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Inspection on 01/12/06 for Donnington Nursing Home

Also see our care home review for Donnington Nursing Home for more information

This inspection was carried out on 1st December 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has an experienced and qualified manager, who demonstrates a thorough understanding of her role. Residents or their representatives are given the necessary information prior to admission to enable them to make an informed decision about moving in. A detailed pre-admission assessment is undertaken, to ensure that the home can meet the needs of the prospective resident. Detailed care plans and records of care are in place and subject to ongoing improvement to ensure that residents` social and healthcare needs are addressed effectively. Residents generally felt that their dignity and privacy were addressed well, and that their individual preferences were usually listened to. The home`s medication systems are effective and residents who are able to self-administer are enabled to do so, following a risk assessment. An appropriate range of social activities is provided, and there are also opportunities for outings in the community. Contact with resident`s families is supported, and residents` spiritual needs are provided for when necessary. Residents receive a balanced diet from a varied menu, which they are able to influence. Choices are available to residents at each meal. An appropriate complaints procedure is in place, which is made readily available to residents and relatives.Appropriate systems are in place to protect residents from abuse. The home provides a safe, well-maintained and attractive environment, apart from the majority of the bathrooms and toilets, which are not of the same standard. The lounges and other communal areas are attractively decorated and furnished, and provide a warm, homely environment for residents. Staff receive a good induction and core training. Care staffing was reported to be in line with required levels to meet the needs of residents, though some residents felt there was a need for more staff. Good progress is being made on NVQ by the care staff. The home uses in-house bank staff rather than agency staff to make up any shortfalls on the rota. Recruitment and vetting practice is sound, and the home is subject to a variety of internal audit and quality systems. Systems are in place to protect the financial interests of residents. The health, safety and welfare of residents are promoted effectively.

What has improved since the last inspection?

Care plans have been improved following a previous inspection requirement, and further changes are planned for next year. The manager has made improvements to the supper arrangements to improve residents` choice and there is more encouragement for residents to come to the dining room. Menus have also been improved, in consultation with residents. Handrails were being fitted during the inspection to support residents` mobility. The area of garden outside the building has now been block-paved, and a new sensory garden constructed. The home has changed pharmacy supplier to obtain a better service.

What the care home could do better:

The review process for privately funded residents should be improved, to ensure that appropriate consultation/involvement of the resident and relevant others takes place. The majority of the bathrooms and toilets are drab and unattractive, and require upgrading to bring them up to a satisfactory standard. There remains room for improvement in quality assurance processes and reporting, and Regulation 26 reporting, and the scope of the Annual OperatingPlan could be broadened to address all aspects of an annual development plan, to avoid the need for duplication. Accident recording needs to be improved to include records of accidents on the relevant resident`s case record in addition to the collective record, which is already in place.

CARE HOMES FOR OLDER PEOPLE Donnington Nursing Home Wantage Rd Newbury Berkshire RG14 3BE Lead Inspector Stephen Webb Unannounced Inspection 1st December 2006 10:30 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 Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Donnington Nursing Home Address Wantage Rd Newbury Berkshire RG14 3BE 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) 01635 521272 www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Miss Joanne Kate Taylor Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Chronically disabled adults under the age of 65 years will not be received except for convalescent or respite care for periods not exceeding three weeks. Date of last inspection Brief Description of the Service: The Donnington Residential and Nursing Home was originally a large private house built in the late 19th Century that has been extended and converted. The home, which is owned by BUPA, is registered to provide care/nursing for up to 45 older people. The home is located approximately 1.5 miles from Newbury and is in a secluded area away from shops and other facilities. The home enjoys the benefits of an activities organiser who provides a varied programme of in house arts and crafts; exercise classes and trips out. The home also has a computer available for the exclusive use of service users. Current fee levels at the time of inspection were £600-£800 per week. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.30am until 6.30pm on 1st of December 2006. The inspection also included reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversations with service users, a relative, management and staff at the unit, and from six returned service user questionnaires, which were completed by relatives or staff with or on behalf of service users, and six returned relatives’ comment cards. The inspector also toured the premises and had lunch with the service users. What the service does well: The home has an experienced and qualified manager, who demonstrates a thorough understanding of her role. Residents or their representatives are given the necessary information prior to admission to enable them to make an informed decision about moving in. A detailed pre-admission assessment is undertaken, to ensure that the home can meet the needs of the prospective resident. Detailed care plans and records of care are in place and subject to ongoing improvement to ensure that residents’ social and healthcare needs are addressed effectively. Residents generally felt that their dignity and privacy were addressed well, and that their individual preferences were usually listened to. The home’s medication systems are effective and residents who are able to self-administer are enabled to do so, following a risk assessment. An appropriate range of social activities is provided, and there are also opportunities for outings in the community. Contact with resident’s families is supported, and residents’ spiritual needs are provided for when necessary. Residents receive a balanced diet from a varied menu, which they are able to influence. Choices are available to residents at each meal. An appropriate complaints procedure is in place, which is made readily available to residents and relatives. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 6 Appropriate systems are in place to protect residents from abuse. The home provides a safe, well-maintained and attractive environment, apart from the majority of the bathrooms and toilets, which are not of the same standard. The lounges and other communal areas are attractively decorated and furnished, and provide a warm, homely environment for residents. Staff receive a good induction and core training. Care staffing was reported to be in line with required levels to meet the needs of residents, though some residents felt there was a need for more staff. Good progress is being made on NVQ by the care staff. The home uses in-house bank staff rather than agency staff to make up any shortfalls on the rota. Recruitment and vetting practice is sound, and the home is subject to a variety of internal audit and quality systems. Systems are in place to protect the financial interests of residents. The health, safety and welfare of residents are promoted effectively. What has improved since the last inspection? What they could do better: The review process for privately funded residents should be improved, to ensure that appropriate consultation/involvement of the resident and relevant others takes place. The majority of the bathrooms and toilets are drab and unattractive, and require upgrading to bring them up to a satisfactory standard. There remains room for improvement in quality assurance processes and reporting, and Regulation 26 reporting, and the scope of the Annual Operating Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 7 Plan could be broadened to address all aspects of an annual development plan, to avoid the need for duplication. Accident recording needs to be improved to include records of accidents on the relevant resident’s case record in addition to the collective record, which is already in place. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 8 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 Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 3. Standard 6 is not applicable: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents or their representatives are given the necessary information prior to admission and a detailed assessment is carried out, to ensure the prospective resident’s needs can be met. EVIDENCE: Residents or their representatives are given a copy of the statement of purpose and service user guide as well as details of the complaints procedure and other useful information within an information file placed in each bedroom. The resident/their representative also receives a copy of the terms and conditions, (which is also copied to their file), and a copy of the latest inspection report is available in a folder in the entrance hall. Residents/their representatives are informed of changes to fees via letter. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 10 Residents and a relative confirmed they had received the necessary information prior to admission. It is suggested that the statement of purpose is dated to ensure its regular review. The home has a detailed assessment format and pre-admission assessments are undertaken on all prospective residents. Copies were on file for the casetracked residents. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans and records of care are in place and subject to ongoing improvement to ensure that residents’ social and healthcare needs are addressed effectively. The periodic review process for privately funded residents should be improved, to ensure appropriate consultation/involvement. Residents generally feel their dignity and privacy are addressed well, and that their individual preferences around daily routines were usually listened to. Medication systems are effective and residents who are able to self-administer are enabled to do so, following a risk assessment. EVIDENCE: Individual care plans are in place for each resident within a standard system, which has been amended with tabs to identify the various formats, though this is due to be replaced in 2007. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 12 Individual care records include mobility, continence and nutrition assessments, details of social and spiritual needs, personal care monitoring, a dependency profile and other detailed records, which now include more evidence of individual choices and preferences, and identify aspects of the individual’s preferred routines within a specific format. Daily notes are also kept on each resident. Each resident has a named nurse who has lead responsibility for their care, though it is suggested that the provision of their name and photo within the resident’s room or information file, might be beneficial, to help the resident or representative identify their key nurse. There are also plans to introduce allocated carers next year in addition to the named nurses. Residents funded by the local authority have regular reviews, to which the resident or their representative, are invited, copies of which were on file. For privately funded residents the manager undertakes informal internal reviews. The details of any necessary changes appear as dated amendments within the care plans, but there is no specific consultation with the resident/their representative, as part of this process. It is recommended that the manager devise a basic written review format for reviews of privately funded residents for use at least every six months in addition to the routine ongoing care plan reviews. These six-monthly reviews should involve consultation with the resident or their representative to obtain their views. The manager agreed to develop such a system. Records of residents’ healthcare appointments are made within the doctor’s notes section of the care record. Monthly pressure area returns are prepared and pressure area care is monitored and recorded. At the point of inspection, only one resident had a pressure sore, which was responding to treatment. Regular visits from opticians and support from the hearing aid clinic and audiologist address the current sensory issues for residents, with glasses and hearing aids provided as required. Speech and language therapist support has also been obtained where necessary. Feedback from residents and a resident’s relative during the inspection, was very positive regarding the care provided by the staff, for the most part. The residents confirmed that their privacy and dignity were addressed and that staff generally responded promptly and listened to their wishes. Residents confirmed that they could get up and go to bed when they wished. Staff referred to providing care behind closed doors and ensuring that dignity was maximised using towels when providing support. They also confirmed that daily routines were flexible, and that residents’ preferred forms of address Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 13 were used. The bedrooms and bathrooms were fitted with appropriate locks. Care staff were seen to be attentive to residents and there was evident warmth in the observed interactions. All but one of the bedrooms are single occupancy, with the one double room only being shared where two people specifically wish to do so. Some residents have chosen to have their own telephone in their bedroom. Sampling of the home’s medication records indicated the home has an appropriate medication management system in place. The manager had focused on making improvements in this area and the home had also changed pharmacist following concerns about the previous supplier. The new pharmacy supplier provides medication training to the staff who administer medication. A recent pharmacy review indicated that the home’s medication systems are appropriate. The medication records provide an audit trail for the medication, and there is a separate record made of all incoming medication. The use of individual homeopathic remedies by a resident, is first checked with the GP. Two residents self-administer, following a risk assessment, and staff monitor the returned empty medication packs. The medication for these residents is appropriately secured in their bedrooms. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided a good range of social activities and have opportunities for outings in the community. Contact with families is supported, and spiritual needs provided for when necessary. Residents are supported to make choices in their daily lives. Residents receive a balanced diet from a varied menu, which they are able to influence. Choices are available at each meal and the dining room provides a pleasant environment. EVIDENCE: Residents can choose to take part in a range of activities provided. The home’s activity file includes individual activity profiles detailing the likes of individuals and records of who took part in the activities sessions provided. Individual monthly activities plans are also kept in residents’ information files, and the activities coordinator, who works five days per week, Monday to Friday, also keeps records. Care staff also support activities and outings during the week and at weekends. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 15 Visiting entertainers come to the home regularly and In February, a travelling farm visited, bringing a range of farm animals into the garden, which was reported to be very popular with the residents. A sensory garden, designed by the local Brownies group, has been provided in the garden with an ornamental pergola, and the manager plans further developments next year. Staff have also put on a fashion show for residents in the past, and were preparing to perform a Christmas pantomime for them. The activities record also includes details of the residents who took part in outings in the community, such as regular pub lunches and shopping trips. The availability of activities and outings was confirmed by feedback from residents. Two Christmas shopping trips were planned for December. The spiritual needs of residents are provided for by visiting clergy, when identified, and the home has links with various denominations. The activities programme is displayed with photos etc. on a notice board in the entrance hall. One member of staff confirmed that they had recently passed the mini-bus driving test, along with two other colleagues, which would enable them to take residents out in the mini-bus available from another BUPA home. This is a positive development and should further increase the range of opportunities in the community. Contact with family and other visitors is recorded within daily notes, rather than a specific contact sheet, which makes it harder to monitor the regularity of this, if necessary, for reviews etc. The inspector noted a number of visitors in the home during the inspection and spoke briefly to one of them, who confirmed that there was a good range of activities and outings available, including bingo, art and craft, singing and trips out for pub lunches and to shows. As already noted the care plans include details of the preferred daily routines and evidence of other choices. Feedback from staff confirmed that daily routines were flexible to individuals’ choices. Residents confirmed that their preferences were generally provided for, and that they had day-to-day choice about the time of rising and retiring, clothes, food, activities participation etc. The menus are varied and provide for choices at each meal. Snacks and drinks are freely available between meals. The chef provides a mixture of home-made and bought cakes with afternoon tea. A large print menu for the day was located on each table in the dining room, and staff offered the choices again Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 16 verbally, to residents at the mealtime. Residents can suggest meals for inclusion in the menus during residents meetings, held every 6-8 weeks. Residents opt to have breakfast in their bedrooms, which can include a hot breakfast if they wish, though they could have it in the dining room if they preferred. Residents feedback about the food was very positive, for most residents, as was that from the visitor who was also happy with the menu provided. The dining room provides a pleasant dining environment, and there was a good level of conversation during the mealtime. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure which is made readily available to residents and relatives to enable any issues to be raised. Appropriate systems are in place to protect residents from abuse. EVIDENCE: The home has an appropriate complaints procedure, which is posted on the notice board in the entrance hall as well as being included within the resident’s information file and the statement of purpose. A monthly complaints return is sent to head office. Complaints and compliments forms are readily available in the entrance hall, without recourse to staff, which is good practice. The complaints log indicated only one complaint in the previous year, which had been addressed appropriately. Several residents indicated they were aware of the complaints procedure, though some of the relatives feedback indicted they were not aware of it. Protection of Vulnerable Adults (POVA), training is provided to staff, in-house by the training coordinator, who is an accredited POVA trainer. The majority of Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 18 staff received this training in 2005 or 2006. Two further POVA training sessions were scheduled for December for the remaining staff who require this. BUPA has a procedure for the protection of vulnerable adults and a whistleblowing procedure in place. The home has an appropriate system in place for the protection of residents’ funds, where it has any responsibility for these. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20 and 26: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are provided with a safe, well maintained and attractive environment, with the exception of most of the bathrooms and toilets, which are not of the same standard and require upgrading as a priority. Lounges and other communal areas are attractively decorated and furnished, and provide a warm, homely environment. The home is clean and hygienic and provided with appropriate laundry facilities. EVIDENCE: The home’s entrance hall is welcoming and attractive, and copies of the previous inspection report and statement of purpose were available as well as the complaints procedure and compliments and complaints leaflets. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 20 The communal areas (with the exception of bathrooms and toilets) are attractively decorated and furnished so as to be homely. The handyman was in the process of decorating one of the empty bedrooms, and this was being done to a noteworthy high standard. Handrails were being fitted to the upstairs corridor during the inspection to maximise residents’ mobility. Although four of the single bedrooms are beneath the ten square metres standard, they are only just undersize and are satisfactory bedrooms as long as mobility and/or transfer aids are not required to meet the needs of their occupants. The bedrooms were attractively decorated and homely, with lots of personal items in evidence. Bedroom doors were fitted with appropriate locks. One of the bathrooms had been provided with a walk-in shower and had been attractively tiled to make it more homely. However, the remaining bathing facilities and some of the toilets were not up to this standard and were in poor decorative condition and rather unwelcoming, needing upgrading to the standard of the completed shower room as a priority. The manager plans to upgrade these when funding is made available. As noted earlier, there is now a sensory garden beneath an ornamental pergola in the home’s garden, designed by local Brownies, who also helped with its development. The manager plans to provide a suitable path to this feature next year, to maximise its accessibility to residents. An area of block-paved patio has also been laid outside the building. The laundry facilities were appropriate to the needs of the home. The home was found to be clean and odour free, and this was confirmed by a relative. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Then needs of residents are met by a team of nursing and care staff who receive a good training in core areas. Care staffing was reported to be in line with required levels to meet the needs of residents, though some residents felt there was a need for more staff. Good progress is being made on NVQ within the care staff, and the home uses staff from an in-house bank, rather than agency staff, when the need arises. Recruitment and vetting practice is sound. EVIDENCE: The training spreadsheet indicates that a range of core training has been provided to most staff, though some gaps remain in required training. Staff confirmed the availability of a range of appropriate training, and there was a general sense of teamwork, with everyone working together. Staff confirmed there were regular meetings of the various grades, though overall team meetings were rare owing to the need to staff the unit. One staff member confirmed they are an accredited moving and handling trainer. Staff who are responsible for meal preparation undertake a distance learning food hygiene course with an examination. All staff receive a detailed Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 22 induction. POVA training is provided by the training coordinator, who is appropriately accredited. A number of staff remain in need of POVA training and this is scheduled for two dates in December. The standard shift pattern is a minimum of two RGN’s and seven carers in the mornings, a minimum of two RGN’s and five careers for afternoons and evenings, and two RGN’s and two carers on waking nights, which the manager reported was in line with the required levels. Opinion over staffing levels was divided, with some residents suggesting there was need for more staff to ensure a speedy response when necessary, and others being happy with the availability of staff. Feedback from relatives suggested they were happier with the staffing levels. Staff were described variously as being caring and respectful, very kind and generally as listening to residents. Bank staff from an in-house team of five staff, are used to provide for additional cover for shortfalls, and agency staff are no longer used. Good progress is being made on NVQ, with eight staff having NVQ level 2 and one having level 3. Two further staff have been nominated for level 2 and four are still undertaking induction and foundation training, but will go on to do NVQ afterwards. There are twelve RGN’s on the team. The home is accredited by “Investors In People”, and also supports the “Personal Best” training programme, which enables staff to pursue training in special areas of interest, relevant to their role, intended to enhance the care experience of residents. A sample of recruitment records indicated an appropriately rigorous recruitment and vetting process was in place to protect residents. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced and qualified manager, who demonstrates a thorough understanding of her role. Although subject to a variety of internal audit and quality systems, there remains room for improvement in quality assurance processes and reporting, and Regulation 26 reporting, and it is suggested that the scope of the Annual Operating Plan is broadened to encompass all aspects of the required annual development plan, to avoid the need for duplication. Systems are in place to protect the financial interests of residents. The health, safety and welfare of residents are promoted effectively, though improvement in one aspect of accident recording is required. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is appropriately qualified and experienced and attends various training to keep up-to-date. She has a certificate in management and is an inhouse assessor. A BUPA quality assurance survey was undertaken in August, and previously in 2005. The questionnaires from this were returned directly to the external company undertaking the survey on behalf of the provider. The summary report was still awaited, at the time of this inspection. Questionnaires had been provided to residents only, not to relatives or other stakeholders, though there had reportedly been a previous survey to relatives. In order to provide the fullest quality assurance feedback, questionnaires must be provided to relatives and other stakeholders in future, and the summary report should be made available promptly to contributors, to demonstrate effective responses and encourage future participation. The home was subject to an Investors In People audit in September 2006, which led to retention of the provider’s IIP status. The manager undertakes bimonthly care plan audits for head office and has also carried out a nutritional audit to monitor the service’s performance in this area. In house quality audits were also previously undertaken in 2004 and 2005. There are also regular residents meetings every six to eight weeks and twice yearly relatives and residents meetings, both of which are minuted, which provide other forums to raise any concerns. Regulation 26 monitoring visits are undertaken monthly by the provider, though the resulting reports often lack significant detail or information and do not represent the most effective use of the audit and monitoring opportunity provided by Regulation 26. It is recommended that their current use be reviewed. There was an annual operating plan in place for the year to 31/12/07, which fulfils some of the requirements of an annual development plan, but this could be further expanded to address the full range required of an annual development plan to avoid duplication. A sample of health and safety-related service certification indicated that checks were up to date. Staff were aware of their health and safety responsibilities and had received relevant training. Accident records are held collectively for monitoring and three-monthly accident returns are sent to the provider. There is a good system of follow-up forms for 24 and 48 hours after accidents to record any subsequent Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 25 information or injuries that emerge later on. This is good practice. However, copies of accident records were not also being filed on the relevant individual case records as required. The manager needs to ensure that accidents to residents are also recorded within their case record. The simplest way is to copy accident forms to the relevant resident’s file on completion. The home has an appropriate system for managing and recording resident finances where it takes on this responsibility. Monthly reconciliations are done of managed personal allowances, and each resident has a personal allowance bank account, which is interest bearing. Records are audited regularly. Small amounts of cash are given to individual residents who wish to hold some money for themselves. Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 26 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 4 X X X X X 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 3 X 2 X 3 X X 2 Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 27 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 OP19 Regulation 23(2)(d) Requirement The manager/provider must ensure that the identified bathing facilities are brought up to a satisfactory standard of décor. The manager/provider must ensure that questionnaires are provided to relatives and other stakeholders, and that the required summary report is made available promptly. The manager must ensure that accidents to residents are recorded on their case record as well as collectively. Timescale for action 01/03/07 2. OP33 24 01/03/07 3. OP38 17(1)(a) & Sched. 3.3(j) 01/03/07 Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 28 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 OP7 Good Practice Recommendations The manager should devise a review format for privately funded residents as discussed, to ensure that private residents or their representatives are appropriately consulted and informed about the results of reviews. The manager should consider broadening the scope of the Annual Operating Plan to enable it to fulfil the requirement for an annual development plan. The provider should consider reviewing the current Regulation 26 reporting to ensure that effective use is made of this monitoring opportunity. 2. 3. OP33 OP33 Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Donnington Nursing Home DS0000010982.V322805.R01.S.doc Version 5.2 Page 30 - 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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