Inspection on 12/07/05 for Doneraile

This inspection was carried out on 12th July 2005.

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

The inspector 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

Doneraile 13/06/08

Doneraile 30/11/06

Doneraile 05/01/06

Doneraile 18/01/05

Doneraile 15/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Doneraile 24 College Road Newton Abbot Devon TQ12 1EQ Lead Inspector Mark Sharman Announced 12 July 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. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Doneraile Address 24 College Road, Newton Abbot, Devon, TQ12 1EQ 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) 01626 354540 01626 354540 Graham Paul Jones Karen Jones Care Home 25 Category(ies) of Care HomeDementia (25), Old age, not falling registration, with number within any other category (25), Physical of places disability over 65 years of age (25) Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 18/1/05 Brief Description of the Service: Doneraile is situated in a quiet, attractive residential area about a mile from Newton Abbot town centre. The home is registered to care for people aged 65 and over, including those with physical disability problems and dementia (although severely confused people are not accommodated). All but one of the bedrooms are single rooms, and there is a lounge and separate dining room. More than half of the bedrooms have en suite facilities, and there is a shaft lift. There are attractive views from some rooms, including the communal lounge. There is a sun terrace (at present being extended) and garden, and there is plenty of car parking on the road outside. Immediate access to the home is via a fairly steep drive. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over about 7 hours. A questionnaire completed by the owners was received before the inspection. Also received were four comment cards completed by residents and one completed by a relative. A sample of residents’ care records was inspected. Twelve residents, two relatives and four staff were interviewed, and most of the rooms in the building were inspected. What the service does well: What has improved since the last inspection? The main improvements are to the building, which is currently surrounded by scaffolding because the whole roof is being renewed. At the same time the whole of the exterior is being repainted. The terracing at the side of the building has now been completed, and in addition the terrace at the front is being significantly extended. When finished this will give residents a much Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 6 larger, level outdoor area overlooking the garden, with level access from the house. 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. Doneraile D54-D07 S3691 Doneraile V224118 120705 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 Doneraile D54-D07 S3691 Doneraile V224118 120705 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) 3. Standard 6 is inapplicable. The registered providers are well aware of the importance of obtaining an accurate assessment of a possible new resident’s needs, and no-one moves into the home unless an assessment has been carried out. EVIDENCE: In the three residents’ files inspected there was a completed assessment, carried out (by hospital staff in each of these cases) prior to the resident being admitted to the home. In each case the home’s own assessment form had also been completed by home staff, including a social history. Mrs Jones visits prospective residents in their own home or in hospital if practicable, usually with a senior carer as well. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 9. The residents’ health care and personal care needs are described in an individual care plan, and these needs are being well met. There is a safe system for handling residents’ medication. EVIDENCE: The care plans of three residents were examined. These specified actions to be taken by staff in respect of the residents’ health care and physical care needs, although there was rather limited information in respect of social care needs. Each care plan included a risk profile and the resident’s preferred daily routine. There were brief records of monthly reviews having taken place. All residents are registered with general practitioners. Dental services are accessed, including NHS dentists, and chiropody and optician. A district nurse attended one of the residents during this inspection. Some equipment in respect of pressure area prevention was on loan to the home, including an airflow type mattress. The medication cabinet was inspected, as was a sample of medication administration recording sheets. The staff handover meeting at change of shift was attended, at which a number of residents’ health problems (and emotional problems) were discussed. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 10 Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 14. The activities and entertainment on offer suit the residents’ preferences and particular interests, and they are able to make choices for themselves. They are helped to maintain contact with their relatives and friends. EVIDENCE: Residents said that routines are reasonably flexible, for example they may have meals in their own rooms (which some do). A staff member is assigned to activities each afternoon, and on this day one of the staff held a drawing/painting session for those who were interested. Regular activities include weekly bingo, videos and professional musical entertainment. A variety of musicians are employed, and two singer/guitarists entertained residents on the morning of this inspection (which was very popular). An programme of activities for July was displayed. A few of the service users said that they regularly go out for walks in the vicinity of the home. Many residents have regular visitors, and two visitors spoken to said that they are always made welcome. Many of the bedrooms were personalised by their occupants, and some had facilities such as a refrigerator or equipment for making hot drinks. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 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 standard(s) 16 and 18. There is a satisfactory complaints system, and arrangements for protecting residents from abuse are also satisfactory. EVIDENCE: The home’s complaint procedure was displayed on the notice board. The residents spoken to said they were confident that Mr and Mrs Jones would try to deal with any complaint they might have, although in fact no complaint was expressed. No complaint about the home has been received by the Commission for Social Care Inspection since the last inspection. There are written policies and procedures designed to minimise the risk of abuse, including a whistleblowing policy. A summary of the abuse policy is displayed on a notice board. Staff spoken to said that the policies are always available to them, and they were aware of the home’s whistleblowing policy. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 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 standard(s) 19, 25 and 26. The home is in an attractive location and provides comfortable accommodation, and there is an ongoing improvement programme. Safety will continue to be compromised until bedroom radiators are guarded. The home was clean and hygienic. EVIDENCE: The whole building is currently being re-roofed and the exterior is being repainted. The terrace at the front of the building is being extended, and other external improvements have been made recently. Access to outside areas has been improved. Mr Jones said that communal areas will be re-decorated when the new roof is completed. The radiators in communal areas have been covered. Those in the bedrooms (where there is less staff supervision) have still not been covered, and this was discussed with Mr and Mrs Jones. Upstairs windows are restricted, with one exception which was discussed. All parts of the home inspected were clean and there was no unpleasant odour, and the residents said that the home is always kept clean. The laundry is Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 14 adequate, although the floor is not impermeable and the walls have a rough finish. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 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 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, 29 and 30. Staffing arrangements are satisfactory and staff morale is high, resulting in an enthusiastic workforce. The recruitment practice was satisfactory, and the staff receive training appropriate to working with this client group. EVIDENCE: All of the residents spoken to said that there are enough staff employed to cater for their needs, and that for example their call bells are answered promptly. They also said that the staff are very helpful and cheerful, which was apparent from observation on the day of the inspection. Staff spoken to said that the staffing levels maintained are normally sufficient. Criminal Records Bureau disclosures were inspected for the most recent staff, and a sample of references was also seen. About half of the care staff have achieved NVQ level 2 (or 3) or are currently working towards it. The staff training file was inspected and contained a substantial number of certificates of achievement or attendance at training events. This also showed that the two most recent carers have had induction training to NTO specification. All staff receive external training in manual handling, fire safety, food hygiene and first aid. Some have recently attended training on dementia care, falls prevention and diabetes. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 33, 35 and 38. Although the registered providers have substantial contact with residents and staff there is no formalised quality monitoring system. Residents’ financial interests are safeguarded. In general there is a good health and safety regime, but bedroom radiators are yet to be guarded. EVIDENCE: It was clear that the registered providers spend a substantial time working at the home. They are in regular contact with residents and staff, but it is recommended that there should be a system for obtaining feedback from residents, relatives and staff on the quality of the services provided. The personal money of several residents is administered by Mrs Jones and written records of this were available, including receipts. With regard to health and safety staff receive regular training in fire safety (twice yearly), manual handling and first aid, and certificates of attendance were seen. All staff also receive food hygiene training. The registered providers said that all upstairs windows are restricted with the exception of one Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 17 bedroom, in respect of which the risk has been assessed. Some cleaning chemicals were being stored in the sluice room, and an immediate requirement was made to keep these in a locked area. With regard to health and safety issues the principal concern remains that of radiator guards, which are still not fitted in the bedrooms. A further requirement was made in respect of this. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 18 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x 2 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 Standard No 16 17 18 Score 3 x 3 x x 2 x 3 x x 2 Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 19 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 25 Regulation 13 Requirement All pipework and radiators accessible to service users must be guarded or have low temperature surfaces. (Previous timescale 31/7/05). Cleaning chemicals must be stored in a secure area. Timescale for action 31/1/06 2. 38 13 With immediate effect. 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 26 Good Practice Recommendations The laundry floor should be made impermeable and the wall should be readily cleanable. Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 20 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 Doneraile D54-D07 S3691 Doneraile V224118 120705 Stage 4.doc Version 1.30 Page 21 - 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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