CARE HOME ADULTS 18-65
Dunraven Lodge 8 - 10 Bourne Avenue Salisbury Wiltshire SP1 1LP Lead Inspector
Thomas Webber Unannounced Inspection 3rd February 2006 12:30 Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 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 Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 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 Adults 18-65. 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. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Dunraven Lodge Address 8 - 10 Bourne Avenue Salisbury Wiltshire SP1 1LP 01722 321055 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) Mrs Brigid O`Connor Mrs Eileen O`Connor-Marsh Care Home 20 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (20), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (4) Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th September 2005 Brief Description of the Service: Dunraven Lodge is a privately owned care home, which offers accommodation and personal care to twenty younger adults with a mental disorder. Dunraven Lodge is one of three registered care homes operated by Mrs O’Connor and Mrs O’Connor-Marsh in the Salisbury area which have been in operation since the 1980s. Dunraven Lodge is a large detached Victorian house, which is located next door to one of its sister homes: Dunraven House. The location of the home is convenient for residents who make use of the facilities and amenities of Salisbury. The administration of all the homes is centred at Dunraven House and staffing is also organised centrally for all three homes. The premises provide both single and shared accommodation for residents’ use and these are located on upper floors, which are accessed by use of a staircase. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, undertaken during the course of one day from 12:30 to 15:00. The primary focus of the inspection was to ascertain the views of the residents regarding the care and services provided. To this end, seven residents were spoken to on an individual and group basis. Standards assessed during this inspection included residents’ decision making, food menus, complaints, accommodation and staffing levels. What the service does well: What has improved since the last inspection? What they could do better:
The home needs to ensure that an appropriate level of heating is maintained to all parts of the home. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 6 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. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not checked during this inspection, as the core Standard had been satisfactorily assessed at the last inspection. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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 Residents are encouraged and supported to achieve their greatest level of independence and control over their lives and make decisions within a somewhat structured regime. EVIDENCE: Residents are encouraged and supported to achieve their greatest level of independence and control over their lives, which includes the right to make their own choices and decisions. The home has an understanding of the rights of residents who can come and go without restriction and opt in and out of any activities. Mealtimes can be made flexible to accommodate for this. Residents can, within reason, get up and go to bed when they want within a structured environment. Residents spoken to confirmed that they are expected to get up for breakfast, they can come and go without restriction, including how to spend their time, but are expected to be in their bedrooms by 22:30, where they can watch television if they want. Residents commented that they were happy with these arrangements. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Residents receive a varied and satisfactory diet. EVIDENCE: A satisfactory and varied menu is in operation which provides a choice at all mealtimes, including a cooked breakfast at weekends. A cook is employed to undertake the cooking duties. There are various dining areas within the home and there is an expectation that residents will eat their meals within these. Drinks are also available for residents at other set times of the day and staff would facilitate this. Residents spoken to commented very favourably about the quality and quantity of food provided, stating that they receive plenty. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not checked during this inspection, as the core Standards had been satisfactorily assessed at the last inspection. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Information is provided to all residents on how to complain. EVIDENCE: Management reported that no complaints have been received by the home since the last inspection. The home has established an appropriate written complaints procedure and each resident has been provided with a copy. The procedure informs complainants that they can contact the Commission for Social Care Inspection at any stage should they wish to do so. Residents spoken to commented that they had no complaints/concerns. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Residents live in a comfortable, safe and well-maintained environment, which meets their individual and collective needs. The home is kept clean and tidy and provides sufficient communal space together with adequate bath, shower and toilet facilities. However, there were some deficiencies to the level of heating to some parts of the building. Residents have personalised their bedrooms to varying degrees but to their individual wishes. Adequate laundry facilities are in place to meet the needs of the residents. EVIDENCE: The location of the home is convenient for residents who make use of the facilities and amenities of Salisbury. The property is in keeping with its surroundings and the residential neighbourhood, although the design and layout of the home is not suitable for wheelchair users. The premises provide sufficient lighting and ventilation with the standard of furnishings, fittings and decoration being maintained to a good standard. However, it was noted that the level of heating to the top floor of one part of the building was not being maintained at the appropriate temperature. Management and staff reported that this deficiency, identified at the previous inspection, had been addressed but will be further considered. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 14 The premises provide both single and shared accommodation for residents’ use with two of the single bedrooms being provided with en-suite facilities. Most of the residents’ bedrooms are located on upper floors, which are accessed by use of a staircase. Residents’ bedrooms are suitably furnished and they can bring limited items of furniture and personal possessions to make their bedrooms more homely. Residents can and have personalised their bedrooms to varying degrees but to their individual wishes. As stated in Standard 24, it was noticed that the level of heating was insufficient to one resident’s bedrooms located at the top of the building. Residents’ bedroom doors are not provided with locks but management reported that locks could be fitted at the request of the residents. Residents are provided with a lockable storage space within their bedrooms. Residents, who expressed a view, stated that they were happy with their level of accommodation with these being kept clean and tidy. The home provides adequate bath and toilet facilities to meet the needs of the residents accommodated. These facilities consist of three bathrooms, two of which have shower facilities, two separate shower rooms together with ten toilets, five being separate from the bath and shower facilities. All bathroom and toilet doors are fitted with suitable locks. The communal space consists of two lounges, two dining rooms and a dining area within the kitchen. These facilities are comfortable and suitably decorated and furnished. A chalet is located at the rear of a well-maintained garden, which has been designated as the smoking area for the home thus providing a smoke free zone to all other parts of the environment. The home continues to be maintained to a satisfactory standard being clean and tidy. Residents are encouraged and supported by staff to keep their bedrooms tidy. The laundry room is located on the ground floor and attached to the building of Dunraven House, which provides adequate facilities to meet the needs of both homes. A smaller washing machine is available for those residents who wish to undertake their own washing. However, staff tend to undertake the laundry duties. Residents, who commented, stated that they were happy with the laundry arrangements in place. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 The home ensures that there are sufficient numbers of staff on duty to meet the needs of the residents. EVIDENCE: The deployment of staff ensures that there is a minimum of two members of care staff on duty throughout the waking day, although there are usually three with two care staff sleeping in each night. There are also three domestics employed who are deployed to work throughout all three homes, providing a full clean in each home once a week with additional cleaning undertaken daily by the care staff. The staff team reflects the gender composition of the residents and residents commented very positively about the care provided by staff. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not checked during this inspection, as the core Standards had been satisfactorily assessed at the last inspection. Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 18 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 YA24 Regulation 23(2)(p) Requirement The responsible individuals must ensure that all parts of the home are heated to an appropriate temperature. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dunraven Lodge DS0000028277.V278632.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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