Inspection on 24/10/05 for Donnington House

This inspection was carried out on 24th October 2005.

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 10/10/06

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 Mrs B Tye Announced Monday 24 October 2005, V245676 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 V245676 241005 Stage 4.doc Version 1.40 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 01243 790174 Mr John Hugh Shipstone Shippam Mrs Anne Elizabeth Bareham Care Home (CRH) 28 Category(ies) of Old age, not falling within any other category registration, with number (OP) - 28 of places Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - Up to 28 male and/or female service users in the category old age, not falling into any other category. 2 - Only persons over 65 years of age may be admitted. Date of last inspection 13th June 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. 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 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 H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 24th October 2005. Prior to the inspection the inspector examined information on the current file spanning the last six months. These included a detailed pre-inspection questionnaire completed by the manager and eleven service user comment cards sent in by the residents. Four residents, two relatives and a musician (who attends the home on a weekly basis) were interviewed. All confirmed they were very happy with the standard of care provided at the home. The inspector examined health and safety records, staff supervision and training records, meeting minutes, the new care-planning format and relevant policies and procedures. The manager, Mrs Anne Bareham assisted the inspector and provided relevant information throughout. THIS REPORT SHOULD BE READ IN CONJUCTION WITH THE INSPECTION REPORT DATED 13th JUNE 2005. BOTH REPORTS COVER ALL STANDARDS IN FULL. What the service does well: Donnington House offers a homely and comfortable environment. From information gathered prior and during the inspection it was evident the staff were fully meeting the health and care needs of the residents. Residents said they experienced a high standard of care and that the staff treated them with dignity and respect. Observations on the day supported this. New administrative systems have been implemented relating to training, supervision and care planning. These enable staff to work effectively with the residents and working practices are recorded and monitored. The building is safely maintained and the environment was clean and tidy throughout. Relatives spoken to said they felt supported and were positive about working practices within the home. The staff and managers showed commitment to ensuring the residents receive a high standard of care. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 6 This was evidenced through discussions on the day of inspection, examination of records, observations and overall feedback from residents and visitors. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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 V245676 241005 Stage 4.doc Version 1.40 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 - 6 There has been no change in these assessed standards since the last inspection. All standards were previously met and the outcome for residents was good. EVIDENCE: 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. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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 standard(s) 11 Residents can be assured at their time of death, staff will treat them and their relatives with care, dignity and respect. EVIDENCE: The inspector viewed the homes policy on Death and Dying, which provides detailed guidance to staff on appropriate practice and responses. In addition to this the manager has created a document for information purposes, which details the effects of bereavement on carers. 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. This information was further evidenced by feedback from interviews with residents and relatives. A residents’ wife had died whilst residing at the home and he praised the staff on their ‘excellent care’ and continued support. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 10 The musician who played at the home on a weekly basis did so in part, as a thank you for looking after his wife before she died a year previously. He stated that the staff ‘had been wonderful and seemed to know exactly what his wife needed in her final days’. Other visiting relatives whose family members were extremely ill and needed high level nursing care confirmed the home was ‘very supportive’ and the staff were ‘wonderful’. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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 standard(s) 14 This previous requirement has now been met in full. The inspector concluded residents are able to exercise choice and control over their lives whilst living at the home. Therefore the outcome for residents was good. EVIDENCE: The manager and the staff team have worked extremely hard since the last inspection to put into place a comprehensive care-planning system, which details all aspects of each resident’s care. The inspector examined the system and concluded it was well ordered and efficient. Risk assessments are included in the plans to support residents’ independence whilst identifying and reducing risk. Action plans are discussed with individuals by their key-workers and the resident or appropriate relative will sign the information to confirm it has been agreed. Each aspect of care is reviewed on a monthly basis and records showed the resident or their relative then agree each change. 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. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 12 The inspector viewed minutes of monthly resident meetings. These meetings give residents the opportunity to voice any concerns and contribute to the decision making and running of the home. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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 standard(s) 17 and 18 The previous requirement made in relation to Adult Protection has now been met in full. The inspector concluded residents are protected from abuse and their legal rights are protected within the home. The outcome for residents in these areas was good. EVIDENCE: 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. The manager of the home, Anne Bareham is attending ‘Protection of Vulnerable Adults’ training on the 25th October 2005 to enhance her knowledge and skills base in this area. She will then train staff in-house in line with West Sussex Adult Protection procedures training guidelines. All staff employed by the home will undertake this training. To support this, the home now has an up dated policy on ‘Elder Abuse’ and staff have been issued with information leaflets. The inspector noted all staff had signed the policy to show it had been read and understood. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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 standard(s) 25 and 26 A previous requirement made in relation to hot water checks has been met in full. Residents live in a safe and comfortable environment, which is pleasant and hygienic. The outcome for the residents in relation to these standards was good. EVIDENCE: A shed has now been built in the garden to the rear of the property, which has solved the homes storage difficulties. Since the last inspection the fire escape has been re-painted and a non-slip surface applied to reduce risk to residents should a fire occur. The hot water within the home has always been regulated. The manager now carries out regular temperature checks to ensure the system does not exceed the appropriate temperature. This reduces the risk of injury to residents. Records were seen by the inspector and found to be up to date and in good order. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 15 The manager has researched and enhanced infection control within the home by implementing the use of Tea-tree shampoos and soaps. Since this has come into practice the home has eliminated two cases of MRSA. Infection control within the home is adhered to and the inspector observed staff using aprons and gloves when appropriate. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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 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 and 30 The home employs staff who are committed, trained and competent to do their jobs. Feedback from the resident and relatives highlighted that the staff demonstrate good working practices and are valued within the home. EVIDENCE: Donnington House has a full compliment of staff at present. Three new staff members are due to start on the 25th October 2005. The manager has implemented a new induction checklist, which assesses staff competence and identifies training needs. Once the induction is complete staff will undertake additional (long-distance) learning modules to ensure competency in all areas. In addition to this staff complete the in-house training programme and undertake the National Vocational Qualification. A senior member of staff is employed for additional hours as a Training Officer. Her role is to identify training needs, liaise with colleges and support staff to gain qualifications where needed. The training officer and manager meet on a regular basis to plan workloads in addition to training requirements. The inspector viewed training records and concluded the home provides specialist training over and above mandatory requirements. This equips staff with the skills and knowledge to deal with individual specialist care needs of residents. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 17 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. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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 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) 31, 35, 36 and 38 The residents live in a home where their health, safety and welfare are promoted by good working practices. The manager is competent and of good character, able to provide a good standard of leadership to the staff. The previous requirement made in relation to staff supervision has been met in full. All health and safety checks were in good order and up to date, providing residents with a safe living environment. The inspector found the outcomes for residents in all these areas was good. Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 19 EVIDENCE: Donnington House is has undergone an overhaul of their administrative systems. The manager has implemented a range of more efficient administrative procedures. These are all monitored by the management on a regular basis. The inspector examined the new systems during the inspection and acknowledged the manager and her team had worked hard designing and putting into practice the new ways of working. 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. All records were up to date and in good order. Financial interests of residents are protected by up to date policies and procedures. Information relating to finances are detailed on individual care plans. Supervision occurs every two months within the home. Each senior sister is allocated members of staff to supervise, the sisters are supervised by the manager. The inspector viewed the ‘supervision planner’ in place at the home. This highlights staff training and practice issues identified by management. Ensuring working practices and issues arising are monitored and addressed at the earliest opportunity. The Quality Assurance report is published and available to visitors of the home. 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 H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 x 9 x 10 x 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 3 x x 3 3 x x 3 Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 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. 1. 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. Refer to Standard Good Practice Recommendations Donnington House H60-H11 S58333 Donnington House V245676 241005 Stage 4.doc Version 1.40 Page 22 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. 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