inspection, 9 residents and 3 relatives were interviewed. Discussions were also held with staff members and the Manager and Provider. What the service does well: What has improved since the last inspection? The programme of fitting regulation valves to hot water outlets on baths continues. The electrical wiring has a safety certificate, and the laundry has been refurbished. The new manager has introduced a thorough induction system for new staff. The room number of the room to be occupied should be stated on residents contract. A number of residents commented that they thought that recently the quality and choices of meals had greatly improved. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 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. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5. Prospective residents are able to use a comprehensive service users guide and statement of purpose to influence their choice of care home. They can be confident that Dewisant will meet their care needs. EVIDENCE: Dewisant has a service users guide and statement of purpose, both of which are available in large print if required. Individual records are kept for each of the residents, and records evidenced that the acting Manager had completed a pre admission assessment for recently admitted residents, in order to be sure that their care needs could be met in the home. Information had also been gathered from GPs, families, district nurses, and the residents care manager. A resident confirmed that they had the opportunity to visit the home prior to their admission. In order to ensure that the staff have the skills to enable them to meet residents care needs, records and discussion with care staff and the manager evidenced that staff have received training in first aid, food handling, moving and handling, and in the care of people who have dementia. Contracts contained most of the information required, but do not specify the number of Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 9 the room to be occupied. These contracts were signed by the resident or their representative. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10. Residents can be assured that staff will treat them with respect, and their health and personal care needs will be met. EVIDENCE: Individual care plans were in place for all service users, and contained detailed information regarding how health and personal care needs would be met. There was evidence to show that these care plans are reviewed at least monthly or when needs changed. Service users confirmed that they are involved in reviewing their care plans, and were aware of where the plans are kept and that they could see them if they wanted to. From discussion with residents, management and staff, and from information contained on care plans and documents, Dewisant is able to evidence that it can fully meet the health and personal care needs of its residents. All residents are registered with a GP of their choice. A District nurse visits the home on a regular basis, and a charge nurse operates a weekly health clinic in the home for any general health queries. It was observed during the inspection that privacy and dignity was respected by staff when they were undertaking personal care tasks with residents. Medication is dispensed only by care staff that have received medication training. Medication records were found to be correct and well maintained. Controlled drugs are appropriately stored. Exercise is encouraged Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 11 to aid mobility, and staff appear to have a positive and enabling relationship with all of the residents. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15. Social activities and meals are both well managed, with input from residents encouraged. There is a daily variation in activities provided. EVIDENCE: A number of residents were spoken to during the inspection, and all commented on how much the meals had improved recently, with a greater variety and residents choices included in the menus. Menus evidenced that a good variety of wholesome and nutritious meals are provided. The dining room is a pleasant area, and mealtimes were observed to be relaxed and unhurried. The home operates a two sitting system at lunchtimes. All bedrooms are lockable. A cordless telephone is available for residents to use for private telephone calls. Residents confirmed that daily living routines are flexible, and the home offers an activity programme. Some residents are independent and go to social clubs in the area, or shopping. The home does offer one to one staffing for residents who wish to go shopping. The home has recently undertaken consultation of residents to discover what activities they would like to do. Relatives of service users were spoken to during the inspection, and confirmed that they are always made to feel welcome, and are able to visit at any reasonable time. Service users are able to handle their own money if they wish, and lockable storage is provided in their bedrooms. The home offers an independent advocacy service. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 13 Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 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 standard(s) 16,17,18. Residents can be confident that their concerns will be listened to, taken seriously and acted upon. The homes vulnerable adults procedure is robust which will ensure the protection of residents. EVIDENCE: There is a complaints policy and procedure, and a record of concerns and complaints was examined. No complaints have been received at CSCI during the last six months. Residents stated that they felt that any concerns are taken seriously by the manager and staff, and all residents spoken to were aware of whom they should speak to in the event of a complaint. A complaints procedure was displayed in the home. There is an adult protection policy and procedure, and a staff whistle blowing policy. Staff have attended adult protection training. Records evidenced that residents money is stored securely, and records were found to be up to date and accurate. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26. Dewisant is pleasantly decorated and is very clean, warm and well lit. Gardens are pleasant, with a fully accessible patio area. Overall, Dewisant provides a comfortable and safe environment for residents. EVIDENCE: A tour of the building including all bedrooms evidenced that the interior and exterior of the home are generally in a good state of repair, and are well maintained. All bedrooms are pleasantly decorated and have been personalised by the residents. The home has 34 bedrooms, all are single rooms, with toilet and bathroom facilities nearby. All bathrooms and toilets have were equipped with soap and clean towels to facilitate infection control. The home has two large lounges and a pleasant dining room. Dewisant has a no smoking policy inside, however residents may smoke outside if they wish. The home does not have a passenger lift, but does have a chair lift to all three floors. The home was very clean on the day of inspection, and was free from offensive odours throughout. A maintenance book is kept and any repairs needed are noted and carried out. The Manager confirmed that bedrooms are redecorated when they Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 16 become vacant. There are plans to replace the landing carpet once plumbing work has been carried out. One bathroom would benefit from refurbishment, and the manager confirmed that plans are in place to undertake this work. There is a call bell system in place, and it was noted that call alarms were always accessible to bed ridden residents. The home is heated with electric storage heaters. These are guarded. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. Care staff numbers are adequate to meet the care needs of the current residents. The home has a robust recruitment procedure, and this offers protection to the residents in the home. There is a well qualified staff team who are committed, caring and appropriately skilled to proved care to the residents at Dewisant. EVIDENCE: Staff rotas evidenced that there are adequate numbers of staff on duty at all times, and training records, and discussion with staff evidenced that staff are well trained, experienced and have the skills to meet the needs of the residents. The home has a robust recruitment procedure, and staff files examined evidenced that these procedures are followed. Staff files contained two references, CRB checks, and medical and identity checks are obtained. Residents and relatives spoken to during the inspection confirmed that there was always enough staff on duty and they always came quickly if needed. Staffing at the home is as follows: 8am – 2pm – 6 care staff plus the Manager 2pm – 9pm – 4/5 care staff nights – 2 waking night staff The home also employs 2 cooks and domestic staff. Staff receive at least three paid training days per year, and there is a commitment from the owners of Dewisant towards the training of staff. Staff stated that Dewisant is a relaxed and happy place to work, and believed that they were valued and well trained. Staff supervision and appraisal records Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 18 were available for inspection. The new Manager is developing a thorough induction programme for new staff. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,37,38. A competent manager has been appointed who has respect from the staff team and is highly regarded by the residents. There is a management structure operating in the home that is clearly effective. EVIDENCE: All records are securely stored in the home. The previous registered Manager has recently resigned, and the acting Manager will seek registration in the near future. She has the respect of the staff and is clearly a motivating force in the home. The prospective Manager is qualified to level 4 NVQ in care, and is undertaking her Registered Managers award. Residents spoke highly of the Manager and owners. A quality assurance system should be developed in the home, where the results are recorded and actioned. Health and safety is a priority in the home, and records evidenced that fire safety precautions and drills for staff were up to date. Accidents are recorded appropriately. All areas of the kitchen are cleaned regularly and records kept. Infection control Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 20 practices, policies and procedures were found to be satisfactory. Substances hazardous to health must be locked away. Portable appliance testing has been undertaken. Certificates of safety tests were seen for the chair lifts, hoists and bath chairs. Risk assessments have been carried out for residents, staff and the building that cover all safe working practice topics. The programme to fit hot water temperature regulators to baths is continuing. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 x 3 3 3 2 Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13 Requirement The home must complete its programme of controlling the hot water temperature in the baths and where identified as providing a risk to the health and safety of the service users. Timescale for action 30/9/05 2. 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. Refer to Standard OP33 OP2 Good Practice Recommendations The quality assurance system should be reviewed to provide a system of reviewing the quality of care provided in the home. Rooms to be occupied should be stated on the contract. Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dewi Sant D52-D04 S3475 Dewi Sant V222039 070605 Stage 4.doc Version 1.30 Page 24 - 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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