Inspection on 13/06/05 for Donnington House

This inspection was carried out on 13th June 2005.

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

The inspector 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 10/10/06

Donnington House 24/10/05

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 Beth Tye Unannounced Monday, 13 June 2005 V231923 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. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Donnington House Address 12 Birdham Road, Chichester, West Sussex, PO19 8TE 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) 01243 783883 Donnington House Care Home Limited Mrs Anne Elizabeth Bareham Care Home 28 places Category(ies) of Old age, not falling within any other category registration, with number (OP) 28 places of places Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2004 Brief Description of the Service: Donnington House is a registered Care Home able to accomodate up to twenty eight people over the age of 65 with nursing and residential needs. The home is situated close to Chichester town centre, with a regular bus service nearby. Accomodation is provided over two floors, with access to the upper floor via a lift. All rooms are single occupancy, five of which have ensuite facilities. There is a mature garden to the rear of the property with access for wheelchair users. The registered providers are Donnington House Care Home Ltd. Mrs Ann Bareham is the registered manager in charge of the day to day running of the home. Mr J Shippam is the named responsible individual for the organisation. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 13th June 2005 over a period of 5 hours. Prior to the inspection the inspector examined information on the current file spanning the last eight months. Five residents and a visitor were spoken to during the inspection. Four staff were interviewed. All confirmed they were satisfied with the standard of care provided. Care plans for four service users were examined, along with health and safety systems, staff files and training records. A tour of the home was undertaken on arrival. The manager of the home, Mrs Ann Bareham was working in the home at the time of the inspection and spent some time assisting the inspector in gathering relevant information. What the service does well: What has improved since the last inspection? The manager demonstrated she has been working hard since the last inspection to provide more efficient administrative systems, which will support care provision at the home. These will enable staff to spend more time with residents and less on paperwork but still ensure the records contain all relevant information. They will also provide staff with better accountability, promote clear roles and responsibilities whilst enabling the manger to monitor the care provided more effectively. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 6 Some of these systems were still in draft and not in place on the day of inspection. These will all be reviewed on the next inspection at the home 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. Donnington House H60-H11 S58333 Donnington House V231923 130605 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 Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 - 5 Residents and family members are able to visit the home and are given information about the service to help them decide whether it is suitable. The manager completes a written individual assessment prior to admission to ensure residents needs can be met appropriately. Each resident is provided with a written contract of Terms and Conditions, along with a Statement of Purpose and Service Users Guide. This ensures residents are clear about their rights within the home. EVIDENCE: All residents spoken to said they or their relatives had visited the home prior to admission. Most were local to the area and knew of the home by its good reputation. Each resident spoken to confirmed they had been seen and assessed by the manager before moving to the home. The inspector examined four detailed pre- admission assessments, which supported this information. Each assessment forms a basis for an on–going care plan and includes areas such as personal care, physical needs, diet, nursing needs, daily living and health. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 9 This information enables both parties to decide if the home is suitable and able to meet the needs of prospective residents. Additional information and correspondence by involved professionals were seen on file. Relevant risk assessments were in place and had been updated. All residents said they had received a copy of their Terms and Conditions for the home, which they had signed following admission. Copies of these were seen on each residents file. Intermediate care is not provided at the home. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 -10 All healthcare needs are clearly recorded on individual care plans. Any intervention by community health professionals is also recorded. Feedback from staff and residents, along with detailed records show the healthcare needs of each resident is met to a good standard. Medication procedures are in place and supported by staff training, which promotes good practice when dealing with medication. Service users are able to self-administer medication if they wish. This procedure is supported by disclaimers and risk assessments, promoting independence of individuals where possible. Feedback from residents and observations by the inspector showed residents are afforded privacy and treated with dignity within the home. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 11 EVIDENCE: Four care plans were examined in full and each contained well-ordered, detailed information relating to individual health and personal care needs of the residents. The inspector noted that none of the care plans seen had been signed by the residents, which made their involvement of the care planning process unclear. The manager stated this was due to the information being transferred to a new format and each resident would be seen to agree and sign the forms. This process will also include the introduction of new review forms. This will be monitored at the next inspection. The home has detailed policies and procedures in place for dispensing and storing medication. Residents who wish to self medicate are supported to do so by detailed risk assessments and disclaimer forms. The staff are all due to take a training course to promote good practice when dispensing medication in the home. The manager informed the inspector that the home will be adopting a new and more efficient method of storing and dispensing medication. This will be monitored and assessed at the next inspection. Staff handovers occur at each shift change during the day, keeping staff up to date with immediate needs of the residents. A qualified nurse leads each shift to offer specialist advice and support to carers. Some specialist health needs are referred to community based professionals via the GP’s. Information seen on individual files supported this. All the residents spoken to by the inspector stated they felt the standard of care was high within the home. They commented ‘staff are very kind and caring’. One resident who was very positive about the home, also stated that the staff had not put the call bell in her reach whilst she was immobile in bed. This could cause a potential risk to the individual. Consequently, the manager was informed and reassured the inspector it was an oversight that would not happen again. She made a note to remind staff of this during handover. Overall, observations on the day of inspection reflected that staff treated individuals with respect and dignity. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 - 15 Resident’s visitors are welcomed to the home and contact with friends and family members encouraged. Activities are held in-house on a regular basis offering stimulation to those residents who are less able to explore interests outside the home. Transport is provided to those who wish to peruse interests in the wider community. The activities provided support residents to satisfy their social, recreational and cultural needs. The home provides varied meals, which the residents stated were ‘very good’. The home holds regular meetings for relatives of residents but does not hold residents meetings. This would enable residents to contribute to the way the service is run. EVIDENCE: The inspector saw the homes activities log, which confirmed the home provides regular in house entertainment for its residents, including; music, pantomimes, a pianist, bingo and puzzles. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 13 Some residents go out regularly with family members and carers provide one to one activities for residents in the lounge. One visitor stated she ‘is always welcomed and encouraged to visit the home as often as she wished’. Staff were seen chatting to residents and the atmosphere was relaxed and friendly. The main lounge has a television and music system available. There is also a second lounge which provides privacy for visitors if they want it. The cook was interviewed by the inspector and is dedicated to providing a good standard of food to the residents. She told the inspector she spoke to individuals on a regular basis to ensure she was cooking meals that they like. Residents appeared to enjoy their food and all those spoken to confirmed they were offered a choice and the food was always ‘very good’. The manager has recently organised a relatives group, which offers support and information on a regular basis. However, there was no similar group for residents. The inspector felt that the home needed to be more pro-active in enabling residents to contribute towards decisions about their care and the running of the home. Absence of input to individual care plans and no opportunity for group meetings could deny residents opportunities to exercise choice and control in their lives. The manager was in full agreement with this and stated her intention to address this area as soon as possible. This will be monitored at the next inspection. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has a policies and procedures in place relating to Whistle Blowing, Complaints and Protection of Vulnerable Adults. A Complaints procedure is included in the Service Users Guide informing residents of how to complain and who to. Records showed that staff had not completed any Adult Protection training. Therefore the inspector could not conclude the residents are protected or an allegation of abuse would be dealt with appropriately. This significantly increases risk to the residents in the home. A requirement has been made in respect of this. EVIDENCE: The complaints book for the home was examined. There have been no complaints made since the last inspection. All service users and the visitor spoken to said they knew how to complain, who to and would feel confident in doing so. The home had county procedures and a policy in place for protecting vulnerable adults from abuse. However the staff had not been formally instructed in adult protection procedures. Three of the staff interviewed knew how to act internally but were unclear of procedures for reporting outside the home. A requirement has been made to provide staff with relevant training in this area so staff can act effectively should an incident occur. Therefore providing better protection of residents living in the home. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 - 26 The communal areas of the home and residents bedrooms were clean and homely providing residents with a pleasant living environment. Ramped access to the well-kept garden gives residents the option to sit outside in warmer weather. There are sufficient toilets and bathrooms to meet the resident’s needs. Renovation of the upstairs bathrooms and bedrooms is planned for end of 2005, as some areas need modernising. Specialist occupational equipment has been provided to maximise the independence of residents. The home currently has limited storage space, which results in wheelchairs being stored under stairs and in communal areas. Plans for a large shed to be built in the garden are underway, which will solve this problem. In the meantime risk assessments have been completed for the use of storage in the home to minimise risk. Some maintenance records were not up to date increasing potential risk of injury to residents. A requirement was made in respect of this. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 16 EVIDENCE: The residents have access to a large community lounge/dining area, which is comfortably furnished and has a homely atmosphere. A second lounge allows residents privacy for visitors if they want it. A passenger lift gives access to upper floors for those with limited mobility. Bedrooms were safe and comfortable and contained personal possessions of the occupants, giving them a sense of ownership in their personal space. Each resident spoken to said how much they liked their rooms. Each resident has lockable facilities to store money and valuables. A handyman, cleaning and laundry staff are employed to ensure the premises is kept clean. This also allows carers to focus on prioritizing care provision rather than completion of domestic tasks around the home. En-suite facilities, shared bathroom and toilets on each floor provide the residents with sufficient toilets and washing facilities. Aids and adaptations are provided throughout the home to maximise residents’ independence. An on call pager system in every room enables staff to respond promptly to residents who summon assistance. Staff must ensure all call bells are accessible to residents who are bed bound to ensure staff can respond speedily if needed. The home has up to date policies and procedures relating to infection control. Anti bacterial hand-wash and paper towels were seen at each sink. Kitchen and cleaning staff were observed wearing plastic gloves. Colour coded bins were in evidence for waste disposal and a sluice room is used for soiled garments. All these measures actively reduce the risk of infection spreading within the home. All rooms are naturally ventilated. Low impact radiators have been fitted to reduce the risk of burns to residents. Hot water outlets are fitted with thermostatic valves. All records relating to health and safety were in order with the exception of the hot water temperature checks, which were not up to date. Although the hot water in the home is regulated, failure to test the supply regularly could result in scalding or injury to a resident. A requirement has been made in respect of this. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 - 30 The duty rotas showed there were enough staff on duty over a twenty-four hour period to meet residents needs. Recruitment policies and procedures are in place and were evidenced on staff files. Each staff member completes a comprehensive induction on arrival and a mandatory training programme during their first year in post. Staff spoken to said that they all felt supported by the seniors and manager and all attend regular staff meetings and staff handovers. This promotes good practice within the home. EVIDENCE: A completed staff rota was examined by the inspector who concluded there was sufficient nursing, care and ancillary staff to meet the needs of the residents. A qualified nurse works on each shift, in addition to the manager to provide specialist support and advice to care staff. An induction and training programme are run within the home and 60 of staff have an NVQ Level 2, providing the necessary mix of skills and experience to meet residents needs. Donnington House has no vacancies at present and does not use agency staff. This ensures consistency of care for the residents. Staff complete a comprehensive induction prior to working with the residents in addition to completing mandatory training held at the home. This includes, first aid, manual handling, infection control, food hygiene and medication training. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 18 Staff interviewed all said they felt ‘very supported’ within the home and stated the ‘communication was very good between senior staff and the team.’ The inspector concluded these areas contributed to good practice within the home as staff were confident and competent in their roles. Recruitment policies and procedures are in place to ensure the staff employed at the home have the necessary skills and experience to fulfil their roles. CRB checks, terms and conditions and job descriptions were all seen on staff files. An efficient recruitment process provides residents with protection and reduces risk within the home. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 36, 37 and 38 Donnington House is currently undergoing a systems overhaul by the manager who is implementing more efficient administrative procedures. The inspector concluded the new systems were proactive in promoting good working practices within the home. Record keeping in respect of health and safety was checked and found to be in good order, with the exception of the water temperature checks (See Environment). Regular supervision of staff is not in place at present, records showed staff were last supervised in November 2004. A requirement has been made in respect of this. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 20 EVIDENCE: The manager, Ann Bareham has been working to develop more efficient systems and working practices throughout the home. Her commitment to the welfare of service users and promotion of good practice were evident during the inspection. Staff and residents praised the high standard of care and stated they did benefit from the leadership and management approach within the home. Risk assessments for the environment, policies and procedures were up to date and in line with current legislation, promoting good working practices within the home. Quality assurance and monitoring systems were in place and feedback forms from residents and relatives contributed to the annual review process. There was no record of regular supervision meetings for staff, which would highlight personal development and training needs of individual staff members in addition to promoting good practice. A requirement has been made in respect of this. The majority of record keeping relating to the health, safety and welfare within the home (with the exception of hot water checks) was in good order and up to date, significantly reducing risk to service users. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 3 x x 2 2 3 Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 22 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 18 Regulation 36 Requirement The registered person must make arrangements to train staff to prevent residents being harmed, suffering abuse or being placed at risk or harm 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. The registered person shall ensure records within the home are kept up to date. The registered person shall ensure the care plan is completed in consultation with service users or their representative Timescale for action 17th October 2005 17th October 2005 2. 36 18 3. 4. 38 7 17 15 17th October 2005 17th October 2005 5. 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 14 Good Practice Recommendations The home should ensure a process of consultation is H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 23 Donnington House provided in order to maximise service users capacity to exercise choice and control within the home. Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 Donnington House H60-H11 S58333 Donnington House V231923 130605 Stage 4.doc Version 1.30 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!