Inspection on 22/06/07 for Dunniwood Lodge

This inspection was carried out on 22nd June 2007.

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

Dunniwood Lodge 24/06/08

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dunniwood Lodge 229 - 231 Bawtry Road Bessacarr Doncaster South Yorkshire DN4 7AL Lead Inspector Susan Vardaxi Key Unannounced Inspection 22nd June 2007 09:00 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 DS0000070009.V347544.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. DS0000070009.V347544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunniwood Lodge Address 229 - 231 Bawtry Road Bessacarr Doncaster South Yorkshire DN4 7AL 01302 370457 01302 533568 NONE 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) Mimosa Healthcare (No.6) Limited Diane Katherine McKenna Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places DS0000070009.V347544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: Dunniwood Lodge is purpose built care home providing accommodation on two floors accessed by stairs and lifts. The home can accommodate 44 older people, 65 years and above and provides personal care. There are 42 single rooms all with en-suite except one and a double room with en-suite. Communal areas are spacious The home is in Bessacarr near Doncaster with good bus routes into town. The weekly charges for the service in June 2007 are £550 to £650. Hairdressing and Private Chiropody are charged extra. People are made aware of the service and the role of the Commission in the service user guide. DS0000070009.V347544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which occurred on 22nd June 2007 over 9 hours commencing at 09:00 and ending at 18:00 hours. The visit included talking with people living at the home, a relative, the manager and five staff, a walk round the building occurred and some records were checked Some surveys forms were sent to people who live at the home, their relatives and health workers to record their views of the service. At the time of this visit four were completed and returned to the Commission. Since the visit a survey completed by a GP has been received and the comments were generally positive. Information about the service had also been provided by the manager prior to the visit. A letter of serious concern was sent to the provider and manager following the visit for improvements to be made to the administering, recording and storage of medications. The Commission has been informed since the visit that the manager has taken action to address the issues raised. The inspector would like to thank the people living at the home, the manager and staff and all who participated with the overall inspection process and their hospitality throughout the visit. What the service does well: What has improved since the last inspection? DS0000070009.V347544.R01.S.doc Version 5.2 Page 6 The manager is currently introducing a new format for recording care plans. She said there is an ongoing rolling programme for refurbishment and decoration, which will help to maintain the current pleasant environment. A new boiler had been fitted after it was observed that water temperatures were above those recommended to prevent scalding. The company has developed an equality and diversity policy and procedure for staff. 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. The summary of this inspection report can be made available in other formats on request. DS0000070009.V347544.R01.S.doc Version 5.2 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 DS0000070009.V347544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for ensuring people’s needs can be met prior to people’s admission are satisfactory. DS0000070009.V347544.R01.S.doc Version 5.2 Page 9 EVIDENCE: The details on the registration certificate seen had been included into the statement of purpose so people are given full information about the care needs the service is registered to provide. Some records seen showed that pre admission assessments had occurred and contracts provided. The manager said she always visits people in their own homes prior to a decision being made in respect of admission; evidence was seen on records checked. Some people spoken with said that they had visited the home prior to admission. The home does not provide intermediate care. DS0000070009.V347544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are satisfied with the care provided however, the information in care plans does not ensure people’s identified needs would be met appropriately. People’s health could be at risk if medication is not administered as prescribed. EVIDENCE: The manager said she is currently reviewing the format for recording care plans. Some care plans seen were not always specific to the person’s individual needs. Also the action to be taken by staff and specific timescales for action to be taken had not always been included. This was discussed with the manager who said she would make the necessary changes to make sure the needs are met. Risk assessments had been completed for some people for falls, mobility, nutrition and pressure areas. DS0000070009.V347544.R01.S.doc Version 5.2 Page 11 Staff had not always completed the monitoring charts in a person’s bedroom. A member of staff who had assisted the person to get up said she had not been aware that the charts were in the room. This was brought to the manager’s attention who said that information in respect of people living at the home was passed on to staff verbally at shift handovers. The daily records seen showed that there are various books used to record information relating to the people on a shift basis which could lead to information not being passed to staff. This was discussed with the manager who agreed to introduce one method of recording, which would be on the daily records on a shift basis A care plan for pressure area care had not been completed. Records seen showed that of people’s weights had been checked. Records seen showed that the GP and other health professionals visit the home when requested, this was confirmed by the manager and some people spoken with. Comments made by a GP on a survey form were generally positive. The manager said all staff who administer medications have been trained, this was confirmed by some staff spoken with and on information provided prior to the visit. Some medications and medication records were checked with manager and a senior carer present, the following concerns were observed: The number of signatures on two people’s medication administration records (MAR) and the number of tablets in stock showed that the medication had not been given as prescribed e.g. two people had more tablets in stock than should have been. This was brought to the attention of the manager and senior carer who agreed the discrepancies. The manager has told the Commission that since the visit she has discussed the discrepancies with the staff who had not been able to clarify why the discrepancies had occurred. Movicol sachets were not being stored appropriately. A communal box was being used to store two people’s sachets; the name and directions on the label were for someone no longer living at the home, which could result in people not being given medication as prescribed. The medication and medication trolley were being stored in a locked cupboard and medication in stock had been kept to a minimum, which was recommended at the last visit to make monitoring easier. The manager has informed the Commission that since the visit another medication trolley has been provided to help with the storage of medications and Movicol sachets are now stored individually. The names of some medications could not be clearly seen as the hole made in the sheet for filing purposes had been punched over the printed directions. The manager has told the Commission since the visit that arrangements are being made with the pharmacist to rectify this DS0000070009.V347544.R01.S.doc Version 5.2 Page 12 Hand written entries made on the MAR sheet had not been signed and countersigned by staff to confirm the details are accurate and the manager has since told the Commission that this has been discussed with staff. Pharmacy labels had been stuck onto the medication records, these could become loose and accidentally transferred onto the wrong sheets and the Commission have been told that this has been discussed with the pharmacist and staff A visitor spoken with said “staff always knock on the bedroom door before entering”. People spoken with said they were satisfied with the care provided and spoke highly of the staff team. People looked comfortable and relaxed, their clothes well laundered and attention given to personal hygiene. Comments made on survey forms received prior to the visit included “personal care good, service cannot be improved, it is excellent” “on the whole they are very kind”. Staff were observed throughout the visit and they were seen to respect people’s privacy and dignity at all times. DS0000070009.V347544.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People appeared very much at home and the home is run in accordance with their wishes and the provision of activities is sufficient to ensure people are motivated and contact with the community is maintained. EVIDENCE: The home employs an activities person who works weekdays. She was in the home during the visit and a game of bingo, which was well attended, was taking place in the morning. People spoken with said that they spend their days in various ways, one person was knitting, others were reading the daily newspapers, and one person said they join other people in the lounges in the evenings. A visitor said that their relative had recently been on an evening outing to a local concert with other people who live at the home and had thoroughly enjoyed it. People spoken with said that relatives and friends could visit them in private in their bedrooms. DS0000070009.V347544.R01.S.doc Version 5.2 Page 14 A comment made on one survey received stated “ keep the residents interested in everyday happenings”. The manager said the home does not handle people’s finances, she said relatives have taken responsibility where people are unable to handle their own affairs. The people were joined in the dining room for lunch, discussion on a range of topics occurred with the five people at the table. The table linen was well laundered and flower arrangements were placed on every table. The meal served was fish and chips or mashed potato and vegetables; an alternative meal and choice of dessert were available. The fish was fresh, the meal was cooked and presented to a good standard, and waste was minimal. The people spoken with were very positive about the meals provided. Staff were observed assisting people appropriately, the interaction between the people living at the home and with the staff was good and the meal was a social occasion, relaxed and lively. DS0000070009.V347544.R01.S.doc Version 5.2 Page 15 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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s complaints are taken seriously, they are investigated and records kept. EVIDENCE: Two complaints made to the home were recorded in the complaints book; they had been dealt with appropriately. A complaint made to the Commission since the last visit was passed to the provider and was dealt with through the homes complaints procedures. Staff spoken with and records seen showed that safeguarding training is provided. DS0000070009.V347544.R01.S.doc Version 5.2 Page 16 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): 19, 23, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a pleasant environment for people to live in. EVIDENCE: The home is set in very well maintained grounds, which provides a very pleasant environment for people to sit and relax in or to walk in. The laundry room fire door was wedged open at the beginning of the visit a member of staff was in the room. The manager arranged for the maintenance person to fit an automatic door closure to the door before the end of the visit. The home was clean and generally decorated to a good standard no unpleasant odours were observed. DS0000070009.V347544.R01.S.doc Version 5.2 Page 17 However there are some areas where the paint on the woodwork has been damaged. The manager said there is a rolling programme for decoration and general refurbishment. The records for this were not requested at this visit. A carpet in a bedroom located on the first floor of the home was stained; this was brought to the manager’s attention at the visit that said she would arrange for the carpet to be cleaned. Emergency call systems were in place in all bedrooms and those seen were in easy accessible if needed, faeces was seen on one extension cable, this was brought to the manager’s attention and she made a note for this to be dealt with. People’s bedrooms visited were personalised with some items of furniture, pictures, family photographs, books and general personal items. The running hot water temperature records were seen and showed that when temperatures had risen to 50 degrees centigrade and above action had been taken and new boilers have since been installed. The temperature recordings seen taken since the boilers were installed showed readings around 43 degrees centigrade recommended to prevent scalding. The sluice machine located on the first floor of the home is broken for some time, the manager said this needed to be replaced, and however a replacement has not been ordered to date. A domestic assistant spoken with said staff currently clean commodes with a disinfectant spray solution and cloth, which does not afford the cross infection solution that, the use of the sluice will give. The laundry room looked clean and tidy and cross infection procedures were seen to be in place. DS0000070009.V347544.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and training at the time of the visit were sufficient to meet people needs, although Protection of Vulnerable Adults from Abuse (POVA) First clearance must be obtained and Criminal Records Bureau (CRB) checks sought before staff work at the home to ensure people are cared for by suitably checked staff. EVIDENCE: The manager said she tries to maintain staffing levels to four carers during the waking hours and three carers on duty at night. Some staff rosters were seen and confirmed this; on occasion five carers had been rostered in the mornings. The manager and staff spoken with said that on occasion staffing levels can be reduced however this is only when staff sickness occurs. The manager said that other carers will work to provide cover whenever possible. The carers do not undertake any other duties, two domestic staff are employed and cover seven days a week and the home employs a laundry assistant. One completed survey received stated “at times there are not enough staff on duty”. DS0000070009.V347544.R01.S.doc Version 5.2 Page 19 Information provided prior to the visit shows that staff training is provided on an ongoing basis, this includes mandatory and induction training, staff spoken with said there were plenty of training opportunities for them and they had achieved NVQ care qualifications. Two staff files seen showed that they had commenced working at the home before Protection of Vulnerable Adults from Abuse (POVA) first checks had been completed. The manager said she had sought advice about this however she had not checked the Department of Health web site. Discussion occurred with the manager at the visit about recruitment practices needing to comply with regulation and the Department of Health Guidelines. Other recruitment checks required had been completed and were available on the records seen. The company (Mimosa Healthcare) have developed an Equality and Diversity policy and procedure for staff. DS0000070009.V347544.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager works to ensure people living at the home receive a good quality care service in a safe environment. EVIDENCE: The manager was on duty during the visit; through discussion she demonstrated a good knowledge of the needs of older people. Staff spoken with said that the manager’s door is always open if they have a problem. DS0000070009.V347544.R01.S.doc Version 5.2 Page 21 The home has a quality assurance system, which includes obtaining the views of the people who live at the home, those seen were positive. The manager has a system for auditing the overall service on a regular basis, this was discussed fully with her, she said she find the audits beneficial. The home does not keep money on behalf of the people, the manager said people or their relative/representative generally deal with finances. Staff spoken with said that formal supervision with the manager occurred at 6 weekly intervals. Information provided by the manager prior to the visit showed that mandatory training and infection control training is provided and updated although an issue relating to the sluice is detailed in standards 19-26. The fire officer had visited the home in February 2007 and no recommendations had been made. Information provided by the manager prior to the visit stated fire drills are held, fire equipment is tested and fire training provided. There were no health and safety concerns observed in the areas of the home visited other than a fire door issue in standards 19-26. Information provided by the manager prior to the visit showed that health and safety training is provided. DS0000070009.V347544.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X N/A X 3 X X 3 DS0000070009.V347544.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(3) Requirement Arrangements must be made for Movicol sachets to be stored so that the pharmacy label on the container in which they are stored clearly identifies the person they have been prescribed for. • • To ensure people are given medication that has been prescribed for them. To ensure medication is stored safely and prevent communal use. Medication must be administered to people as prescribed to ensure people’s health is not affected when medication is not given as prescribed by the GP. Timescale for action 29/06/07 • Risk assessments must be completed for people who administer their own medications to ensure people are able to administer their medication safely. DS0000070009.V347544.R01.S.doc Version 5.2 Page 24 2 OP29 19 Schedule 2 (7) Staff must be recruited in accordance with the Department of Health Guidelines. • Potential staff must not start work at the home without a Criminal Records Bureau (CRB) and Protection of Vulnerable Adults from Abuse first check (POVA) has been completed and a satisfactory outcome obtained. 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations • • Care plans should include the individual’s assessed needs and the action needed by staff to meet the needs appropriately. Care plans should state specific timescales that people should be assisted e.g. two hourly and not use “regularly” to provide continuity of care and accurate information for staff ensuring needs are met. Communication systems between staff in the home need to be improved to ensure information regarding the needs of the people living at the home are met. Hand written entries on the medication records should be signed and countersigned by staff to confirm accuracy. Pharmacy labels should not be stuck on the medication records, which could become loose and be accidentally transferred to other people’s records. • 2 OP9 • • DS0000070009.V347544.R01.S.doc Version 5.2 Page 25 • Arrangements for another method of filing the medication records should be discussed with the pharmacist so the holes made in the sheet for filing purposes are not punched over the printed directions. The medication fridge temperatures should be checked and recorded daily top ensure medications are being stored at the recommended temperatures. 3 OP26 The sluice facility located on the first floor of the home should be repaired or if needed replaced to prevent the risk of cross infection occurring. DS0000070009.V347544.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000070009.V347544.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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