Care Home: Sister Dora Nursing Home

Similar services:

• Aston Court Nursing Home
• Breme
• Ravenhurst
• Ashcroft Hollow Nursing Home
• Westmead
• Bricklehampton Hall Nursing Home
• Briar Hill House
• Radbrook Nursing Home

What the care home does well The home provides a lively, warm and friendly environment in a picturesque setting. They encourage people who use the service and their relatives to think of the home as their own and they actively welcome comments on how the home should be run, and what improvements they can make in order to make their stay at the home as fulfilled and as enjoyable as possible. What has improved since the last inspection? Audits are carried out by the manager and other trained nurses on care plans and documentation in order to make care plans more specific. Other Health care professionals are encouraged to document their visits in these care plans. The senior care role has been developed with all seniors now having N.V.Q level 3 or in the process of achieving it and will receive training in giving residential medications and performing clinical observations. They also carry out audits on a monthly basis to make sure that key worker duties are being carried out and initially speak to staff not doing so. All care staff are involved in writing in care plans particularly on the care which they themselves have assisted in or given. People that use the service, relatives and representatives are welcomed and encouraged to participate in their care if desired and as long as consent for this has been given. Participation in all activities continues to be encouraged and welcomed. What the care home could do better: Continue to improve care documentation in all areas, monitor through audit, individual staff supervision and training. Key inspection report Care homes for older people Name: Address: Sister Dora Nursing Home Brocton Road Milford Stafford Staffordshire ST17 0UH     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Joanna Wooller     Date: 2 4 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 25 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 25 Information about the care home Name of care home: Address: Sister Dora Nursing Home Brocton Road Milford Stafford Staffordshire ST17 0UH 01785661024 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Leyton Healthcare (No 8) Limited care home 47 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia physical disability Additional conditions: The maximum number of users who can be accommodated is 47 The registered person may provide the following category of service only: Care home with nursing: - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD, maximum number of places, 47 Dementia - Code DE, maximum number of places, 47 Physical disability Code PD, maximum number of places, 47 Date of last inspection Brief description of the care home Sister Dora is situated on the edge of Cannock Chase in beautiful countryside with very pleasant views. It provides nursing care for 47 people, within a mixture of single and shared accommodation. The home is a victorian building with modern extensions. There are two lounges and one dining room in the main block with a smaller lounge Care Homes for Older People Page 4 of 25 2 7 0 1 2 0 0 9 47 47 47 Over 65 0 0 0 Brief description of the care home and dining area in a small annex, this can provide accommodation for four elderly people. There is a hairdressing facility and extensive social facilities available for the benefit of those who live in the home. Care Homes for Older People Page 5 of 25 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means that that people who use this service experience good quality outcomes. This unannounced inspection took place on 24th November 2009 by one inspector over one day. The Manager was in the home and participated in the inspection process. The inspection included the following elements, a walk around the building, observation and inspection of records relating to provision of care, discussions with people, who use the service, case tracking whereby we select several people who use the service, chat to them and look at their care plans and lifestyle in the home. discussions with several of the staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, training, recruitment and health and safety. Care Homes for Older People Page 6 of 25 We were made welcome in the home and all assistance was given to gain the evidence required for the report. We had dealt with no complaints since the last inspection. People who use the service were very complimentary about the service and the care their relatives received. The home manager sent us their annual quality assurance assessment (AQAA) when we asked for it. This document was completed to a good standard and gave us all the information we asked for. Care Homes for Older People Page 7 of 25 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 25 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 25 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People moving into the home do so having had their needs fully assessed and assurances are given that they will be met. The home does have intermediate care places which are well managed. Evidence: The AQAA told us A full assessment is undertaken by a trained nurse from Sister Dora prior to any new Service User being admitted. People that use the service told us that they had a pre admission assessment prior to admission and they met the manager. They told us they were invited to look around the home if they wished. One lady told us This is by far the best home in the area, the staff are marvelous, very friendly and welcoming at all times. One gentleman told us I am really happy here and have been since day one. We saw that the people were assessed prior to admission and assurances were given Care Homes for Older People Page 10 of 25 Evidence: that their individual care needs could be met. People were given the information they needed to make an informed choice and relatives input was welcomed at all times. Care Homes for Older People Page 11 of 25 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service have their health, personal and social care needs set out in an individual care plan. They are able to make decisions about their care including the assistance required with medication administration. People living in the home feel that they are treated with respect and their right to privacy is upheld. Evidence: The AQAA told us Each resident has a plan of care generated from the initial assessment. Care Plans are reviewed at least once a month. The promotion and maintenance of residents health is maintained and where needed, access to external health services is accessed. There is a comprehensive policy on the handling of medications in line with N.M.C guidelines. All residents are treated with dignity with most rooms having en suite facilities. We saw, through case tracking, that people who use the service receive personal and health care support using a person centered approach with support based upon the rights of dignity, equality and respect. Some people who use the service were able to tell us that they are respected and very well looked after. Care Homes for Older People Page 12 of 25 Evidence: Personal health care needs including specialist health, nursing and dietary requirements are clearly recorded in each care plan. A new care plan system has been introduced, however the named nurses must ensure that correct and clear recording of events and reviews are documented. It was noted that more meaningful reviews were required to evidence that the care and social needs are being met. Personal support is varied depending on the individuals needs and preferences. The delivery of personal care is also individual and is flexible to each persons ability. Relatives spoken to told us that the staff encourage the people to do things for themselves and the staff do respect privacy and dignity and are sensitive to the individual people. We saw staff listen to people and take account of what they wanted. People who use the service have full access to health care and specialist nursing services. Tissue viability nurses and continence nurse specialists have visited the home recently to support the staff. The local doctors manage the overall care of the individuals in the home. At the time of pre admission assessments being carried out the manager ensures that the home has the aids and equipment that they need for the person. This equipment is well maintained to support them and staff in daily living. We saw records of hoist servicing which means that the service is taking the correct action to make sure that equipment is safe and in good working order. The manager demonstrates through supervision the need to treat individuals with respect and dignity. She observes staff working with people who use the service and maintains an open door policy for everyone at the home to speak to her should they need to. The home has a robust medication policy and procedure which the staff are audited by the management to adhere to. The local pharmacy supplies and monitors the stock and prescriptions. Care Homes for Older People Page 13 of 25 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home find that their lifestyles match their expectations, they maintain contact with family and friends and have choice and control over their life. People receive a wholesome, appealing balanced diet in pleasing surroundings at a time convenient to them. Evidence: The AQAA told us Residents have no set routines and are given as much choice as possible in all areas of daily living. The Home has an extensive choice of activities for residents with representatives encouraged to join in and participate. Residents relatives are encouraged to visit on a regular basis and are offered refreshments as desired. Residents are assisted to maintain links with social clubs and to continue to attend social events and functions. Residents make decisions on a daily basis in areas of daily living. Catering staff frequently ask residents and their representatives for feed back on menus and this has been taken on board in order to provide a well balanced nutritious menu. The routine of daily life is made flexible for the people who use the service. One relative spoken to told us Mum is sometimes in her bedroom and sometimes in the lounge. She likes the way the staff allow the people to walk about the home. We saw Care Homes for Older People Page 14 of 25 Evidence: that an activity plan was on display in the dining room and other areas of the home. The homes activity co-ordinator spends dedicated time with the individuals and records of activities carried out are recorded in a file. She is a very motivated person who ensures that all the people living in the home lead a fulfilling lifestyle. Many events are planned due to popular request such as the museum bus, the computer bus, pat the donkey sessions and pottery painting. Many individuals enjoy flower arranging, baking and craft sessions. We saw evidence that Christmas will be celebrated in style with partys, carol singing and a Victorian Fayre. Craft items made by the people who use the service will be sold at these events. The home have recently adopted a donkey and some individuals have been on an outing to see their new pet at the donkey sanctuary. One to one sessions and group activities are offered and provided. The people who use the service told us that they enjoy dominoes, bingo, art, hand massage, reminiscence and sing-a-longs. Occasionally fish and chip suppers are arranged and film nights are planned. Relatives told us that they are invited to join these events if they wish. An abundance of event photographs are displayed in the home and stored in a photograph album. One lady who we spoke to told us that she really enjoyed dancing and singing and occasionally the staff danced with her in the lounge, which she really loves. We were told by many people that use the service that the staff are all lovely and friendly. We saw many complimentary thank you letters from grateful relatives who wished to show gratitude to the staff for their excellent delivery of care and attention. Care Homes for Older People Page 15 of 25 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service are confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse. Evidence: The AQAA told us The home has a simple comprehensive complaints policy. The Home has a company policy on protecting service users from abuse which also includes a whistle blowing policy. We looked at the homes Complaints Procedure that was displayed in the hallway and also within the Service Users Guide and Statement of Purpose. We saw that the home had a complaints folder in place. Eight complaints/concerns were documented and now resolved. We talked to two people that used the service who told us they knew how to make a complaint, and how to refer complaints or concerns that people using the service may have and who to refer them to. We were told that the service had no people registered on Depravation of Liberties Register. We talked to a few relatives who visit the home regularly who told us they knew who to talk to if they were unhappy about something. We saw evidence that the staff were suitably trained and confident to report any concerns following policy and procedures. Care Homes for Older People Page 16 of 25 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service live in a safe, well maintained environment that is clean, pleasant and hygienic. Evidence: The AQAA told us The home is located in a country setting with abundance of wild life for service users to enjoy. The Home employs a maintenance man to deal with minor maintenance issues promptly. The Home also has a maintenance programme to ensure the decor is maintained on a routine basis. Laundry is washed separately for specific residents to comply with Infection Control purposes, and two members of staff attend Link meetings on infection control to update all other staff on best practice. We found the home to be odour free and exceptionally clean. The domestic lady we spoke to told us The team of cleaners work hard to maintain a home, which is clean and welcoming. The cleaning schedule is followed to ensure that the standard is kept. Staff are vigilant to any problems, which may arise, and they alert the domestics to this. We looked at the laundry and sluicing areas and found that these provide adequate safeguards against infection. We were told that there had been no outbreaks of any infections in the home and the staff are trained in infection control procedures and the is a good supply of protective clothing in the home. The home has been well maintained since our last inspection and health and safety Care Homes for Older People Page 17 of 25 Evidence: issues for the people who use the service are monitored, to ensure their personal safety. We saw that many bedrooms had been upgraded with a new decor, bedding and curtains. Some new furniture was in place and some was still to be delivered. The manager has asked for some new chairs in the lounges. Flooring has been changed throughout most of the home and this has improved the overall appearance. Some lighting has been upgraded and more work in this area is planned. Care Homes for Older People Page 18 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service have their needs met and are kept safe by the number and skill mix of staff. The homes recruitment policy and practices protect the people living in the home. The staff are trained and competent to do their jobs. Evidence: The AQAA told us Off duty is planned in advance taking into consideration the skill mix of staff on duty at any one time. Staffing levels are reviewed on a frequent basis in line with requirements, and reviewed as the needs and dependencies of the residents change. At the moment we have 30 of staff who have N.V.Q level 2 with 70 at various stages of completing this qualification. (2 staff are in the process of completing level 3). The home has a rigorous recruitment procedure for prospective employees Staff receive all mandatory training with a comprehensive training programme in place. We saw that there were sufficient staff to meet the needs of the people using the service. We saw records that told us 70 of staff are trained to National Vocational Qualification Levels 2 and 3. The homes Manager has the registered Managers Award. We were told that the home does not generally use agency staff for any shortages as these are covered by the existing staff. Care Homes for Older People Page 19 of 25 Evidence: We looked at the files of the last three members of staff employed. Files contained two references, Criminal Records Bureau and Protection of Vulnerable Adults checks. This means that staff had been appropriately recruited. We saw that staff had received a statement of their terms and conditions and job description. We saw that there is a staff training programme/plan in place for the development of staff. We saw in staff files records of induction and individual training records. There is also a training matrix that gives an overall picture of training completed and training due. Care Homes for Older People Page 20 of 25 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home which is well managed by a person of good character. The home is run in the best interests of the people living in it and their financial interests are safeguarded. The health, safety and welfare of people who use the service and the staff are promoted and protected. Evidence: The AQAA told us The Home manager has the registered managers award. Residents and their representatives have three monthly meetings in order to discuss any general aspects with more specific concerns being held in private on a one to one basis upon request. Questionnaires are also useful in order to establish positive and negative feedback to make sure that we are providing the services which residents and relatives want. Service users can keep money personally if they wish or can have it kept safe in the safe on site with access to in office hours. Receipts are given for any monies kept for safe keeping. The company made arrangements for an independent Health and safety adviser to visit the home in September 2009 and advise on any issues or omissions requiring attention. Care Homes for Older People Page 21 of 25 Evidence: The Manager is a registered nurse and has the required experience to run the home. She has completed her Registered Managers Award. The Manager has again made considerable progress in many areas since our last visit. A visiting relative commented on the positive changes made in the home by the Manager and how the atmosphere in the home was now pleasant and relaxed. The relaxed and open atmosphere was evident during this inspection. Staff again made a valuable contribution to the inspection process. We saw that a Quality Assurance system has commenced with surveys completed by relatives and some people who use the service. The manager completes audits for the kitchen, laundry, domestics and the home. She is keen to use these as a means of service improvement. The manager has responsibility for the health and safety issues, the nurses and carers support her with this. We saw that risk assessments are in place for people who use the service to ensure their safety is maintained at all times. Fire risk assessments for the service are completed, but further work is required including the fire evacuation plan, which individually describes the action to take should the building need to be evacuated. We found that equipment is serviced and checked as required and water temperatures are tested and recorded. We saw that sixteen staff are trained in first aid and more staff will be trained in the next planned session. We saw that accident records are recorded correctly. Reviews were carried out by the GP following any fall or accident to ensure medication was correct and no underlying condition had occurred. Care Homes for Older People Page 22 of 25 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 23 of 25 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Care plan reviews should be well documented to demonstrate the persons care that is being delivered, any social activities and that their needs are being fully met. Care Homes for Older People Page 24 of 25 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 25 of 25 - 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!