Inspection on 05/05/05 for Dussindale Park Nursing & Residential Home

This inspection was carried out on 5th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dussindale Park Nursing &... 11/11/08

Dussindale Park Nursing &... 26/06/07

Dussindale Park Nursing &... 30/06/06

Dussindale Park Nursing &... 07/11/05

Dussindale Park Nursing &... 26/10/04

Dussindale Park Nursing &... 29/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Dussindale Park Nursing Home Mary Chapman Close Dussindale Norwich NR7 0UD Lead Inspector Susan Golphin Announced 05 May 2005 09:30 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 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. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dussindale Park Nursing & Residential Home Address Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD 01603 701900 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Alphacare Services (UK) Ltd Manager in post - application to register expected soon. Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Fifty-eight (58) Service Users may be accommodated of either sex who are aged over 65 years. 2. From time to time a service user between the age of 50 and 65 years may be accommodated. 3. The total number not to exceed fifty-eight (58). Date of last inspection 26 October 2004 Brief Description of the Service: Purpose built in 1994, Dussindale Park is situated in a modern residential suburb of Thorpe St Andrews on the outskirts of Norwich. The home can accommodate 58 older people with residential or nursing needs, in 38 single and 10 double rooms; 38 of the rooms have en-suite facilities and some of the ground floor rooms open up to patio areas. The accommodation is on the ground and first floor levels, and can be accessed by passenger lift. The second floor is used for offices and storage. The surrounding lawns and garden areas are well maintained and can be accessed by service users. There is ample parking space at the front and to the rear of the premises. The home is supported by the local GP practices and other health professionals. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out with new manager Ms Joanne Paul who has been in post for five weeks. AlphaCare Services (UK) Ltd acknowledge that the home requires positive leadership from a manager with a strong sense of direction and purpose to achieve the aims and objectives of the home. Priority is being given to reviewing the staffing levels against the dependency of the service users, and ways in which the stability of the staff group can be improved, to promote commitment and professionalism. A short tour of the premises was undertaken, the home is well maintained and in good order. Some small items of furniture and furnishings were noted to be in need of replacement or and repair and these were acknowledged, and receiving attention. This inspection was announced and carried out between 9.30am and 5pm .The pre inspection information was completed prior to the day, and the inspector spoke to four service users and three staff during the course of the inspection. Care plans and staff files and other documentation relevant to this inspection were made available during the inspection. The home are currently meeting the healthcare needs of 18 residential service users and 35 with nursing needs. What the service does well: What has improved since the last inspection? improvements in staff supervision, training input and clinical practice have been maintained but are continuing to be reviewed by the incoming manager as part of her own planned review. The requirements made at the last inspection have been met other than for those related to ongoing reviews or achieving NVQ training which are acknowledged as work in progress and have an extended timescale. Monitoring of the recruitment and selection processes is helping to maintain the stability of the staff group. The manager has improved the working protocol and communication systems with other healthcare professionals. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 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. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 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 standard(s) 1,3,5 The home have a statement of purpose and service users guide which is issued to all prospective service users and their representatives. The information is up to date and enables prospective service users to make an informed choice about living in the home. The assessment process has been improved and updated. It provides an account of each service users health care needs and how they can be met by the home. EVIDENCE: The assessment format has recently been reviewed to include additional questions which relate to the mental health status of prospective clients. The management are also seeking information about family relationships which may effect the care of the service user once accommodated in the home. The management have taken this positive action as a direct result of dealing with limited information about people who want to live in the home. Five care plans, were seen on the day of the inspection. All the relevant information was in place and gave an account of the service users healthcare needs. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 9 The information about the home which is available to all service users and is on display in the reception area will be updated with information about the new manager . Relatives and visitors spoken to on the day of the inspection said that they were clear about the service provision and who to contact for information. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 The care plans provide staff with information to meet service users healthcare needs. Specialist needs are met by the clinical nursing staff with the support of other healthcare professionals Individual care and support in this home is offered in a respectful and dignified way, and promotes privacy and independence EVIDENCE: Five care plans were seen on the day of the inspection and provide appropriate information and details relating to service users healthcare needs. The format has been in use for some time and the manager is to review the planning process. The new care plans will be discreetly kept in each service users room to confirm ownership and ensure that records of events incidents and individual care are recorded at the time the care service is delivered and thereby ensuring staff accountability and responsibility. The CSCI acknowledge this as a major piece of work which will significantly improve the service.( see recommendation) During the discussions service users gave examples of good care practice in the respectful approach to situations and personal kindnesses shown by staff. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 11 Visitors and relatives also commented favourably on the care service and said they would welcome meetings with staff and management to discuss progress and changes and to be involved in the care planning processes. The inspector was also able to talk to the nurses and care staff on duty and to observe the care of service users with high nursing needs and who were unable to participate in the inspection process. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12,15 Group recreational activities take place each day, but the new manager plans for more individual sessions. The meal arrangements in place offer a good range of choices with specialist meals and dishes to meet identified dietary needs . EVIDENCE: There is a social activities organiser in place and a group activity is offered each day . Information about social events is displayed in the communal areas but some service users are not aware of what is available each day either because of their limited mobility or have difficulty remembering what the notice board says. The organiser Zoe Goodsen is motivated and committed to promoting stimulating and interesting events and activities. The manager will be reviewing the current weekly programme and time allocated to this provision and also looking at ways in which Zoe can develop personal and individual activities for service users in addition to the group ones. (see recommendation) Service users commented favourably about the choice of meals and range of meal choices One service user said that he liked standard ‘old fashioned ‘ meals and that’s what the home do best. Staff were observed serving meals and assisting people to eat .Service users did say that they couldn’t always Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 13 remember what they had chosen for their meals and acknowledged that it would be nice to have something to refer to each day. During the discussions it was agreed that a simply printed ‘flyer’ stating the weeks menu on one side and the activities to be held in the home on the other and distributed to each persons room at the beginning of the week would be one way of ensuring that service users their relatives and staff were informed about food and events. (see requirement) Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16,18 There is a satisfactory complaints process in place in the home, with evidence to support any complaints made by service users and their representatives are listened to and acted on The arrangements for the protection of vulnerable adults is in place and there is improved staff knowledge and understanding of adult protection issues . EVIDENCE: The home have a complaints procedure in place and written information is displayed in the reception area and a ‘’how to complain’’ notice displayed on the wall by the reception desk. One service user said that if they had any concerns that they would speak to the manager of the home . One visitor to the home said that they were aware of the leaflets and information available and would also speak to staff or the manager. All complaints or concerns raised through the homes own procedure are logged and maintained in chronological order. The Nurse Care Manager audits the information when carrying out the regulation 26 ( Care Homes Regulations) visits and reports. The management of the home have recently dealt with an adult protection issue in conjunction with the Adult Protection Unit and CSCI The allegation has not been substantiated but the management are carrying out their own internal investigation which will involve a review of pre admission assessment processes. The manager will also be checking cultural differences and approaches of care staff when meeting service users needs and monitor and re-assess staff practice. (A recommendation has been made in relation to continuing adult protection training) Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19,22,26 The standard of the environment within this home is good, providing service users with a homely place to live. EVIDENCE: A short tour of the premises was undertaken and five service users rooms , and communal rooms were seen on the day. All were decorated and furnished to a good standard and offered appropriate equipment such as adjustable beds and hoists, stand aids and assisted bathroom facilities. Currently the home needs an additional hoist to meet client need and the management confirmed that the equipment is on order. During the tour it was noted that some of the service users rooms would benefit from a review to ensure that minor decoration , furnishing and curtains are replaced or refurbished where necessary. A number of the adjustable bed tables used both in the communal rooms and the service users own rooms are showing signs of wear and tear and need to be replaced in sufficient numbers to ensure each person has an adjustable table for use whilst sitting in a chair or in bed. ( see requirement) Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 16 On the day of the inspection the home was clean, hygienic well maintained and free from any unpleasant odours. There is a policy in place for the safe handling and disposal of clinical waste and infection control. Protective clothing is available to staff and the manager is reviewing the use of other medical materials and procedures to ensure that staff comply with procedures and clinical practice to prevent cross infection. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 Progress has been made in promoting the stability and skill mix and training of the staff group to maintain a consistency of care in the home. EVIDENCE: The staffing rota supplied with the pre inspection information reflected the numbers of staff on duty. In addition to the full time nurse manager there are 3 trained nurses on duty throughout the day and 2 at night.The trained staff are supported by between 6-9 care staff each day and 3-4 each night There are also designated domestic, catering staff and maintenance staff on duty each day. There are 11 trained nurses and 4 care staff with NVQ qualifications. Clinical practice training is in place and includes wound care, first aid ,adult abuse awareness, and continence management. Mandatory training is also in place and includes moving and handling, fire procedures, dementia care . One of the trained nursing staff is to become the first aid trainer for the home (and care group) he will be completing the trainers course on 16 May 2005. The new manager has instigated some practice changes in the home which include improved handover meetings especially in the mornings. The manager is also reviewing working styles and methods to promote and improve service delivery. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,38 The newly appointed manager of the home has a clear development plan for the home and is effectively beginning to communicate to the service users staff and relatives. EVIDENCE: Staff and service users gave positive responses about the recent changes in management and there is a sense of improved team work and growing stability within the group. The manager is a trained nurse with a current registration, and has previous managerial experience of both nursing for older people in the community and in a residential and nursing home. The manager said that it is her intention to work towards better person centred philosophy for the home which will support good practice and service delivery. A good example of this relates to work on the care planning process which will promote service users ownership of their plans and encourage better contribution and involvement in their own care. It was agreed that the Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 19 managers application for registration will be submitted to the CSCI by 1st August 2005. ( see requirement). Safe working practices are monitored and equipment and mechanical and electrical systems are regularly serviced and checked in keeping with relevant legislation. Generic and individual risk assessments are in place and the processes for reporting accidents, incident are documented and in place. The Nurse Care Manager audits these processes each month as part of the regulation 26 report visits and also as the three monthly quality assurance review. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x 2 x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x x x x 3 Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 21 Yes 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 15 Regulation 16 Requirement The providers and management must ensure that the information about meals and meal choicesin a format to suit service users. The registered providers must review and replace worn furniture and fittings in service users rooms. The providers and the management must continue to promote and provide training opportunities for staff to undertake NVQ must submit an application to register the manager The providers and management must ensure that all mandatory training is in place and updated including Basic Food Hygiene training and appropriate training for staff handling and preparing food. Timescale for action immediate and by 30th June 2005 immediate and by 30th June 2005 immediate and ongoing by 1st August 2005 immediate and by 30th June 2005. 2. 22 23 3. 28 19 4. 5. 31 38 19 17 6. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 7 12 18 Good Practice Recommendations It is recommended that the manager undertake a review of the care planning process to update the format. It is recommended that the manager review the current activities programme to include more individual input. It is recommended that the management continue to promote training in the protection of vulnerable adults and awareness of adult abuse practices. Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 Dussindale Park Nursing Home I55s44398Dussindale217316(an)050505 Stage 4.doc Version 1.30 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!