CARE HOMES FOR OLDER PEOPLE
Doneraile 24 College Road Newton Abbot Devon TQ12 1EQ Lead Inspector
`Mark Sharman Unannounced Inspection 5th January 2006 13:30 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 Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 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.V262739.R01.S.doc Version 5.1 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 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.V262739.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: None. Date of last inspection 12/07/05 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 up to 25 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 lounge. There is a large sun terrace (recently extended) and garden, and there is plenty of car parking on the road outside. Access from the road to the home is via a fairly steep drive. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection and about three hours were spent at the home. Time was spent with the owners, and a small sample of the care records was examined. Ten residents (and one visitor) and three of the staff were spoken with. All of the communal areas of the home and several of the bedrooms were seen. What the service does well: What has improved since the last inspection? What they could do better:
Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 Page 6 One requirement has been repeated again in this report, namely that the radiators in residents’ bedrooms must be guarded to prevent burns in the event of a fall. This is regarded as a priority. Two recommendations have also been made. The laundry floor should be made impermeable and the wall should be readily cleanable. Secondly, in her role as manager of the home it is recommended that Mrs Jones should work towards achieving relevant formal qualifications (the registered managers award and NVQ level 4 in care). 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 DS0000003691.V262739.R01.S.doc Version 5.1 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.V262739.R01.S.doc Version 5.1 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): 3. (Standard 6 is inapplicable.) The needs of potential new residents are assessed before a decision is made about their admission to the home. EVIDENCE: The files of the two residents admitted since the last inspection were examined. In both cases these people had come to the home from hospital, and a completed assessment form had been received by the home from nursing staff. In one case a social worker’s assessment had also been received. The home’s own assessment form had also been completed in both cases. Mrs Jones said that she had seen both of these residents before their admission to the home. Trial visits and stays are offered to help with the decision as to the home’s suitability, and one lady was soon due to visit the home for this purpose. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 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): 7 and 10. The residents’ health care and personal care needs are described in individual care plans. They are treated in a respectful and caring manner by the staff and owners. EVIDENCE: The care plans for the two newest residents were examined. They specified actions to be taken by staff in respect of the residents’ health care and physical care needs, and both care plans included a risk profile and the resident’s preferred daily routine. The risk profiles included a mobility assessment. The residents spoken with said they were satisfied with the care they received and were very complimentary about the attitude of the staff. Those who were asked said that their privacy and dignity are respected by the staff, for example when personal care is carried out. Indeed the staff were seen to treat residents with respect throughout the inspection. Many of the residents have their own telephone, and some were seen. There is a public phone in the hall, and also a cordless one is available if privacy is required. All of the bedrooms are single rooms except for one, currently occupied by a married couple. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 Page 10 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 15. There is a range of appropriate activities and entertainment on offer to the residents. The catering arrangements are satisfactory. EVIDENCE: Regular activities include weekly bingo (called by one of the residents), videos and weekly professional musical entertainment. Three different sets of musicians are engaged in order to provide some variety for the residents. From time to time a trip out is arranged in the locality, for example to a local garden centre. Over the Christmas period all but four of the residents were taken out to a local restaurant for a Christmas lunch. A few of the residents said that they still go out for walks in the vicinity of the home. A staff member is assigned to running activities each afternoon with the residents, for example a quiz or craft activities. Without exception all of the residents who were asked were very satisfied with the meals provided and said that they were offered plenty. The current week’s menu was displayed in the dining room and showed a good variety of meals, including something hot each tea-time. Staff confirmed that there is always an option of something hot for tea. Home made cakes were available with a hot drink during the afternoon. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 Page 11 Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 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): 16. There is a satisfactory complaints system, and residents were confident that any complaint would be taken seriously. EVIDENCE: The home’s complaint procedure was displayed on the notice board. Several residents 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 during the inspection. No complaint about the home has been received by the Commission for Social Care Inspection since the last inspection. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 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, 23 and 26. The home is in an attractive location and provides comfortable accommodation, and has been substantially improved recently. It was warm, clean and tidy. EVIDENCE: The whole building has recently been re-roofed and the exterior has been repainted. The terrace at the front of the building has been considerably extended, and other improvements have been to the front door area thus improving the residents’ access to the terrace and garden. Mr Jones said that communal areas of the home will be re-decorated now that the new roof is completed. The radiators in communal areas have been covered but those in the bedrooms (where there is less staff supervision) have still not been covered, which was discussed with Mr and Mrs Jones. A toilet seat (pointed out to Mrs Jones) in the upstairs bathroom was in need of re-fixing. All parts of the home inspected (including bathrooms and toilets) were clean and there was no unpleasant odour, and residents said that the home is kept
Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 Page 14 clean. Laundry equipment includes a commercial washer and dryer, but the laundry room floor is not impermeable and the walls have a rough finish. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 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): 27 and 28. The staffing arrangements meet the residents’ needs, and staff receive appropriate training for working with this client group. EVIDENCE: This was an unannounced inspection and it was clear from observation that the number of staff on duty was sufficient for the current residents’ needs. Several residents said there were normally enough staff on duty (for example call bells were answered fairly promptly), and this was confirmed in discussion with the staff. They said that they work well together and morale is high. The NVQ target of 50 of care staff with NVQ level 2 (or equivalent) is met at present. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 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 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. The home is managed in a professional way by the owners, who are well regarded by the residents and staff. EVIDENCE: One of the owners, Mrs Jones, also acts as the home’s manager. She has now managed the home for over four years and has gained substantial experience with this client group. She has attended numerous training sessions with her staff, and the residents made it clear that they have confidence in her. However she does not have the formal qualifications envisaged by the Standard, and so it cannot be met unless these are achieved. Accordingly Mrs Jones should work towards the qualifications herself or employ a registered manager who has them. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 Page 17 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 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x 3 x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x x x Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes. 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 All pipework and radiators accessible to service users must be guarded or have low temperature surfaces. (Previous timescale of 31/07/05 not met). Timescale for action 31/07/06 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 OP26 OP31 Good Practice Recommendations The laundry floor should be made impermeable and the wall should be readily cleanable. In her role as manager Mrs Jones should work towards achieving the registered managers award and NVQ level 4 in care. Doneraile DS0000003691.V262739.R01.S.doc Version 5.1 Page 19 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
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