Inspection on 03/05/05 for Donnington House

This inspection was carried out on 3rd May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 21/09/05

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 EX39 1JD Lead Inspector Andrew Towse Announced 3 May 2005 10:00 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 D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 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 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 DE Dementia (25) registration, with number OP Old age (25) of places PD Physical disability (25) Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14 October 2004 Brief Description of the Service: Donnington House is a large detached property situated in the seaside resort town of Westward Ho!. It is registered to accommodate up to 25 older adults who may also have dementia or physical disability. The accommodation is on three floors but as yet access between floors is mainly by stairs with one having a chair lift. The home currently is only using two of its double occupancy rooms with all the remaining rooms being used for single occupancy. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of eight and a half hours. During which time the inspector collated information from various sources. These included, discussion with the manager and the triangulation of information during further conversations with staff and service users. Records, including service users’ care plans were inspected, and additional information was obtained by reference to the pre-inspection questionnaire circulated by the C.S.C.I prior to the inspection and the return of comment cards from service users and their relatives. What the service does well: What has improved since the last inspection? What they could do better: The report highlights several issues regarding the physical structure of the home. The home does not have a passenger lift and a chairlift is only available between two of the floors. One bedroom does not have much natural light. The home does not have a sluice facility which results in staff taking commodes to an unused bathroom on the second floor for cleansing. Staffing levels are less than those required by Devon County Council. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 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 D54 D06_s53386_donnington_v216619_030505 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 D54 D06_s53386_donnington_v216619_030505 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) 1,2,3 and 5 Donnington House provides appropriate documentation, which coupled with contact with the manager, ensures that prospective service users have the information they need to make an informed choice about whether to reside there, although some of the documentation needs reviewing in order to ensure it is factually accurate. EVIDENCE: The home’s Statement of Purpose states the criteria for admission to the home and refers to a representative of the home carrying out an assessment of need which will then be discussed by the manager and Senior Care Team. Thereafter a placement will be offered if the needs identified by the assessment can be met by the facilities and services on offer at the home. Separate discussion with the manager and a Senior Carer confirmed that this procedure was adhered to. There had been three admissions since the last inspection. The admissions process for two of these service users involved the manager visiting them in hospital to conduct an assessment and the third was visited at her home. Donnington House has its own admissions form entitled ‘Initial Interview Form Prior To Admission’. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 9 From discussion with the manager and entries on the assessment form and files it could be seen that the manager, as well as talking with prospective service users also included information from nurses, care managers and the relatives of prospective service users. Service users’ files were also seen to contain Shared Assessments and Nursing Referral Forms. The Statement of Purpose states that ‘wherever possible the Resident and his/her relatives should be encouraged to visit the home as the first step of the assessment process.’ Entries on service user files and in the diary gave evidence of the home communicating with relatives. Due to the frailty and situation of the prospective service users, none had managed to visit the home as part of the admissions process however relatives of all the prospective service users had visited the home and discussed the placement with the manager. The Statement of Purpose, although well written does contain some inaccuracies, one being that all Care Team members have or are in the process of attaining NVQ level 2. The four service user files inspected contained contracts. These did not contain details of the room to be occupied as required by the regulations. All had been signed by relatives of the service user concerned. Donnington House D54 D06_s53386_donnington_v216619_030505 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) 7,8 The home has regularly reviewed care plans which meet the health care needs of service users. EVIDENCE: Four service user files were inspected. All contained care plans. These contained information obtained from relatives and professionals involved with the service user. On file are review forms, which are compiled monthly and cover aspects such as changes in mobility, orientation and continence. It is the responsibility of the key worker designated to oversee the care of specific service users to ensure that these reviews of care plans take place. Service users are assessed upon admission to the home and the care plan is compiled thereafter as further information is obtained through interaction with the service user, his/her relatives and professionals. Files were seen to contain details as required by the National Minimum Standards such as date of birth, home address, preferred term of address, next of kin and a photograph of the service user. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 11 Two service users are bedridden. Neither of these has bed sores. Their care plans refer to a programme of regular turning, which was confirmed in discussion with two members of staff. There was evidence on another file of the involvement of a District Nurse in offering advice regarding reducing another service user’s susceptibility to pressure sores by the use of dressings, actions and equipment necessary for the promotion of tissue viability. Other entries on files showed that assessment covered issues relating to aural and personal hygiene. Service users have annual eye tests. The file of a service user who had psychiatric symptoms was inspected. This demonstrated that guidance regarding her care was obtained through the involvement of a psychiatric nurse. District nurse involvement was apparent through records on other files which showed that service users had been reassessed regarding their continence and that fluid balance charts had been kept in accordance with their instructions. Donnington House D54 D06_s53386_donnington_v216619_030505 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) 13, 14, 15 The home has a commitment to ensuring that family members are made welcome. Although there are activities available within the home and efforts are made by the registered manager to elicit the views of service users regarding their choice of activities a more formal structuring of staff hours and responsibilities is required to ensure that residents can engage in the activities they wish on a regular basis. EVIDENCE: The assessment carried out when service users arrive at Donnington House contains a section on lifestyle choices and preferences. Entries showed that some service users preferred to take certain meals in their bedrooms, others liked to get up early or have a nap after lunch. Also listed were individual resident’s interests. The Resident’s Guide, which is included in the pack given to all service users, refers to service users’ spiritual needs being met and to this end communion is provided once a month at the home and service users who wish, attend church. The Statement of Purpose states that ‘visitors are welcome at the home at any time’. This was confirmed following discussion with a service user who spoke of her regular contact with a family member and also in discussion with the manager. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 13 The home has lists of activities which are available and these are displayed around the home. There was also a guide on the office wall which was requesting that staff undertook activities such as taking service users on escorted walks, arranging bingo or doing exercise classes if they had the time. In discussion with the manager 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 the activities requested on the aforementioned guide. Minutes of a service user meeting held in March showed that the issue of activities had been raised, but the manager was experiencing difficulties in getting an ‘accurate’ picture of what service users’ wanted due to many of them having short term memory problems or a level of confusion. The inspector had a meal with service users in the ground level dining room. The meal was seen to be leisurely. Not all service users could be accommodated in this dining room. Those on the lower level tended to remain in the chairs they occupied all day and eat from tables placed in front of them. In discussion they appeared content with this arrangement. Donnington House D54 D06_s53386_donnington_v216619_030505 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 The home has a complaints procedure, which is available to staff, service users and their relatives. It needs amendment to ensure that those wishing to use it are aware that they can contact the CSCI at any time during the investigation process. EVIDENCE: Details of Donnington House’s complaints procedure are contained in the Residents’ Guide and in the corporate pack which is given to all prospective service users. The procedure outlines the stages of making a complaint from addressing it to the manager, then the owner and if the complainant is not satisfied, the C.S.C.I. The final paragraph states that the complainant can at any time by pass the above stages and go straight to the C.S.C.I. This aspect of the complaint procedure is not included in the Resident Guide which only gives the service user recourse to the CSCI when the complaint remains unresolved after being referred to the manager and then the owner. Records of complaints made are kept on service users’ files. With the exception of one complaint which was made directly to the NCSC the only other complaint recorded was from March 2004. This was investigated by the home who concluded that it was upheld and took appropriate action to resolve the issue. Although at the time of the inspection there was no advocacy scheme available to service users the manager had recently acquired details of the ‘Care Aware’ advocacy service and intends to incorporate information regarding the scheme into the home’s admissions process to ensure service users are aware of the scheme. The manager has introductory forms for service users to complete. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 15 All service users have voting cards which were given out by the manager with the post and were seen in service users’ bedrooms. One service user wanted to exercise his right to vote and the inspector was informed that the home was to provide transport to enable him to do so. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,25,26,24 Whilst the home has many positive aspects there are several areas which would benefit from upgrading in order to achieve a better living environment for service users. Whilst many of these should be addressed with the planned enlargement of the premises others, from the previous inspection need to be fully actioned. EVIDENCE: The home has a maintenance book in which staff note down any items of refurbishment which they consider necessary to maintain an appropriate and save living environment for service users. Entries ranged from repairing a broken radiator cover and a broken drawer, to fitting new curtain rails, redecorating specific bedrooms and fitting an air vent in the laundry. Externally the home has an enclosed rear garden area which can be accessed by service users, and which is well maintained with the home employing a gardener. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 17 The home is on three levels and does not have a passenger lift but has a chair lift which facilitates access between the lower and ground floor. Access to the bedrooms on the first floor is by stairs only. The owner is currently applying for planning permission to increase the size of the home and incorporate a passenger lift which will facilitate service user access between the lower and ground floors. Currently the home does not have a sluice facility. Staff confirmed that a bathroom which is not accessed by service users and is on the first floor is used as a facility for cleaning commodes. A bedroom on the lower floor has poor access to natural light. This has been discussed previously with the owner and part of the proposed refurbishment will include an enlargement of the existing window to allow more natural light into the room. The manager said that in a shared room a mobile screen was used to ensure the privacy and dignity of the two bedridden occupants. Discussion with two staff confirmed that this did occur. Some bedrooms on the lower floor were seen to have doors which incorporated Georgian plate glass windows. Whilst the occupant of one of these rooms did not find it an issue, the inspector considers that these windows should either have curtains or be obscured to ensure the privacy and dignity of its occupants. Whilst most bedrooms are carpeted, two were seen not to have this facility. In discussion it transpired that one of the occupants of this room had previously not had a carpet as this person had problems with continence. These issues had now been resolved however the room remained without carpet. Radiator covers had not been installed in all service users’ bedrooms although this was a requirement made in the previous inspection. The carpet in part of the lower floor was stained and there was a malodour in this area of the home. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 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 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) 27,28,29 In the area of staffing, the rotas show that there are occasions when staffing levels fall below that expected and there is little evidence of specialist training being available although levels of NVQ trained staff meets that required by the National Minimum Standards but falls below that stated in the home’s Statement of Purpose. EVIDENCE: Staffing levels did not meet the minimum required by Devon County Council. The Statement of Purpose refers to all staff being on NVQ 2 training or having completed this. Records show that this is not the case. Previously in this report it has been noted that staff did not always have the time to engage in activities with service users to ensure that they have a stimulating environment. The Statement of Purpose states that there are First Aiders on duty at all times. On certain nights the files of the staff on duty did not confirm that they held First Aid qualifications. The home is encouraging staff to complete NVQ 2, however not all staff wish to do this qualifying course. The home employs 13 care staff, currently seven have NVQ 2 of which two are also on NVQ 3 training, which means the home has achieved above the National Minimum Standard of 50 of care staff achieving NVQ 2 by 2005. Staff files and details from the pre-inspection questionnaire showed that staff had attended required training on subjects such as moving and handling, but, wit the exception of the manager who had attended a course on depression in Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 19 care homes in February 2005, there was little evidence that staff had specialist training in the field of dementia or the effects of alzheimer’s disease, which would be relevant when offering care to some of the service users at Donnington House. The recruitment procedure shows that references and CRBs are obtained as required. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 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 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) 31,36, The manager has the qualifications and experience to run the home which is complemented by the introduction of a good system of communication and record keeping. EVIDENCE: The registered manager has been in post for almost two years. She is near to completing the Registered Managers Award and her NVQ 4 in Care. Prior to becoming manager she had four years experience as a care assistant working with older adults and six years working in the community doing agency work. The manager has instigated good record keeping systems and has enhanced communication within the home through regular minuted meetings for both staff and service uses. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 21 She has demonstrated an interest in promoting service users’ rights by obtaining information regarding advocacy and incorporating it into the information available to prospective service users. The manager has also completed annual appraisals for all the staff. Staff are involved in these and submit their own appraisal forms for discussion. Appraisals were seen to include the developmental needs of staff and to have a service user focus. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x 2 1 1 STAFFING Standard No Score 27 1 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 x x x x 3 x x Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 23 yes 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 25 Regulation 13(4)(a) Requirement Timescale for action 31.7.05 2. 26 13(3) 3. 27 18(1)(a) The registered person shall ensure that all parts of the home to which service users have access are so far as is reasonably practicable free from hazards to their safety. The registered person shall make 30.9.05 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall 31.7.05 ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. 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 24 Good Practice Recommendations That the Statement of Purpose be reviewed and any factual inaccuracies be amended. D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 24 Donnington House 2. 12 3. 16 4. 19 5. 6. 24 24 That having researched the hobbies and interests of service users and the activities they would like to participate in, staff are given designated time to ensure service users receive the stimulation they need. The registered person ensures that written information is provided to all service users for referring a complaint to the CSCI at any stage should the complainant wish to do so. Where a timescale has been set for compliance with any standard relating to the physical environment of the home, a plan and a programme for achieving compliance is produced and followed and records kept. Service users are provided with keys unless their risk assessment suggests otherwise. The home provides accommodation for each service user which assures privacy. Donnington House D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 D54 D06_s53386_donnington_v216619_030505 stage 4.doc Version 1.30 Page 26 - 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!