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Inspection on 13/10/05 for Duncote Hall Nursing Home

Also see our care home review for Duncote Hall Nursing Home for more information

This inspection was carried out on 13th October 2005.

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 is bright and airy and maintained to a high standard. Residents spoken to stated that the standard of care and attention was high and that the food was good. Residents seen appeared well groomed and well cared for. A comprehensive programme of activities is on offer and residents were enjoying taking part in a crossword at the time of the inspection.

What has improved since the last inspection?

Further work has been undertaken on the resident`s care plans, and these now give clear instruction to staff on meeting resident`s needs.

What the care home could do better:

Residents who had "cot sides" in place did not have the required protection or padding of these aids in order to reduce the risk of injury or entrapment. Medication records were good with the exception of one resident who had been ordered an enema by his General Practitioner and neither the order or administration of this was recorded on the drug administration record. Evidence was available in the daily records that this had been given. The home was required to address these issues.

CARE HOMES FOR OLDER PEOPLE Duncote Hall Nursing Home Duncote Towcester Northants NN12 8AQ Lead Inspector Mrs Linda Preen Unannounced Inspection 13th October 2005 9.30 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 Duncote Hall Nursing Home DS0000012612.V255256.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. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Duncote Hall Nursing Home Address Duncote Towcester Northants NN12 8AQ 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) 01327 352277 01327 359168 duncotehall@aol.com Minster Care Management Limited Darren Lee Peter McGregor Care Home 41 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (41) of places Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of service users in the home must not exceed 41 No one falling into the category of Dementia over 65 years of age may be admitted into the home where there are 10 persons with Dementia over 65 years of age already accommodated in the home. One named service user in the category of Terminally Ill under the age of 65 Years may be admitted to the home. 9th May 2005 3. Date of last inspection Brief Description of the Service: Duncote Hall is set in 8 acres of grounds in a small village. Accommodation is in a mixture of single and double rooms, all of which have en-suite facilities. There are 3 general sitting rooms, a dining room and conservatory as well as extensive gardens. A mixed client group is accommodated and includes the elderly frail as well as mentally frail clients. The company has been taken over since the last inspection and the home is therefore under new ownership. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One hour was spent prior to the inspection reviewing previous requirements and recommendations, and statutory notifications from the service. The inspection took place over a period of four hours as part of the statutory inspection programme. Two residents were chosen in order that their experience in the home could be monitored. This included looking at their records, talking to them and also to the staff concerning the care received. In addition to this staff records and medication records were seen. A limited tour of the environment was undertaken. The Commission had received one complaint for Social Care Inspection since the last inspection. This concerned the provision of dressings and incontinence appliances and was unfounded. What the service does well: What has improved since the last inspection? Further work has been undertaken on the resident’s care plans, and these now give clear instruction to staff on meeting resident’s needs. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 6 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. Duncote Hall Nursing Home DS0000012612.V255256.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 Duncote Hall Nursing Home DS0000012612.V255256.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): 1,3 and 4 Residents have the information required to enable them to make an informed choice concerning admission to the home. EVIDENCE: Resident files seen demonstrated that comprehensive assessments are undertaken prior to residents being admitted to the home. An updated Statement of Purpose is available in the home. Duncote Hall Nursing Home DS0000012612.V255256.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): 7, 8, 9 and 10 Staff have the information needed to ensure that resident needs may be met. Residents are treated with dignity and respect. EVIDENCE: The selection of care plans seen demonstrated that resident’s needs had been assessed and that plans had been formulated to meet these needs. Residents at risk of developing pressure ulcers had been provided with appropriate pressure relieving mattresses and cushions. Those residents currently being nursed in bed were observed to be comfortable and appeared well cared for. Where cot sides were in place, these did not have padding in place to avoid the risk of residents becoming entrapped. A requirement was made concerning this. A Chiropodist was in the home and stated that she attends every two weeks in order to ensure that all residents needing her attention can be provided for. She confirmed that the home is well organised when she arrives and that treatment takes place in the treatment room, ensuring privacy for the residents. Systems in place for the ordering, monitoring, administration and disposal of medication were seen to be satisfactory, except that one resident had been Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 10 given an enema on the general practitioners instruction and this enema had not been prescribed or signed for on the medication records. A requirement was made concerning this. A new contract is in place for the disposal of medication in order to meet the latest guidelines. Residents spoken to confirmed that the standard of care and attention was very good and that staff treated them well. Staff were observed to be treating residents with dignity and respect. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Social activities and meals are well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: The home employs a dedicated activities co-ordinator who has devised an interesting programme according to resident’s requirements. The programme on display advertised such things as a Gardening club, French club and Culture club as well as current affairs discussions and quizzes. Residents were involved in completing a crossword during the inspection and stated that they liked to do this every morning. Records of preferred activities were available on individual files. Residents are allowed pets where they are able to take care of them, and one lady had a small dog as her companion. Meals are served in a very pleasant dining room, where tables are set with attractive cloths and napkins with small flower arrangements in place. Residents spoken to confirmed that the standard of food was good and that they are offered choice at meal times. Menus seen were varied and provided nutritious options. The kitchen was observed to be well organised with regular deliveries of fresh produce. The cook stated that the problem previously reported concerning tough meat was being monitored and that a change of Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 12 supplier to a local butcher was currently being negotiated. Kitchen staff hold Food Hygiene certificates, as do care staff who are involved with the serving of food. The cook holds records of resident’s individual food likes and dislikes and stated that she buys in curries for one resident who likes spicy food. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents may be confident that their concerns will be addressed. EVIDENCE: The Commission had received one complaint for Social Care Inspection since the last inspection. This concerned the provision of dressings and incontinence appliances. The complaint was investigated by the Registered Manager in an efficient manner and was unfounded. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 and 26 Residents live in homely surroundings, which are well maintained and clean. EVIDENCE: A limited tour of the environment was undertaken. This demonstrated that all communal areas of the home were comfortable and decorated to a good standard. Resident rooms seen had evidence of personalisation in the form of ornaments, photographs and small pieces of furniture. The home was bright and airy, with a very pleasant atmosphere. In addition to a variety of lounge areas, there is a pleasant dining room and extensive grounds, which may be enjoyed when the weather permits. Two maintenance men are employed to deal with both the internal and external environment. Domestic staff are employed in addition to care staff to ensure that the standard of cleanliness in the home is maintained. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 15 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): 27, 28, 29 and 30 Staff recruitment and training ensure that residents are supported and protected in the home. EVIDENCE: Duty rotas demonstrate that sufficient staff are employed to meet the needs of the current resident group. Staff is organised into teams in order that accountability may be held for specific groups of residents and their care. The new company have confirmed that a second Registered Nurse may be on duty with the Registered Manager in order to enable him to fulfil his management duties. Recruitment to this position is currently in progress. A selection of staff files demonstrated that appropriate references, Criminal Records Bureau Checks and POVA 1st checks are in place for staff employed in the home, in order to protect residents from potential harm. 4 staff currently hold NVQ level 2 certificates and 1 holds level 3. In addition to this, a further 5 staff are working towards level 2 and 1 towards level 3. An induction and training programme in line with the TOPPS standards is in place. Records of this training were seen to be maintained to a high standard. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 16 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, 32, 33, 35, and 38 The Registered Manager ensures that the home is run efficiently, in a way that serves the best interests of the residents. EVIDENCE: The Registered Manager is a first level Registered Nurse with several years experience of managing a care home. He is currently working towards the Registered Managers Award. Residents meetings have recently been introduced and it was reported that a requested trolley for the purchase of sweets, stationery and toiletries was currently being sourced. Moving and handling assessments had been carried out on service users chosen to track, and staff seen demonstrated that they had undertaken moving and handling training. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 17 The maintenance staff were undertaking checks of the fire alarm system during the inspection and confirmed that this was done on a weekly basis. Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 18 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 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 x 3 3 x x 3 3 3 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 3 3 x 3 x x 3 Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 19 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 2 Standard OP8 OP9 Regulation 12(1) a 13(2) Requirement All “cot sides” must be covered and padded to reduce the risk of injury or entrapment. Administration of all medication must be prescribed and recorded on the individual resident’s medication administration sheet. Timescale for action 01/11/05 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Duncote Hall Nursing Home DS0000012612.V255256.R01.S.doc Version 5.0 Page 21 - 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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