CARE HOMES FOR OLDER PEOPLE
Doveridge Care Home Doveridge South Street Colyton Devon EX24 6PS Lead Inspector
Teresa Anderson Unannounced Inspection 10:00 16 September 2005
th 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 Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Doveridge Care Home Address Doveridge South Street Colyton Devon EX24 6PS 01297 552196 01297 551493 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) Doveleigh Care Limited Amy Jane Burt Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th April 2005 Brief Description of the Service: Doveridge is a detached 2 storey former farmhouse close to the heart of the village of Colyton. It has been extended and adapted for use as a care home. Accomodation and personal care is provided to up to 20 residents who have needs related to old age and/or dementia type illnesses. The home has 18 single and 1 double bedroom on the ground and first floors. The home has two floors but these are spread over 3 levels with stair lifts linking all areas. The home has 2 lounge/dining areas, one on each floor and a quiet area on the first floor. In addition there is a large conservatory forming the entrance to the home where many residents like to sit. To the front of the house is a patio area with seating and a small parking area. Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place as part of the normal programme of inspection between 10.30am and 1.30pm. During the inspection approximately twelve residents, one visitor, two members of staff, the manager and the owner were spoken with. Records in relation to residents’ monies, activities and meals were inspected. The inspector saw all of the communal areas of the home and some bedrooms. On entering Doveridge a number of residents were sitting in the conservatory. Classical music was being played and residents were relaxing, reading the paper or ‘watching the world go by’. The door was answered promptly and staff were courteous and helpful. In order to get a complete picture of the Standards inspected by CSCI, this inspection report should be read in conjunction with the report written following the announced inspection which took place in April. What the service does well: What has improved since the last inspection? What they could do better:
During this inspection it was noted that the area below the main staircase was crowded with combustible materials and a fire door was propped open.
Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 6 Immediate Requirements were issued and the manager immediately put these issues right. Residents are not overly impressed with the food at Doveridge. Whilst it is well cooked, well presented and fresh, residents still feel dissatisfied. The manager and owner are aware of this problem. Activities for residents could be further improved to include activities which would engage residents who have dementia. 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. Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were inspected at the inspection in April. EVIDENCE: Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were inspected at the inspection in April. EVIDENCE: Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Activities on offer do not always engage those service users with dementia and meals do not always satisfy residents’ preferences. Residents benefit from strong links with the local community and are encouraged to continue making choices about how they live their lives. EVIDENCE: Activities at Doveridge include bingo, music, matinee movies, manicures and hand/feet massage. Some time is allocated for one to one work between carers and resident. The local ‘charabang’ bus is used as much as possible to take residents out. Residents who were able to speak with the inspector said that they enjoyed the trips out and wished they could have more. Community contact is good and when residents cannot join in local events, the events are replicated in the home. This was done recently by celebrating the Colyton Carnival in the home. Whilst it is difficult to ascertain from those with dementia the type of involvement or engagement they would like from carers, there is no clear evidence in care plans that good practice guidelines are being followed. Residents described the food at Doveridge as ‘OK’, ‘variable’ and ‘nice’. Food is usually a major topic for discussion at residents meetings, but despite the changes made as a result of these discussions and a major increase in the food bill, satisfaction has not increased accordingly. The manager and owner know this to be an issue and are considering options.
Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were inspected at the inspection in April. EVIDENCE: Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25. Residents would benefit from radiators that are covered or are cool to touch to prevent accidental scalding. EVIDENCE: Many of the radiators have no protective guards and this poses a potential risk to residents. The owner has agreed to guard all un-protected radiators by 2007. Risk assessments determine the order in which covers are provided. Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were inspected during the inspection in April. EVIDENCE: Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Residents benefit from a manager who has a clear vision for the home and who keeps residents at the centre of that vision. Systems for user consultation are good with a variety of evidence that indicates that residents’ views are sought and acted upon. Systems for managing residents’ monies ensure good protection. Residents are not fully protected by the management of fire procedures. EVIDENCE: The manager at Doveridge has consistently demonstrated her ability in relation to care and home management and to ensuring that residents are treated as valued individuals. She has recently been successful in her application to CSCI to become the registered manager at Doveridge. She has a clear understanding of social care and communicates this effectively to a wellmotivated staff team.
Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 15 Sound systems are in place for consulting with residents. These include frequent staff meetings, resident surveys, relatives questionnaires and staff appraisals linked to resident care and the aims and objectives of the service. Since the last inspection the system for recording service users personal allowances has been improved and all staff have received fire training. The owner plans to build a cupboard under the stairs to house the medications and has been advised to consult with Devon Fire and Rescue Service to ensure his plans comply with fire regulations. The area under the stairs is being used as a storage area and a fire door was propped open causing potential fire hazards. Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x 2 x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 x 3 x x 1 Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 17 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 OP25 Regulation 13(4) Requirement The registered person must ensure that necessary risks to the safety of service users are, so far as possible eliminated. (This refers to the need to cover all hot surface temperature radiators). The registered person must ensure adequate precautions are taken to contain fires. (This refers to the propped open fire door and to the area below the stairs which is being used for storage). Timescale for action 31/12/07 2 OP38 23 (4) 16/09/05 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 Refer to Standard OP12 OP15 Good Practice Recommendations The registered person should ensure that activities are suited to the needs, preferences and capacities of all residents. The registered person should ensure that meals suit individual requirements. Doveridge Care Home DS0000061662.V249235.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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