Inspection on 21/09/05 for Donnington House

This inspection was carried out on 21st September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Donnington House 11/02/10

Donnington House 14/12/09

Donnington House 18/11/09

Donnington House 21/08/07

Donnington House 26/06/06

Donnington House 03/05/05

Donnington House 14/10/04

Donnington House 09/06/04

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 Donnington House 47 Atlantic Way Westward Ho! Bideford Devon EX39 1JD Lead Inspector Andy Towse Unannounced Inspection 21st September 2005 12:30 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 Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 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 DS0000053386.V249277.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Donnington House Address 47 Atlantic Way Westward Ho! Bideford Devon EX39 1JD 01237 475001 01237 424540 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) Stonehaven (Healthcare) Ltd Mrs Jennifer Mary Burrows Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25), Physical disability (25) of places Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Donnington House is a large detached property situated in the seaside resort of Westward Ho! It is registered to accommodate 25 older adults who may also have dementia or physical disability. The accommodation is on three floors. There is access between the floors by stairs and there is a chairlift between the lower ground and ground floor. The majority of residents are accommodated in single occupancy rooms but there are two bedrooms which have shared occupancy. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over a period of four and a half hours. Information contained in this report came from discussion with the registered manager, staff and residents together with examination of records, including care plans. What the service does well: What has improved since the last inspection? What they could do better: The home has staffing levels which, whilst being below the level required by Devon County Council, are, according to the registered manager, adequate to meet the basic needs of residents however to provide a more stimulating environment, including 1:1 work, additional staff would be beneficial. The proposed structural work referred to in the previous inspection has not yet commenced, The home does not have a passenger lift and a chairlift is available only between two floors. Some policies inspected were found not to be specific to the home, and others, for their implementation referred to manuals which were not available. Policies should be specific to Donnington House. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 6 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 DS0000053386.V249277.R01.S.doc Version 5.0 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 DS0000053386.V249277.R01.S.doc Version 5.0 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): Standards 1, 2, 3 and 5 were inspected during the inspection of 3rd. May 2005. Standard 6 was not inspected as Donnington House does not offer intermediate care. EVIDENCE: Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 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): 9 Whilst this home has a medication policy, this was not formulated for Donnington House and should be re-written so that it reflects accurately the policies pursued at the home. EVIDENCE: At the time of the inspection no residents were assessed as being able to self medicate. The home has policies regarding the administration of medication. These, when read, were not written in relation to Donnington House. An example of this being the statement that ‘a clinical area must be available for the storage and assembly of medicine and completion of records. The temperature must not exceed 25oC. The area should possess hard working facilities and sufficient surfaces together with appropriate security measures’. The registered manager agreed that this did not refer to the facilities available at Donnington House and may be part of corporate policies use for homes owned by the Stonehaven group but which are not specific to the practices of individual homes.. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 10 The home has a refrigerator for medicines, and contrary to what is written in the home’s medication policy, the refrigerator is not lockable. The home uses the Boots Monitored Dosage system of medication administration. Records showing the administration of medication were seen to be appropriately maintained. Records showed that medication is checked on arrival by the registered manager and senior carers. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Whilst the home’s Statement of Purpose refers to a ‘full activities programme’ this was not evidenced at the inspection and staffing levels preclude the 1:1interacton which in discussion was felt to be relevant for many residents. EVIDENCE: The inspector was given details of activities available at Donnington House. This information comprised a sheet a paper with a list of activities such as bingo, quiz, coffee morning, reminiscing card game, gardening pots and planters, arts and crafts and exercise class. There were no dates to confirm the frequency or the scheduling of activities, although the manager said that on most days staff tried to arrange an activity. It was said that the prevalence of residents with dementia made it difficult to arrange group activities. In addition to the previously mentioned activities, the home also brings in a couple of paid entertainers who do music and movement and sing-a-longs. The home does not have its own transport. In the previous inspection report reference was made to the home having a list of activities which are available and the guide on the office wall requesting that staff undertook activities such as taking residents out on walks, but that there was a ‘general feeling that the home was not creating as stimulating an environment as it could as staff did not always have the time to carry out such activities.’ Staffing levels have not increased since that inspection. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 12 The Statement of Purpose refers extensively to activities, suggesting the possible installation of a loop system and making reference to an activities organiser. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 13 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): 18 The manager is aware of issues relating to the protection of vulnerable adults and ensures her staff receive training. EVIDENCE: The home has policies relating to residents’ finances which also state clearly that under no circumstances should staff be executors for resident’s wills. Policies also include the issues relating to gifts by residents to staff. The home has used the ‘No Secrets’ training video for protection of vulnerable adults training. The majority of staff are on NVQ 2 training which includes training on abuse, and records showed that further training for staff using the ‘No Secrets’ video had been arranged. The home has policies relating to abuse, which include descriptions of what constitutes abuse. These and the reference to the complaints procedure have been taken from procedures of another home run by the Stonehaven group and have as yet to be amended to refer to Donnington House. The home has a clearly stated policy to protect staff, which states that staff ‘must be aware that their jobs will not be in jeopardy if they alert managers to abusive behaviour to a resident by a member of staff.’ Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 14 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): 24 The registered manager has ensured the privacy of residents by putting curtains on bedroom doors however other issues raised in the last inspection regarding the environment have yet to be addressed. EVIDENCE: At the previous inspection reference had been made to two bedrooms being without carpets. The reason given being that one of these residents had had problems relating to incontinence which had been the reason for the absence of carpet. The issues of incontinence had been resolved at the time of the last inspection, and, although the manager has discussed the matter with the owners, the room still remains without a carpet. As in the previous inspection, the carpet to the landings on the lower floor remains stained. Some bedrooms on the lower floor have bedroom doors which incorporate Georgian Plate glass windows. To ensure residents’ privacy, the manager has, since the last inspection, installed curtains to these doors. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 15 Refurbishment mentioned in the previous inspection has not commenced, so the home remains without a sluice facility with staff using a bathroom, which is not used by residents, to wash commodes. There is a written procedure available which refers to this practice, however there has yet to be discussion with the Environmental Health Officer to confirm the safety and appropriateness of this practice. The home has an infection control policy. The opening policy statements reads that, ‘this infection control policy should be read in conjunction with the Westminster Health Care Policy on Health and Safety.’ This instruction could not be complied with as the home did not have a copy of the Westminster Policy. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 16 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, 30 For this home to offer its residents a more stimulating environment with well trained staff, staffing levels will need to be increased. Whilst the training available to staff will needto be increased if the level mentioned in the National Minimum Standards is to be achieved, the registered manager herself is being pro-active in creating innovative training packs in subjects relevant to the needs of residents. EVIDENCE: As stated in the previous inspection, this home does not have staffing levels which equate to those required by Devon County Council for a home which is registered to accommodate people who, in addition to being elderly, may also have dementia or physical disabilities. In discussion the manager considered that the staffing levels were adequate, however, as from the previous inspection, an increase in the level of staffing could ensure that more time could be spent ensuring that residents have more activities available and a more stimulating environment. The home is registered for people who have both dementia and physical disabilities. The needs of new residents must be assessed as must any change in the needs of existing residents and staffing levels amended accordingly to meet these needs. Records of staff training were seen. Within the last six months the registered manager has attended courses on depression and on the National Minimum Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 17 Standards, which, in addition to other training have taken up over two days. Some of the remaining staff have attended courses relevant to the care of elderly people covering topics such as dementia, mouthcare and statutory courses such as moving and handling.The amount of training needs to be increased if it is to meet the National Minimum Standards target of three paid days training per year. The registered manager has been pro-active in developing staff training and is currently compiling training packs on the care of people who have diabetes and also footcare. Records showed that staff a recent staff member had participated on an induction programme and that this was common to all new staff. The home has yet to introduce a foundation course, however the manager has been in discussion regarding this. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 18 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): 33, 35, 38 The home has systems in place a system for quality assurance regarding the running of the home, however for this to be effective it requires to be conducted on a more regular basis. EVIDENCE: Donnington House runs Quality Assurance audit system. This comprises weekly, monthly, quarterly, 6 monthly and annual audit which are completed by the registered manager before being forwarded to one of the proprietors. The home also sent out questionnaires to stake holders (such as general practitioners) and also to residents. The responses from general practitioners suggested general satisfaction with the services required. The questionnaires were last submitted in July 2004, so a new submission would permit the manager a more contemporary view of both stakeholder and resident opinion. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 19 Residents’ finances were discussed and inspected. Money held by the home on behalf of residents is kept in individual envelopes with expenditure recorded and verified by the retention of receipts. Access to residents’ monies is restricted to senior staff. The home was holding rings on behalf of a resident. These had been found on the floor and placed in an envelopebut there was no recording nor receipt issued for them by the home. There is no safe within this home for valuables to be safely stored. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 20 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 X X X x HEALTH AND PERSONAL CARE Standard No Score 7 X 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 x 18 3 X X X X X 2 X x STAFFING Standard No Score 27 3 28 X 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 2 X X x Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement Timescale for action 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 3 3 4 5 Refer to Standard OP9 OP12 OP24 OP30 OP33 OP35 Good Practice Recommendations The medication policy needs to be reviewed and amended to make it specific to Donnington House The home needs to review and develop its programme of activities if it is to achieve the stimulating environment referred to in its Statement of Purpose. Resident’s rooms are carpeted or equivalent. All staff should receive a minimum of three paid days training per year. Quality monitoring involving the views of residents is carried out more frequently. Records and receipts are kept of possessions handed over for safe keeping and there are secure facilities for the safe-keeping of money and valuables on behalf of residents. Donnington House DS0000053386.V249277.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 DS0000053386.V249277.R01.S.doc Version 5.0 Page 23 - 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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