Inspection on 14/07/05 for Donnington Nursing Home

This inspection was carried out on 14th July 2005.

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

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

Other inspections for this house

Donnington Nursing Home 26/11/08

Donnington Nursing Home 01/12/06

Donnington Nursing Home 13/12/05

Donnington Nursing Home 02/11/04

Donnington Nursing Home 03/06/04

Donnington Nursing Home 26/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Donnington Nursing Home Wantage Road Newbury Berkshire RG14 3BE Lead Inspector Sue Burton Unannounced 14 July 2005 @ 09:00 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 Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Donnington Address Wantage Road Newbury Berkshire RG14 3BE 01635 521272 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) BUPA Care Homes Limited vacant Care Home 45 Category(ies) of Older Person (OP) registration, with number of places Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The number of persons for whom accommodation for nursing is provided at any one time shall not exceed 39 (thirty-nine) The category of persons for whom nursing accommodation is provided shall be that of General Nursing and Medical Care for the Elderly The category of persons for whom nursing accommodation is provided shall be that of General Nursing and Medical Care for the Elderly Chronically disabled persons under the age of 60 years will not be received except for convalescent or respite care for periods not exceeding three weeks. Date of last inspection 2/11/04 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 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. Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection on Thursday the 14th of July 2005 which which took place during the hours of 9 a.m. and 2:30 p.m. The new manager of the home was present for the inspection along with BUPAs Estates Surveyor and Estates Manager, the general manager was also present during the early part of the day.. Following a visit from the fire officer in 2004 significant works in the building had been required to enable the home to meet Royal Berkshire Fire and Rescues guidelines. The majority of the works had been almost completed and the homes fire risk assessment was made available for the inspection. Discussion had taken place prior to the inspection with the organisations operations manager in regard to the new management arrangements of the home. What the service does well: What has improved since the last inspection? A new manager has been appointed since the last inspection, who is currently in the process of gaining registration. Changes were taking place in the building to provide more comfortable and appropriate toilet facilities for residents who use the two front lounges in the Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 6 home. New armchairs, tables and a sofa were being delivered during inspection for the comfort of residents. The home has improved its sluicing facilities to maintain good hygiene and infection control. 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 Nursing Home H52-H01 10982 Donnington V217236 300605 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 Nursing Home H52-H01 10982 Donnington V217236 300605 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) 1,3 Prospective residents have the information they need to make an informed choice about living in the home. Prospective residents have their needs assessed appropriately. EVIDENCE: The manager is updating the statement of purpose to ensure that the change of management is documented. A copy of the new document will be sent to CSCI upon completion. The new management arrangments need to be incorporated into the statement of purpose to ensure residents and their families know the appropriate person to speak to about any particular issue. The pre-assessments of a number of recently admitted residents were examined, information recorded was appropriate and evidenced that the home considered it met their needs. Information seen on file from care managers and other health professionals provided evidence that the home only admitted residents on the basis of a full assessment. Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 9 Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 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) 7,8,10,11 Residents were seen to have appropriate care plans. The health care needs of residents in the home were assessed and documented but not always consistently. Residents in the home are treated with respect and privacy is respected. Residents wishes on death and dying need expoloring and documenting. EVIDENCE: The care plans and documentation for four residents were examined during the inspection. The home provides a professional format for nursing and care staff to document care needs and actions required by the staff to address them. The majority of the care plans are well documented and are reviewed regularly. Discussion took place with the manager in regard to nutritional screening, information was seen to be fragmented and assessments were not fully completed. Residents weights are recorded on admission and evidence was seen of regular monitoring which was not always reflected in every care plan. Where concerns were noted, the actions required by staff were again not reflected in the care plans. Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 11 Staff were seen and heard to be respectful when addressing individuals and when entering their rooms. Issues of privacy were in the new shower area were discussed and appeared satisfactory. Residents were complimentary in their comments about the staff. Discussion took place between the inspector and a number of the residents in regard to their wishes at the time of their death. A number of individuals have very definite plans for how they would like to be treated at the time of their death but had not yet discussed it with the staff. The manager was made aware of some of issues and the need for further discussion with the residents. Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 in part. The home provides a wide range of activities for the residents. Residents are able to exercise choice and control over their lives. The home provides a balanced and varied diet to the residents in pleasant surroundings. EVIDENCE: The inspector spoke to the homes activity organiser, read the notice boards and spoke to the residents about the entertainment and activity provided. The the residents spoke to the inspector about a visit from a choir last week which they greatly enjoyed. Residents had been growing herbs and plants from seed with the support of the activity officer. Residents were very appreciative of the efforts and wide range of activities provided and were happy to take part some days and not others and felt comfortable to make their own choices. Those residents spoken to confirmed they are able to have breakfast in bed if they wish a cooked breakfast if they wish and an alternative choice of meal. They were happy to express their satisfaction with staff and how they are allowed to get up in the mornings and retire at night at a time which is convenient to them and not necessarily to the staff. The inspector had lunch with the residents and was able to enjoy the comfortable and pleasant ambience of the dining room, staff were attentive and sensitive to the residents needs. Meals served were in portions sizes to Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 13 suit the residents and were seen to be appetising and nutritious. Empty plates supported the comments from the residents about how enjoyable food was. Staff visit residents the day before to seek their choice for the meal the next day, alternatives are always provided and dislikes acknowledged. Many of the residents did not appear to remember what they had chosen the previous day and relied on asking staff what was being provided. Discussion took place with a manager in regard to how this could be resolved by either a noticeboard in the dining room rather than the corridor and at a height and in a style suitable for the residents, the option to place a menu cards on the table was explored. Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a clear and accessible complaints procedure which is used by relatives and residents alike. The residents in the home are protected. EVIDENCE: The homes complaints log was examined during the inspection. There were two minor complaints in regard to missing items and the poor state of the front garden. There were four formal complaints entered, two of which were in regard to the lift, and one about another residents behaviour. All complaints entered had appropriate responses and actions recorded. The lift was being serviced during the inspection. A number of thank you letters from friends and and relatives were seen on file praising the staff for their care and kindness. The home has a policy and procedure in place for the protection of vulnerable adults, local guidelines were also available. POVA training had been provided for over 15 staff. Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,30 The home is progressing building works to meet the requirements of the local fire service. Residents would benefit from safe access to the front garden. Access to suitable toilet facilities are being provided. The home has improved the number of working sluice disinfectants available to staff. EVIDENCE: The home had been issued with a fire deficiency notice from the Royal Berkshire Fire and Rescue service in September 2004, it had required that appropriate fire risk assessment takes place and that works were carried out to ensure there was no risk of fire and smoke travel. A requirement from the last CSCI inspection required compliance with the Fire service advice. The organisation had funded and organised these works to take place. The inspector was fortunate to meet the organisations estates surveyor and manager who were visiting the home that day who were able to confirm the progress made in meeting those requirements. Some works were still in progress. The homes fire risk assessment was made available to the inspector Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 16 and copies of the action plan provided. A new office is being built for the homes administrator to comply with the fire authoritys recommendations. Following an entry in the homes complaints log, the inspector visited the gardens at the front of the home adjacent to the car park. Ramped access is provided from the lounge, this then petered out into rough weed stricken gravel which was potentially unsafe for those residents with mobility issues. This area of the home is not used and looked a little untidy, residents could take great pleasure in the level lawn area watching visitors arrive and leave, there is a shady area which could be used more productively. This whole garden area detracts from the pleasant interior of the home. Positive and constructive dialogue took place with the organisations estates surveyor about how this area could be improved and made safe. Both he and the previous home manager had tried in previous years unsuccessfully to gain budgetary allowance to improve this area. The organisation is a required to address this shortfall in safe access. Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 The safety of the residents is ensured by staff working appropriate hours. Appropriate training is provided for the staff team. EVIDENCE: From discussion and examination of the homes shift rotas the inspector was able to see that a previous requirement to reduce the hours of some shifts had been actioned. The previous shift of 13.5 hours had been reduced to 12.5 hours.Discussion took place with the manager in regard to one member of staff who was seen to be working over 50 hours. Further discussion took place with the manager in regard to staff competency and the health and safety of residents when staff are working longer hours. The manager advised the inspector that she compelted the rotas as was monitoring the hours worked. The rotas evidenced satisfactory numbers of staff on duty for the occupancy on the day of inspection. Examination of the training records of staff evidence that POVA training, fire, health and safety and first aid had been provided recently. The kitchen staff have been provided with health and safety and food hygiene training. Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 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) 31,32,33,36 The home is managed by a person who is competent and experienced. Residents benefit from the positive management approach in the home. Feedback from residents is actively sought and encouraged. Staff are appropriately supervised. EVIDENCE: The newly appointed manager is currently awaiting finalisation of her registration with CSCI. The standard will be fully met when registration is confirmed. She has evidenced competency and satisfactory experience appropriate to the management of the home. The manager will confirm with her organisations training department that her existing management award is compatible/appropriate with the registered managers award and confirm this to CSCI to support compliance with the standard. The organisation has been in discussion with CSCI in regard to the management arrangements of this home and another one close by. Both Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 19 homes will have registered managers, but one manager will take responsibility for marketing and purchasing for both homes. Residents meetings take place on a regular basis, the minutes from the last meeting in June were available for inspection. Eleven residents had attended the last meeting and a variety of topics were discussed for example; laundry arrangements, hand rail provision and opportunities for residents to be involved in photo shoot advertising for the home. It was noted that residents asked for their thanks to be recorded for the staffs care and attention. Residents spoken to at the time of inspection were very positive in their comments about quality of life in the home. Supervision records were made available for inspection and provided evidence that appropriate supervision of care staff takes place. There are still some outstanding sessions for the qualified staff to be completed. Training has been supplied to the qualified nurses to enable them to supervise the care staff they are responsible for. Aspects of supervision covered philosophy, career development and practice issues Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 2 3 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 3 x x 3 x x Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 21 no 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 20 Regulation 23 (2) o Requirement The garden at the front of the home is made safe and accessible for residents, and is appropriately maintained. Timescale for action 14/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 8 11 15 Good Practice Recommendations Records/assessments are accurate and are consistently maintained. Residents wishes at the time of death are acknowledged and recorded. Menu choices are to be displayed in the dining room in a format most suitable to the residents Donnington Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Berks RG7 4SA 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 Nursing Home H52-H01 10982 Donnington V217236 300605 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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