Inspection on 10/10/06 for Donnington House

This inspection was carried out on 10th October 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

Donnington House 24/10/05

Donnington House 13/06/05

Donnington House 28/10/04

Donnington House 01/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Donnington House 12 Birdham Road Chichester West Sussex PO19 8TE Lead Inspector Ms B Tye Key Unannounced Inspection 10th October 2006 09:00 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 Donnington House DS0000058333.V317550.R01.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. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Donnington House Address 12 Birdham Road Chichester West Sussex PO19 8TE 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) 01243 783883 01243 790174 donnington@waitrose.com Donnington House Care Home Limited Mrs Anne Elizabeth Bareham Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 28 male and/or female service users in the category old age, not falling into any other category Only persons over 65 years may be admitted Date of last inspection 24th October 2005 Brief Description of the Service: Donnington House is a registered care home able to up to twenty-eight people over the age of 65 years with nursing needs. The home is situated close to Chichester town centre, with a regular bus service nearby. Accommodation is provided over two floors, with access to the upper floor via a lift. All rooms are single occupancy, five of which have en-suite facilities. There is a large landscaped garden at the rear of the property with access for wheelchair users. The registered providers are Donnington House Care Home Ltd. Mrs Anne Bareham is the registered manager of the home and Mr J Shippam is the named responsible individual for the organisation. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection all relevant information and correspondence relating to the home was examined including a pre-inspection questionnaire completed by the homes manager. During the course of the inspection the inspector spoke to some of the people living in the home, interviewed staff and spoke at length to the manager. A tour of the premises was undertaken. The inspector observed lunch being served and staff interaction with residents. Four care plans and three staff files were examined and the inspector saw other records including, staff training, maintenance, incident and accident reports and all those relating to health and safety. This is the first inspection of 2006/2007. This is called a key inspection and will determine the frequency of visits/inspections hereafter. What the service does well: What has improved since the last inspection? Since the last inspection the manager has worked in partnership with the Care Training Consortium to implement a comprehensive induction for new staff. Donnington House is one of the few care homes in the South East that is working under the Gold Standards Framework. The focus of this is to plan care in respect of the dying to avoid hospital admissions. It includes working closely with relevant health professionals and residents to achieve the best possible outcome for them at the end of their life. To date, Donnington has produced some excellent work in this area. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Donnington House DS0000058333.V317550.R01.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 Donnington House DS0000058333.V317550.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager carries out a full assessment prior to admission. This ensures residents’ needs can be met appropriately by the home. Each resident is provided with a written contract of terms and conditions, which is signed by all involved parties, so residents are clear about their rights within the home. EVIDENCE: Pre-admission assessments are completed by the manager prior to admission. This outlines relevant areas of need including; health needs, nursing care, diet, communication, social and cultural needs. Additional information and correspondence by community based professionals is collated to form the basis of an on going care plan. This information is kept in residents’ files in a locked cabinet only accessible by care staff to ensure confidentiality. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 9 Risk assessments were in place for all residents. They contain information relating to their specific needs and identified areas of risk. This promotes independence for residents in all aspects of daily living. All residents stated they knew about the home and had visited prior to admission. They confirmed received information about the home including an up to date Service Users guide. This enabled them to make an informed decision about moving to the home and what to expect. All residents’ files contained a signed copy of their Terms and Conditions for the home, to ensure residents are clear about their rights within the home. Donnington House provides respite but does not offer intermediate care. Donnington House DS0000058333.V317550.R01.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All residents have a comprehensive care plan in place, which ensures healthcare needs are met appropriately by staff in the home. Medication procedures are in place and staff had received dispensing medication training as part of their induction in line with the homes policies and procedures. EVIDENCE: All residents spoken to stated they felt the standard of care at Donnington House, in respect of health and personal care was ‘very good’ and ‘staff were always kind and flexible in their approach’. Four care plans were case tracked and all contained detailed information relating to health and personal care needs of residents. Each file contained a record of monthly reviews, which demonstrate the home keeps up to date with changing needs of the residents. Staff stated information on file was clear and easily accessible, informing them of individual needs and how to respond to them appropriately. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 11 Detailed risk assessments for each resident are held on file, which promote the independence of residents within agreed limitations whilst ensuring their health and welfare are paramount. Any specialist health needs are referred to community-based professionals via the GP’s. Correspondence held in individual files supported this. A senior nurse is on duty for every shift, in addition to the manager to ensure the carers at the home have appropriate support and guidance. In relation to health and personal care needs, observation and feedback from residents reflected that they are treated with respect by staff, and their privacy and dignity is upheld. Staff handover at each of the shift changes during the day ensures each staff member is fully aware of the immediate needs of each resident. This information is transferred to daily records in the care plans. All care records seen were detailed, up to date and in excellent order. Staff have completed relevant training relating to helping people who are bereaved and an ‘End of Life’ course, which is held at a local hospice. These courses cover all aspects of care for the dying including mental and emotional issues and support to relatives. In addition to this the manager is a trained bereavement counsellor who provides support, advice and practice guidance to the staff as needed. The home has an up to date policy, procedure and code of practice relating to dispensing medication. Care files contained signed agreements, risk assessments and policies for residents who self medicate. Medication charts and storage of medicines within the home was examined. These were all completed correctly, demonstrating the staff adhere to the procedures within the home. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices where possible. Residents said their families were made to feel welcome when they visited. Meals offered at the home are nutritionally balanced and varied according to dietary requirements and preference. EVIDENCE: Residents’ visitors are welcomed to the home and feedback from residents confirmed that contact with family and friends is encouraged. Residents stated they are supported to actively pursue areas of interests in the wider community. Some residents at the home lead independent lives and still have established links in the wider community. Activities are organised at the home on a regular basis, offering stimulation to those residents who are less able to explore interests outside the home. Forthcoming activities and events are displayed on the community pin boards throughout the home and recorded in the homes activities log. The manager Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 13 undertakes a regular audit of activities to monitor participation and interests of the residents. The manager has implemented a comprehensive care-planning system, which details all aspects of each resident’s care needs. Risk assessments are included in the plans to support residents’ independence whilst identifying and reducing risk. Each aspect of care has a procedure, which is kept in a staff log. This ensures staff are consistent and accountable in all their work practices. Senior staff within the home monitor all work practices. The menu offered at Donnington House offers a wide range of balanced, home cooked food. Residents spoken to stated the food is of a good standard. Residents are able to eat either with other residents in the dining area or in their own room, should they prefer. The chef speaks with the residents on a regular basis to gain feedback about the meals provided. This promotes choice for the residents and provides an opportunity for them to eat what they prefer. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Donnington House has appropriate systems in place to ensure residents are protected from abuse and their legal rights are protected within the home. EVIDENCE: All staff have undertaken a full induction and Adult Abuse training to ensure they respond appropriately to suspected abuse in the home. The home has up to date policies and procedures on Adult Protection procedures, in line with West Sussex County guidelines. Information about complaints is provided as part of the Service Users Guide. This information is supported by policies and procedures at the home, and distributed to residents prior to admission. Residents spoken to say they felt confident the management and staff would listen to their complaints. The Commission has received no complaints since the previous inspection. The home holds a complaints log and three minor complaints had been made and resolved since the last inspection. The procedures for the recruitment of staff are robust and provide the necessary safeguards to offer protection to the residents living in the home. All care staff have undertaken a Criminal Records Bureau enhanced check to ensure they are suitable to work with vulnerable people. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 15 Staff members have completed or are participating in training leading to a National Vocational Qualification Level 2 and 3. This promotes awareness of what constitutes bad practice. The home has clear Financial policies and procedures in place. Information relating to finances is included in individual care plans and signed by the resident or their representative. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The communal areas of the home and residents bedrooms were clean and homely providing the residents with a pleasant and hygienic living environment. Specialist equipment is provided to maximise the independence of residents. EVIDENCE: Following a tour of the premises and examination of maintenance records it is evident the home provides a well-maintained and safe environment. Recording systems in the home demonstrated all fire; health and safety checks are regularly undertaken and up to date. Equipment is regularly serviced and certificates held on file. All areas of the home have been risk assessed to reduce and where possible, eliminate potential hazards to residents. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 17 Standards of hygiene and cleanliness are high throughout the home, this was evidenced by observations of the use of anti bacterial soap, gloves, colour coded bags and posted health and safety notices at washing areas. The home employs cleaners to ensure the standards of cleanliness are maintained. Residents confirmed their rooms were cleaned and tidied on a daily basis. Policies and procedures are in place for infection control, and staff have attended relevant training. This promotes good practice in the area of hygiene and reduces the risk of infection spreading within the home. Bedrooms seen were furnished with pictures and personal possessions and the option is given to bring furniture from home, giving each resident a sense of ownership in their private space. In addition to their own rooms the residents have access to a communal lounge, a sun lounge and dining area, which are furnished and decorated to a good standard. There were lots of plants and pictures around the home, giving it a homely feel. The property has a large well-kept garden at the rear, which some residents’ bedrooms overlook. The overall standard of accommodation provided of a good standard. All residents spoken to confirm this, by stating they ‘loved being at the home’ and were ‘pleased with their rooms’. A call bell is provided in every room so staff are aware and can attend an emergency situation should it arise. There is a passenger lift for residents with limited mobility to access all floors of the house. Provision of a bath-slide, grab rails and raised seating in toilets provide individuals with limited mobility more independence. The maintenance log showed all maintenance was completed as required on a regular basis by a handy man employed by the home. This means the residents’ environment is kept safe and well maintained. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff numbers are sufficient to meet the assessed needs of residents. Recruitment procedures and record keeping are robust to ensure that residents are in safe hands at all times. EVIDENCE: Donnington House has a full compliment of staff at present. The duty rotas showed an adequate number of staff are on duty at all times. A senior nurse leads each shift to offer guidance and support to care staff as required. The manager has employed additional staff to cover staff sickness and holidays. This eliminates the need for agency staff and ensures consistency of care is provided within the home. Recruitment policies and procedures are in place to ensure staff employed by the home, have the necessary skills and experience to fulfil their roles. CRB checks, terms and conditions and job descriptions were seen on file for staff members. This ensures residents are protected by appropriate recruitment systems. Domestic staff are employed in sufficient numbers to ensure that the standards relating to good food and cleanliness are adhered to. Infection Control policy and procedures were in place to support staff practice in this area. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 19 Staff members, who were interviewed, stated that they found the manager and senior staff to be inclusive and supportive in their approach. Records and certificates were available in respect of mandatory and specialist training. The manager has implemented an induction programme in partnership with the Care Training Consortium to ensure all staff are able to meet residents needs effectively from the commencement of employment at the home. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from the leadership and management approach within the home. Overall the residents’ health, safety and welfare is a priority within the home, and this is supported by efficient administration and monitoring systems. EVIDENCE: Mrs Anne Bareham is a qualified nurse and has completed the Registered Managers Award. Staff feedback reflected that Mrs Bareham provides a clear sense of leadership and direction. Staff spoken to stated she was ‘very supportive and easy to talk to should a problem arise’. This enables staff to seek guidance if needed to ensure residents’ needs met appropriately. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 21 Policies and procedures are in place and kept up to date in line with changing legislation. Mrs Bareham is proactive in gaining information from the Commission website and implementing changes in the home in line with recent legislation. Residents’ finances are protected by policies, procedures and record keeping. All financial transactions are recorded and signed for. Records are up to date and monitored by the homes finance officer. An annual quality assurance report is in place, which includes contributions from service users and their families. Feedback forms received by the commission prior to the inspection reflected residents, family members and health professionals considered Donnington House offers a high standard of care to its residents. Resident meetings allow participants of the home to be kept up to date with changes and able to give their views about how the home is run. However, a recent meeting for residents is now overdue and it was recommended that the manager ensure these take place at regular intervals. The inspector examined record keeping for all aspects of health and safety, risk assessments and policies. The manager monitors these at regular intervals and all those seen were in good order and up to date. This practice ensures the occupants of the home are safeguarded and protected. Most staff spoken to stated they received regular supervision and support from the manager. Some records were evidenced on staff files, however not all records reflected staff supervision was occurring on a regular basis. The manager is aware of this and intends to formalise future supervision sessions, in line with the National Care Standards requirements. A requirement has been made in respect of this, to ensure staff supervision occurs no less than six times a year and is recorded appropriately. The Responsible Individual of the home undertakes monthly Regulation 26 visits. Copies of reports are sent to the Commission on a monthly basis. It was evident the management style at the home suits the residents and staff team, enabling them to live and work positively within the environment. Residents were seen to be confident in expressing their views and staff responded with consideration and respect, reflecting a positive ethos within the home. Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 22 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 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 4 3 Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 23 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 OP36 Regulation 18 Requirement The staff should recieve formal supervision no less than 6x a year, which covers aspects of practice, career development needs, and the philosophy of the home. Timescale for action 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Donnington House DS0000058333.V317550.R01.S.doc Version 5.2 Page 25 - 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. 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