Inspection on 30/11/06 for Doneraile

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 05/01/06

Doneraile 12/07/05

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 Megan Walker Unannounced Inspection 11:00 30 November 2006 th 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 Doneraile DS0000003691.V314973.R02.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. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Doneraile Address 24 College Road Newton Abbot Devon TQ12 1EQ 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) 01626 354540 F/P 01626 354540 Graham Paul Jones Karen Jones Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25), Physical disability over 65 of places years of age (25) Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Doneraile is a privately owned care home registered to provide accommodation and care for up to twenty-five older people (OP) who may also have physical disability (PD(E)) and/or dementia (DE(E)). The Registered Service Providers are Mrs Karen and Mr Graham Jones. There is also a competent senior staff team who contribute to the daily running of the home. The home has a good record of a long-term staff group. Doneraile is situated in a quiet, attractive residential area about a mile from Newton Abbot town centre. 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 adequate bathing and communal toilets facilities. A shaft lift as well as a stair lift provide access to the upper floors. There are attractive views from some rooms, including the lounge. There is a large sun terrace and garden. Access from the road to the home is via a fairly steep drive. The current fees for Doneraile range from £287 to £400 according to the assessment of individual care needs and the room in which the person is accommodated. Extra costs include hairdressing, chiropody, and other sundry items. The Registered Provider provided this information in the Pre-Inspection Questionnaire received by the Commission in November 2006. The home does not provide intermediate care and it is not registered to provide nursing care. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork part of this inspection took place between 11h00 and 19h30 on Thursday 30th November 2006. It included a tour of the premises, observation of interactions between staff and residents in the home, talking to residents, staff and relatives, inspection of care plans, staff files, medication, and other records and documentation. The Registered Provider, Mrs Karen Jones, was present at the time of this visit, and part of the time was spent talking with her about the day-to-day routines, as well as the management of the home. In addition other information used to inform this inspection: • The Pre-inspection Questionnaire completed by the Registered Provider. • Of sixty-nine Comments’ Cards and Surveys sent out, the Commission received back – • Twenty-two Residents’ Surveys • Fourteen “Relatives/Visitors” Comment Cards • Three Comment Cards from “Health and Social Care Professionals in Contact with the Home” • Five from General Practitioners (one was returned uncompleted “in accordance with practice policy”) • Ten Care Workers Surveys • The previous two inspection reports • All other information relating to Doneraile received by the Commission since the last inspection. The Commission will use information collected during this visit about the Service User’s Guide (sometimes called a brochure or prospectus), the Terms and Conditions of the Contract of Care, and the Complaints Procedure, to inform a wider study about older people’s choices. Further details and the results of this study will be available in May 2007 on the CSCI website www.csci.org.uk. One requirement and four “Good Practice” recommendations were made as a consequence of this inspection. What the service does well: Residents’ benefit from an open and transparent management. A dedicated staff team reflect the home’s philosophy of care in their working practices and in their conduct. A very low staff turnover is an advantage for the residents’ welfare. One resident described the carers’ style at Doneraile as “like being looked after by an extended family”. Another resident wrote, “It (the home) couldn’t be better.” Several residents wrote that they are happy living at Doneraile. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 6 Residents are encouraged to personalise their rooms. The home is clean and has a homely, relaxed atmosphere. Residents are supported to maintain their independence and those who are able to go out alone are encouraged to do so. The Registered Provider also arranges short car trips for those residents who wish to go out. Meals are wholesome and cater for dietary needs. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Doneraile DS0000003691.V314973.R02.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 Doneraile DS0000003691.V314973.R02.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, 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective new residents and their families have a range of information about Doneraile to ensure that they can make an informed decision when choosing a care home. Pre-assessed care needs are carefully considered by the Registered Provider to ensure that these can be met within the context of the home. EVIDENCE: The Registered Providers have produced a Service User’s Guide about Doneraile for prospective residents and their families to consider when choosing a care home. Inspection of several residents’ files found that they had a Contract with a Statement of Terms and Conditions. This included the room the individual would accommodate, the fee for care and accommodation per week, and reasons for revoking the contract. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 9 A random sample of residents were asked if they had seen and/or had a copy of the Service User’s Guide; if they had seen and/or had a copy of their Contract of Care and knew of the terms and conditions for living in the home; if they knew what fee they were paying and how they would know if it had changed; and if anyone had talked to them about their care needs before they moved into the home (this could have been a social worker and/or someone from the home). The majority response was that either families or friends had made all the necessary arrangements and continued to deal with the fees and contract. Most of the residents who were asked about how they had chosen Doneraile talked about a crisis that had precipitated their need for twenty-four hour care. In most cases either the resident or a family member lived in Newton Abbott. They either knew of the home or found out by word of mouth when they started to make enquiries about suitable care homes. One resident explained that a family member had found the home on the Internet. The Registered Provider later confirmed that the home is advertised on www.Yell.Com, a website that gives the name and address of the home with a map and directions if required. It does not provide any details about the home. The Registered Provider also said that they are considering creating a website about the home as this will be beneficial with more people becoming computer literate. Inspection of the residents’ care files found that there were assessments of care needs completed by the home’s senior staff. Pre-assessments were kept in a separate file and it was suggested for ease of use that perhaps the Registered Provider could merge these into the individual residents’ Contract Files. Most of the residents who were asked if anyone had spoken to them about their care needs before they moved into the care home, said that they had visited for a day or had already stayed at the home for respite care. The Registered Provider explained that prospective residents were encouraged to spend at least a few hours at the home before deciding if it was suitable for their needs. This also provided staff with a better opportunity to assess an individual’s needs within the home’s environment. The Registered Provider also said that she or a senior staff member would visit a prospective resident in their own home or in hospital whenever possible. She stressed that this was particularly important to confirm the individual’s ability to walk and move around, as hospital-nursing assessments could be contradictory to actual capability. The Registered Provider said that she verbally offers a place to an individual and/or their family however she does not confirm this in writing. It was recommended at the time of this visit that a letter should be sent to prospective residents confirming that their pre-assessed care needs could be met in the home. Doneraile DS0000003691.V314973.R02.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can feel confident that a staff team that is respectful and reliable will ensure that their care needs are met. EVIDENCE: A resident who returned a survey to the Commission wrote: I am very happy and well looked after and I think that goes for all who live here.” Each care file inspected had good care plans with attention to detail for each individual. The Registered Provider confirmed that these were reviewed monthly or sooner if needed, however as all the care plans were in the process of being rearranged and updated the review process wasn’t yet implemented. Each resident or their representative will be asked to sign their care plan when Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 11 it was complete and they will be invited to be involved in any review. Other records seen on residents files were details of any medical appointments, a personal risk assessment, pressure sore risk assessment (where appropriate), a falls risk assessment (where appropriate), and a medication review form. One General Practitioner (GP) wrote: “I consider this to be a very well run, caring home. It maintains a family atmosphere providing excellent care” and in response to “Are you satisfied with the overall care provided to service users within the home?” this GP wrote “excellent”. A Health Care Professional who has regular contact with the home outlined a good piece of work where they and the staff had worked very closely together to support a vulnerable resident in the home, “I believe I have a good working relationship with the home and have no concerns about their care or liaison with me.” Another Health Care Professional in regular contact with the home wrote: A friendly home, with caring, kind staff…. I enjoy working alongside them all.” It was evident from talking to staff and the Registered Provider, and from observation of interactions between staff and residents, that staff know the residents well. Personal preferences and whims are respected and each resident is treated as an individual. For example, a resident who was feeling unwell on the day of this visit was asked where they would like to eat their midday meal and if they would like a glass of water with the food. The staff member knocked on the bedroom door before entering. She was polite and courteous in her manner when talking to the resident. She did not patronise or make the resident feel awkward about having food brought to the bedroom. Another resident liked to have an afternoon nap and staff respected this. A few of the residents spoken to said that they had their breakfast brought to them in their bedrooms and that they could choose what time they wished to get up. The Registered Provider explained that some residents liked to have a “tipple” either at lunchtime or before bed, usually provided by their families. On birthdays and other special occasions all residents were offered sherry and wine by the home. Staff were conscientious in monitoring any alcohol intake to ensure there were no ill effects, for example, from mixing medication and alcohol, and also residents with a known history of alcohol misuse. All the residents spoken to said that the staff were all very caring and kind. One resident described the staff as “all very friendly”. Some relatives who were visiting at the time of this visit took the opportunity to tell the inspector about their relative and the health improvements made Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 12 since moving into the home that in their opinion was due to the care and attention given by the staff. A relative who returned a Comments’ Card to the commission wrote: “My relative has received wonderful care. I cannot find any fault with Doneraile, staff, site or anything.” Another relative wrote:”X is very relaxed and happy with their care. The staff are all fantastic!” In response to the question in the Care Workers Survey, “Is there anything that the home does really well that you would want to tell us about?” a staff member wrote: “We always have plenty of time to spend with the residents listening to them and learning from them.” The medication was seen kept in a lockable cupboard. The MAR sheets were all seen up to date and signed accordingly. At the time of this visit none of the residents required any controlled medication, and no one was responsible for their own medication with the exception of inhalers. A Pharmacist Inspector was consulted after this visit and he advised that it was the Registered Provider ‘s responsibility to demonstrate that the current arrangement for locking the cupboard where the medication was kept was secure. He also advised that should any controlled medication be required by a resident, that a temporary arrangement for fixing a lockable box inside the medication trolley was acceptable, and the person responsible for medication on each shift would then be the only key holder. The Registered Provider has subsequently confirmed in writing that a risk assessment is in place regarding the medication cupboard. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 13 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. Residents experience a lifestyle in the home that satisfies their expectations. EVIDENCE: Throughout the day of this visit residents were seen around the home, choosing where they preferred to be. A list displayed in the kitchen showed a staff rota assigning daily activity tasks for staff to do with residents each afternoon. A Care Worker’s Survey had a comment from the staff member “The home encourages staff to do social activities to make the residents happy and they enjoy it”. Additionally regular outside performers provide different sorts of musical entertainment at the home. Three times a year “The Clothes Shop” visits the home. Staff described how on the most recent visit they had acted as models for the supplier. This apparently had been a huge success both with the residents and the supplier who sold most of the clothes brought along for the event! The week before this visit, staff and the Registered Provider had taken the majority of residents out for the afternoon to a local Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 14 garden centre to shop and have cream teas. Another staff member wrote in the Care Worker’s Survey, “There is a good social side for the residents.... outings to Dartmoor, ‘X’ restaurant and a local garden centre both summer and winter.” During the weeks leading up to Christmas residents have a selection of events to look forward to including a “Sing-A-Long” to which their families and friends are invited, a Christmas party with a Christmas draw, carol singers from a local church, a local school choir to sing Christmas songs, a Christmas meal in a local restaurant, as well as Christmas Day itself and the festivities arranged by the staff to celebrate this day. Doneraile is not specifically a faith-based care home however it maintains connections with local churches. Residents who wish to may share in a short service of Holy Communion at the home. At the time of this inspection all the residents and staff at Doneraile were white, Christian, agnostics or nonbelievers. Some residents are able to go out unaccompanied for short walks. One resident described the pleasure they get from seeing others out walking in the grounds, the greeting wave as they walk by the windows. Other residents talked about the importance to them to be able to come and go even if it was only ten minutes around the home’s grounds. The home has an “open door” policy and therefore is unsuitable for anyone who may wander. Residents were complimentary about the food. One resident explained about their current medical condition that meant a soft food diet. In a later conversation with the cook she too mentioned this person as well as other residents on special diets. All the residents who were asked about their meals said that they had a selection for breakfast and at teatime there was always a choice of hot or cold food. One resident commented that on moving into the home they had been asked their preference for breakfast and now they were given that every morning. Another resident when asked said they had the same each morning “It’s just brought to me”, however the same resident went on to say that they liked what they were given. All the residents who were asked said that there was not a choice a midday unless they were unwell. The home has a four-week menu rota that showed mainly traditional fare of meat and vegetables. There was no choice at midday although the home’s Service User Guide states: “This (Lunch) consists of a main meal of your choice,…An alternative main course is available if residents don’t like either choice or can’t eat for any reason.” One of the home’s cooks (there were three part time cooks at the time of this visit) said that the residents preferred traditional food. She had tried to introduce pasta dishes, apparently without much success. There didn’t appear Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 15 to be a reason for having only one main dish. The cook confirmed that the menu had been the same for a number of years. When asked to describe the cooking duties for the day, it showed that as well as preparing the main meal for midday, the cook was also expected to bake a cake for tea or suppertime. Night staff did some fresh vegetable preparation to assist towards lunchtime. They were also responsible for setting out breakfast trays ready for morning care staff to take to residents in their bedrooms. Afternoon care staff were responsible for preparing tea and supper. Observation of staff at meals times found them being courteous and not rushing residents. The Registered Provider was advised that, for reasons of hygiene and infection control, staff must wear either tabards or protective aprons when they are involved with food preparation and/or assisting with meals. This must be removed if a resident needs to be escorted to the toilet and whilst giving out medication. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 16 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 their families and friends can feel confident that any issues of concern or complaints raised by them will be dealt with appropriately. EVIDENCE: The home’s Complaints Procedure was seen displayed on the wall at eye level outside the entrance to the dining room. Underneath it was the home’s policy on abuse and a charter of “The Rights of Adults”. Residents said that they felt they were always taken seriously, and any problems sorted out quickly. Most residents spoken to did not know of the home’s complaints procedure. In the event of having to make a complaint, they assumed that they would talk to either a senior staff member or go directly to the Registered Provider if it was a more serious matter. A resident told the inspector about how the Registered Provider had dealt with a recent incident appropriately. And expressed her satisfaction about the safety measures now in place to prevent such an incident occurring again. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 17 Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 18 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, 21, 23, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a well-maintained comfortable environment that is clean, pleasant and hygienic. EVIDENCE: A tour of the premises found the residents’ rooms to be personalised, pleasantly decorated and clean. Most of the bedrooms have an en-suite facility. There are plans to convert a further two bedrooms using existing toilet and bathroom facilities, so they too will have en-suites. Some downstairs bedrooms had patio doors that residents in those rooms clearly appreciated. One resident described being able to use these doors to go out and sit outside in the garden. Another resident was delighted to have the benefit of patio Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 19 doors and had arranged some potted plants on the patio that could be seen from the room. The residents’ lounge has large windows overlooking the garden. It is a light, airy room and tastefully decorated. The hallways have been decorated and new carpets laid since the last inspection. Also a new canopy has been erected over the front door. The Registered Provider talked about future plans to further improve the home. This included upgrading the kitchen that is currently dated in style and layout. Also as part of the conversion of the upstairs bedrooms and bathrooms there will be a second laundry facility that staff could use for sorting clean clothes and ironing. The current laundry is situated in the cellar that is divided into a number of small areas. Improvisation and innovative use has been made of these areas (one section is used as a larder another area for storage, and two areas for drying wet washing). It is accessed via a steep stairway that is not ideal for carrying bulky loads up and down safely, however, the Registered Provider stated that staff are instructed to only carry small loads. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 20 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 good This judgement has been made using available evidence including a visit to this service. Residents are cared for by trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. EVIDENCE: Inspection of a random selection of staff files found that all the necessary checks had been completed however two had only one reference. Some of the files required a recent photograph of the staff member. Staff contracts seen were dated however the Registered Provider explained that a solicitor specialising in Employment Law was reviewing and updating all staff contracts and the Employees Guide. One contract showed that the staff member was employed for forty-eight hours. The Registered Provider confirmed that this was now out of date. New staff received an in-house induction and also attended a foundation induction course arranged by an outside training company. At the time of this visit four staff were doing a National Vocational Award (NVQ) in Care at Level 2. The Registered Provider said that several other staff members who already had Level 2 were keen to start Level 3. A senior staff member was expecting Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 21 to start NVQ Level 4 in Care in January 2007 and follow this with the Registered Manager’s Award (RMA) later in the year. All staff had completed mandatory training such as “Safeguarding Vulnerable Adults”, Infection Control, Basic Food Hygiene, Manual Handling and Fire Safety. The local Primary Care Trust (PCT) had provided training on Continence Care, and Falls. Other short courses attended by staff included Anxiety and Depression, and Dementia Care. Over coming weeks after this inspection staff that needed to renew their first aid certificates were booked for training in First Aid in the Work Place and/or Emergency First Aid. Some staff were also going to do training in Wound Care. The cook confirmed that she had attended a Basic Food Hygiene course however neither she nor either of the other two cooks knew about “Safer Food, Better Business”, a manual and training programme produced by the Food Standards Agency about the change to food handling regulations in January 2006. The Registered Provider confirmed that she had been notified about proposed seminars and had responded requesting a place, however had not been successful. Subsequently to this visit the Registered Provider confirmed in writing that she contacted the local authority again and a manual has since been received by the Registered Provider that has been completed. Staff are now on the waiting list for the next course. The staff rota showed a good ratio of staff to residents. On the day of this visit, in the morning there were four care assistants, two cleaners, and a cook. In the afternoon/evening there were three care assistants and a cook. The Registered Provider and the Assistant Manager were both on duty all day. At night the Registered Providers employ two staff, one of who is awake. Comments received from both relatives and staff indicated that at times there were staff shortages, particularly in the afternoon. Some staff wrote that their shifts were split between domestic chores such as cooking and laundry so “I cannot give the attention to the residents that I would like”. Generally the staff surveys reflected a content group who felt they worked well together as a team for the benefit of the residents. Most relatives responded positively about the staff at Doneraile, e.g. “I have always been extremely impressed with the quality of care given at Doneraile. The staff are both friendly and efficient and it’s always a pleasure to visit.” Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 22 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, 37, 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Health, safety and welfare is promoted and protected by a competent and capable manager who is keen to raise standards and achieve positive outcomes for residents and staff. EVIDENCE: The Registered Provider, Mrs Jones, is also the home’s manager. Residents’ and staff surveys, Comments’ cards, conversations with staff and residents, and observation during the visit showed her popularity and that she is Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 23 approachable. She and Mr Jones have worked hard to improve the environment of the home as well ensure that the home meets the National Minimum Standards. Issues identified during this visit were rectified immediately or noted for attention in the near future. The home was seen being run in an open and transparent way with responsibilities delegated appropriately amongst staff. Staff training is taken seriously and a rolling programme ensures mandatory training is kept up to date for all staff as well as offering individual staff members opportunities to go on courses that may be more relevant to their post. At the time of this visit the Registered Provider was setting up a system of questionnaires to monitor the quality of the service provided at Doneraile. She was expecting it to be ready for distribution in the early part of 2007. This will be given out to residents and their families/representatives, staff, and any other regular visitors to the home such as health and social care professionals. The residents living at Doneraile at the time of this visit either handle their own financial affairs or had made alternative arrangements. At the end of each shift staff coming on duty had a handover when they were updated about each resident and any changes in care needs, including changes to medication. The Registered Provider said that she or a senior staff member observed staff in their working practices however they did not have formal one-to-one supervision sessions. The Registered Provider agreed during this visit to consider if the Assistant Manager as part of her forthcoming Registered Manager’s Award course could do this. A number of staff responded in the Care Worker’s Surveys that they would like to have regular staff meetings as a means of effectively communicating information between all staff. The Registered Provider confirmed that all the necessary maintenance checks as reported in the Pre-Inspection Questionnaire were correct and up to date. The Registered Provider was advised to ensure that exposed wiring outside an identified bedroom was boxed-in for both safety and aesthetic reasons. The Accident Book was seen and accidents had been recorded correctly. The Commission had been notified of any incidents affecting the health, safety or well being of the residents. The Registered Provider was advised that for reasons of hygiene and infection control, staff must wear either tabards or protective aprons when they are involved with food preparation and/or assisting with meals, when they are dealing with laundry both dirty and clean, and when they are handling and distributing medication. She agreed to consider contacting the Health Protection Agency to request a nurse to visit the home for further advice and helpful tips in maintaining high standards of hygiene and preventing crossDoneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 24 infection. The Registered Provider also agreed to contact the local council about “Safer Food, Better Business” in order to implement a new kitchen routine, that would comply with the Food Standards Agency regulations and recommendations. (See: “Staffing”) Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 25 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 4 4 2 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X 3 X 4 4 X 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 4 4 2 X 3 X 3 2 Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 26 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 Sch 2 Requirement 19. – (1) The Registered Provider shall not employ a person to work at the care home unless – (b) s/he has obtained in respect of that person the information and documents specified in – paragraphs 1 to 7 of (i) Schedule 2; This relates to the staff files with only one reference and no recent photograph. Timescale for action 31/01/07 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 OP4 Good Practice Recommendations The Registered Provider should write to prospective residents confirming that they can be accommodated at the home and that their pre-assessed needs can be met at the home. The Registered Provider should provide a choice of main DS0000003691.V314973.R02.S.doc Version 5.2 Page 27 2 Doneraile OP15 3 OP33 4 OP38 courses at lunchtime as stated in the home’s Service User’s Guide and review regularly residents’ preferences for breakfast. The Registered Provider should continue with her plans to implement an effective system to monitor the quality of services provided by the home. A copy of the results and subsequent actions taken should be made available to all residents and their families, any interested parties and stakeholders, and to the Commission. The Registered Provider should consult with the relevant agencies to ensure safe working practices including food hygiene and infection control. Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 28 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 Doneraile DS0000003691.V314973.R02.S.doc Version 5.2 Page 29 - 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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