Inspection on 15/06/07 for Duncote Hall Nursing Home

This inspection was carried out on 15th June 2007.

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.

Other inspections for this house

Duncote Hall Nursing Home 10/06/08

Duncote Hall Nursing Home 13/10/05

Duncote Hall Nursing Home 09/05/05

Duncote Hall Nursing Home 01/11/04

Duncote Hall Nursing Home 26/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Duncote Hall Nursing Home Duncote Towcester Northants NN12 8AQ Lead Inspector Irene Miller Unannounced Inspection 15th June 2007 12:00 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.V327939.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. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 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 Vacant 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.V327939.R01.S.doc Version 5.2 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. 13th October 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 current fees range from £550 to £650 per week. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon outcomes for service users and their views of the service provided. This inspection was a ‘Key Inspection’ that focused on the key standards under the National Minimum Standards and the Care Standards Act 2000 and the Care Homes Regulations 2001, for homes providing care for older people. The primary method of inspection used was ‘case tracking’ which involved selecting two people living at the home, reviewing their health, social, emotional and physical needs and tracking the care they receive. Their care plans were looked at (a care plan sets out how the home aims to meet the, personal, health, social and emotional needs of the resident), and discussion took place with people living at the home and staff and general care practices were observed. The homes policies, procedures and records in relation to staffing recruitment and training, concerns and complaints, medication management, and general maintenance and upkeep of the home were viewed. Information was provided on the homes management and administration systems prior to the visit and feedback was sought from people living at the home, their representatives and visiting healthcare professionals who provide medical and healthcare support services. In addition information was gained from reviewing the homes previous inspection reports and other information relating to the home. The general manager Janice Knocks was available throughout the visit, which took place over a period of approximately seven hours. What the service does well: Prospective residents are provided with sufficient information to assist in making a decision as to whether the home would be right for them and they are encouraged to visit prior to moving into the home to meet with residents and staff. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 6 Visitors are made welcome, and arrangements for activities are good in that they take account of individual’s preferences. Additional staff support is available to assist residents in pursuing their preferred hobbies and interests Reviews of the care required for each resident take place regularly and residents have full access to healthcare support services. Any concerns and complaints brought to the attention of the homes management are treated seriously and fully investigated, to ensure that the resident’s care is improved upon. Staff recruitment and selection is robust and ongoing training and supervision is provided. Residents meetings are held monthly, that also involves relatives feedback from relatives was that the meetings are helpful in keeping communication flowing and provide the opportunity to share ideas. Quality assurance tools are in place to measure the quality of care provided. These include audits of medication, housekeeping, health and safety, staff training and monthly unannounced visits are carried out by a representative of the organisation which is usually the operations manager who reports on the conduct of the home and the care provided. What has improved since the last inspection? What they could do better: The care plan aims and objectives need to reflect the current needs of residents, based upon the changing needs identified during the care plan reviews. All staff responsible for the administration of medication must ensure that the medication administration records (MAR) sheets are signed immediately after administering the prescribed medication. Please contact the provider for advice of actions taken in response to this Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 7 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. Duncote Hall Nursing Home DS0000012612.V327939.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 Duncote Hall Nursing Home DS0000012612.V327939.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): Standard 3 (Standard 6 is not applicable). Quality in this outcome area is good. People planning to move into the home can be assured that their care needs will be fully assessed and that admission will only take place once it has been established that the home can fully meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was pre assessment documentation in place, which demonstrated that full care needs assessments had been carried out prior to residents moving into the home. In discussion with residents it was established that they had been provided with sufficient information about the range of services at the home and that they had the opportunity to visit prior to moving into the home to meet with residents and staff. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 10 Information about the services provided is contained within a statement of purpose and a service user guides that were available in the home. Duncote Hall Nursing Home DS0000012612.V327939.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 & 10 Quality in this outcome area is good. Resident’s health and personal care needs are communicated within the staff team, however in some instances the overall aims and objectives of the care plans did not always reflect the residents changing needs and current objectives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From the information contained within the care plans, and in discussion with staff and observations of care practice it was confirmed that residents were receiving the care that was appropriate for their needs. The care plans were reviewed regularly and where residents changing needs were identified this was recorded within the reviews, however in some instances the overall aims and objectives of the care plans had not been updated to reflect the residents changing needs and current objectives. For example one of the care plans looked at stating that the resident could walk, Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 12 and dress unaided, when the residents physical condition and level of independence had significantly changed. There was information available within the care plans and the clinical nursing records of pressure area prevention and treatment. Within the individual residents bedrooms there was monitoring records available that cross referenced to the nursing intervention that was required to prevent residents who were immobile from developing pressure ulcers, and there was pressurerelieving equipment in use. Bedside rails ‘cot sides’ were seen to be in use, and where they were required safety padding was in place to avoid the risk of residents becoming entrapped, within the care plans there was evidence that where possible the consent had been sought from the resident to use this bed safety equipment, however within one of the care plans there was a consent form that had not been completed. There were records available of the frequency and input from healthcare professionals, which demonstrated that residents had full access to healthcare support services. Systems were in place for the ordering, monitoring, administration and disposal of medication and the medication was appropriately stored, the administration records were generally well maintained, however there was some gaps on the medication administration records (MAR sheets) were staff had failed to sign for medication that had been administered. The care plans included residents preferred routines and assistance that was required with personal care and daily living tasks, to ensure that independence was promoted. Relatives and residents spoken with during the inspection were happy with the care provided. Staff were observed to respect residents’ privacy and dignity, they were observed to knock on doors before entering and were in the main heard to speak to residents’ in a respectful manner, however some staff were heard to speak to residents using the terms ‘darling’ and ‘love’, this term of endearment can be perceived as treating residents with lack of respect, unless of course the resident has asked to be referred to in that manner.. The observations were discussed with the general manager and the operations manager and it was established that this was an area that had been noted for improvement, through supervision with individual staff and performance management, records of staff supervisions evidenced that the staffs communication and interpersonal skills were monitored. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 13 Duncote Hall Nursing Home DS0000012612.V327939.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 & 15 Quality in this outcome area is good. The lifestyle within the home matches the expectations of the people that live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with resident’s and staff and observation of practice indicated that the resident’s lifestyle meets with their expectations and that the staff endeavour to accommodate individual’s routines. On the day of inspection some residents were taking part in a game of scrabble in the conservatory with one of the activity staff, care staff were observed to spent some one to one time chatting with residents. Discussion with the activity staff confirmed an awareness of the importance of the inclusion of activities with an element of appropriate physical exercise and mental stimulation. Recently a group of residents had been learning French. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 15 Visiting arrangements were flexible and staff were observed to be welcoming towards visitors and residents’ and relatives spoken with were happy with the visiting arrangements and the care provided by the home. Residents’ choice about where to spend their day is respected, due to physical frailty and failing health some residents stay in their rooms for the majority or all of the day and others spend time in the communal lounges. In discussion with residents they said that they could do whatever they wished, one resident said that they enjoyed knitting and was in the process of making a cardigan; the activity person was seen to be providing support to the resident with their knitting. The home employs a team of three staff to provide activities for residents. In discussion with the catering staff it was confirmed that information about the dietary needs of residents is given in order that any special requirements or preferences can be taken into account. Additional staff are employed to assist at meal times, which allows residents to receive the support at meal times that is required, and allows the care staff to provide personal care when needed. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 16 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 & 18 Quality in this outcome area is good. People living within the home and their representatives can be assured that any concerns or complaints they may have will be listened to and acted upon by the management of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the complaint procedure displayed in the entrance hallway that provides information on the homes complaints procedure. Two complaints had been received since the last inspection and letters of response were seen during the visit indicated that complaints are taken seriously and fully investigated. Residents’ spoken with said that they felt able to raise any concerns that they might have with the manager. Staff training records demonstrated that training is provided in safeguarding vulnerable adults. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. The environment is clean, comfortable and in good decorative order providing a pleasant place for residents to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During a limited tour of the building residents rooms were seen to be clean and personalised, to contain ornaments and small items of personal furniture, Residents spoken with confirmed that they were pleased with their rooms. Observations and discussions with staff identified that staff are aware of the importance of following cross infection control procedures, within the kitchen area food safety standards were followed and there was records available of daily food safety checks and within the laundry area cross infection procedures were seen to be in operation. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 18 The communal areas of the home were pleasant and decorated to a good standard. A large conservatory overlooks extensive grounds, which provides residents with a good opportunity to watch the wildlife, resident who were seated within this area said that they found it very pleasant and liked spending time there. There were records of maintenance checks to equipment in use and records of checks to fire, water, gas, and electrical systems. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is good. The staff team are trained and supported to ensure that they can fully meet the needs of people who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the visit there was sufficient staff on duty to meet residents and the staff were observed to respond to residents needs and to spend time socialising with residents. Relatives were very complimentary about the staff team and the care they provide to residents. A sample check of staff files confirmed that a thorough recruitment process is followed, with references and criminal record bureau clearances being obtained prior to staff working in the home. In discussion with staff it was confirmed that they work in addition to the staff compliment for the first week of employment in order to familiarise themselves with the homes policies and procedures and to become familiar with the individual needs of the residents living in the home. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 20 An induction and training programme is in place, and staff supervision records seen demonstrated that the staff’s competency is regularly assessed and training needs identified to ensure that they receive training appropriate to their role. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. The home is run in the best interests of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An application has been submitted for the general manager to be registered with The Commission for Social Care Inspection to take on the role of the registered manager. During the visit the management arrangements were discussed, the general manager has worked at the home for a number of years during which time she has gained the necessary skills and experience in caring for the needs of the people that live at the home and has achieved the National Vocational Qualification (NVQ) Level 4 and the Registered Managers Award Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 22 (RMA). Standard thirty one within this outcome area is almost met and has therefore been given a score of two, however this is not a reflection of any inability of the general manager to effectively manage the home, other than the registered managers application is under process. Nursing care is provided by a team of qualified nurses under the supervision of a clinical lead nurse. Residents meetings are held monthly, that also involve relatives in discussion with relatives they said that the meetings are helpful in keeping communication flowing and to share ideas. Resident’s finances were individually managed, and arrangements were in place to ensure that residents have access to funds to meet their financial needs. Quality assurance tools are in place to measure the quality of care provided. These include audits of medication, housekeeping, health and safety, staff training and monthly unannounced visits are carried out by a representative of the organisation which is usually the operations manager who reports on the conduct of the home and the care provided. Staff spoken with said that they felt supported by the homes management and that they enjoyed working at the home. Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 X 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 3 X 3 X X 3 Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Residents care plans must reflect the residents changing needs and current objectives for health and personal care to be actioned. Staff who administer medication must sign the medication administration records at all times. Timescale for action 13/07/07 2 OP9 13(2) 16/06/07 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.V327939.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Duncote Hall Nursing Home DS0000012612.V327939.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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