Inspection on 16/08/05 for Abbeyfield Dene Holm

This inspection was carried out on 16th August 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeyfield Dene Holm 19/09/08

Abbeyfield Dene Holm 18/09/07

Abbeyfield Dene Holm 31/07/06

Abbeyfield Dene Holm 19/04/05

Abbeyfield Dene Holm 29/11/04

Abbeyfield Dene Holm 09/06/04

Abbeyfield Dene Holm 08/01/04

Abbeyfield Dene Holm 17/07/02

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield Dene Holm Dene Holm House, Dene Home Road Gravesend Kent DA11 8JY Lead Inspector Jo Griffiths Announced 16 August 2005 09:30am 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. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbeyfield Dene Holm Address Dene Holm House Dene Holm Road Northfleet Gravesend Kent DA11 8JY 01474 567532 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) The Abbeyfield Medway Valley Society Vacant CRH Care Home 47 Category(ies) of DE(E) Dementia - over 65 (21) registration, with number OP Old Age (25) of places DE Dementia (1) Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Care of one younger adult with a diagnosis of dementia is restricted to one service use whose date of birth is 19/06/1941. Date of last inspection 19/04/2005 Brief Description of the Service: Dene Holm is a large purpose built residential unit situated in Northfleet, on the outskirts of Gravesend. The home provides support to older people and people with Dementia. The large downstairs unit in the home is dedicated to supporting people with dementia. The building is accessible to wheelchair users with lift access to the first floor. Dene Holm has a team of staff covering a 24 hour rota. The Manager has applied to be registered with CSCI. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. The Manager was present and gave feedback on the progress made since the last inspection. For the purpose of this report the people living at Deneholm are referred to as the residents of the home. This was a positive inspection with a number of improvements noted. A number of staff and residents were spoken with and comment cards were received from the majority of residents, 1 GP and 17 relatives. What the service does well: What has improved since the last inspection? What they could do better: Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 6 A Statement of Purpose for the home is needed and the Service User Guide must be reviewed to ensure it provides residents with accurate information. The complaints procedure should inform residents that they can contact CSCI at any time and Adult protection training for staff must be provided. It would benefit residents for more staff to undertake their NVQ award and this is planned for this year. Care plans should include how residents social and occupation needs will be met. A record of residents’ weight should be kept to allow nutritional monitoring and it is recommended that seated scales be purchased to achieve this. There were some concerns in relation to the administration of medication and further advice has been sought from the CSCI pharmacy inspector, a separate report will be issued for this. Residents still feel there are insufficient activities and it was difficult to see whether this is the case, as the home are not maintaining good records of activities. The cook plans to review the menu and this will involve the residents. Some furniture needs replacing in the bedrooms and some radiators still require covering to protect residents. The laundry room and sluice currently occupy the same room and this presents an infection control risk, also the 2nd floor sluice room is not appropriate for it’s use. 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. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 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 Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 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, 2, 3, 4 Residents are provided with the information they need, but will benefit from a review of the Service User Guide. Each resident has a contract with the home and has their needs assessed before moving to the home to ensure they can be met. EVIDENCE: A Service User Guide is provided to all prospective residents. This provides people with the information they need about the home, but requires updating to ensure all the information is accurate. Comment cards indicated that some relatives do not know how to access the most recent inspection report. This was displayed on the notice board in the entrance hall. There is not an up to date Statement of Purpose. Residents have a full assessment of their needs before moving to the home. Through feedback from relatives and residents it is evident that the needs of the current group of residents are being met by the home. Where needs change the Manager ensures a new assessment is completed with the GP or other health professionals. Each resident is issued with a contract detailing the terms and conditions of residency. The contracts are signed by the resident or their representative. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 9 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, 9, 10, 11 Residents care plans meet their health needs, some of their personal needs, but not their social needs. Their privacy and dignity are maintained and they know they will be treated sensitively at the end of life. Residents are not fully protected by safe practice for administering medication. EVIDENCE: Care plans detail the support residents’ need in daily living activities. One plan did not contain the required information for staff to support the resident to maintain continence. It is recommended that care plans also be further developed to include how social and occupation needs will be met. External professionals meet residents’ health needs. The home does not have seated scales for weighing residents who have difficulty standing. This has resulted in some residents not having their weight regularly monitored. Medication is stored securely, but there were some concerns in relation to the interaction of medications used together. It is recommended that the pharmacy inspector visit to give some further advice. Residents said they feel the staff treat them well and respect their privacy. The Manager described the home’s policy to support residents sensitively to the end of life. Residents’ wishes in respect of dying are fully respected. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 10 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, 13, 14, 15 Residents do not feel there are sufficient activities to occupy their time. They can receive visitors when they wish. Residents receive a balanced and nutritious diet with plenty of choices. EVIDENCE: Since the last inspection a new activity room has been developed on the ground floor. Residents were enjoying knitting, crosswords, puzzles and drawing. A calendar of activities has been introduced following consultation with the residents, however records do not evidence regular activities taking place in the home. Feedback from relatives and residents indicates they still do not feel there are sufficient activities taking place. Visitors are welcome at any time. Volunteers are providing some activities in the evenings. Staff describe how they support residents to make as many choices as possible in their daily lives. Since the last inspection a new cook has been recruited and some changes have been made to the menu. Fresh meat, bread and vegetables are now delivered daily and some consultation has taken place with residents about their preferences. The cook plans to review the menu. A menu board in each unit now shows residents the menu for the day and records are being maintained of the meals eaten by them. Residents spoken with said they enjoyed the food and had plenty to eat. Condiments, drinks and second helpings were offered at lunchtime. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 11 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 Residents know how to make a complaint if they need to and know their concerns will be taken seriously. Residents are protected from abuse. EVIDENCE: The complaints procedure is displayed on the notice board. It is recommended that it be made clear on this that residents can contact CSCI to discuss any concerns at ay stage. There have been 2 complaints recorded in the complaints book and these have been responded to satisfactorily. There have been no adult protection alerts raised on this home. Staff have not yet received training in this subject, this is planned for this year. Staff spoken with were able to describe whistle-blowing procedures. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 12 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, 20, 21, 23, 24, 25, 26 Residents live in a comfortable environment that meets their individual needs. Generally the home is kept clean although there are some risks to residents from cross infection in the sluice rooms. EVIDENCE: Since the last inspection some communal areas of the home have been redecorated and there are sufficient lounge and dining areas for all residents. There are plenty of toilets and bathrooms to meet the needs of residents and the Manager has begun efforts to make these feel more homely. Residents are all accommodated within single bedrooms with the exception of one married couple. They are provided with the furniture they need although some of this requires replacement. Some radiators have been covered. Currently the sluice and the laundry occupy the same room; this presents an infection control risk to residents. The sluice room upstairs was not clean and the floor and boxing of pipes are permeable and again presents a risk of cross infection. Gloves and aprons have now been provided in all bathrooms for staff use when supporting residents with their personal care. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 13 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, 29, 30 Residents are supported by sufficient numbers of trained staff and are protected by safe recruitment procedures. Residents will benefit from an increase in the numbers of care staff with an NVQ. EVIDENCE: Rotas evidence that sufficient staff are now being deployed in the Dementia unit. The Manager is taking steps to reduce staff sickness. Since the last inspection the majority of care staff have undertaken the 12-week Dementia course. Courses have also been completed in manual Handling and 1st Aid. A number of other course including Fire Safety and Adult Protection are planned for this year. 26 of care staff have completed their NVQ and funding has been obtained for more staff to register. Residents are protected by safe procedures for recruiting staff. Files were randomly checked for employees and found to contain the relevant documents. Several staff were spoken with and it was noted that morale and commitment to the role seems to have improved since the last inspection. Staff were observed going about their duties and were providing care to residents in a positive and respectful way. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 14 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, 32, 33, 34, 35, 36, 37, 38 Residents live in a home that is run by a competent and qualified Manager and well-supervised staff. They are consulted on their views and are protected by safe procedures for managing their monies. Residents’ welfare is protected by policies and training in the home. EVIDENCE: The Manager is a registered nurse and has a diploma in management. Staff and residents spoke highly of the management approach of the home and said they felt the Manager was very approachable. Residents and relatives are consulted on their views by an annual survey carried out by the Abbeyfield head office. The manager has also introduced relatives and residents meetings and hopes to hold these 3 times a year. The Manager holds responsibility for the budget and any monies deposited by residents for safekeeping are stored and accounted for safely. The Manager Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 15 has arranged to add lockable storage space to residents’ bedrooms to allow them to hold their own money safely if they wish to. Staff supervision has now been reinstated and the Manager stated this would be carried out at the recommended 6 times per year. Abbeyfield policies and procedures cover all areas of the home and are being discussed with staff in their supervision sessions. Residents’ health and welfare are protected and risk assessments carried out as needed. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 16 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 2 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 x 3 2 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 3 3 3 3 3 3 2 Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 17 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 OP38 Regulation 23(4)(c,i) Timescale for action The registered person shall, after 31/10/05 consultation with the fire authority, make adequate arrangements for detecting, containing and extinguishing fires. In that, Fire doors must not be propped open. This requirement is carried forward from the previous inspection. 2. OP1 4(1) The registered person shall compile in relation to the care home a written statement (Statement of Purpose) which shall consist of items a-c of regulation 4(1) The registered person shall keep under review and, where appropriate, revise the Service users guide The registered person shall make suitable arrangments, by training staff or by other measures, to prevent service users being harmed or suffering abuse or 31/10/05 Requirement 3. OP1 6(a) 31/10/05 4. OP18 13(6) Action plan to be submitted to CSCI Page 18 Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 being placed at risk of harm or abuse. In that, training should be provided for staff in the protection of vulnerable adults. 5. OP24 16(2c) The registered person shall, having regard to the size of the care home and the numbers and needs of service users, provide in rooms occupied by service users adequate furniture suitable to the needs of the service user. In that, furniture must be maintained in a good state of repair. 6. OP25 13(4a) The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety. In that, all radiators must be covered or have a guaranteed low surface temperature. 7. OP26 13(3) The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. In that, The laundry and sluice facilities on the ground floor must be separated. Also that the flooring and wall coverings in the first floor sluice room must be impermeable. Action plan to be submitted to CSCI Action plan to be submitted to CSCI Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 19 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. 5. 6. Refer to Standard OP7 OP8 OP12 OP15 OP16 OP28 Good Practice Recommendations It is strongly recommended that care plans include how residents social and occupation needs will be met. It is recommended that a record of residents weight is maintained and that seated scales are obtained to weigh residents who have difficulty standing. It is recommended that a record is maintained of the activities provided to allow monitoring of residents levels of occupation. It is recommended that the menu be reviewed. It is recommended that it be made clear on the complaints procedure on the notice board that residents can contact CSCI at anytime. It is recommended that 50 of care staff complete their NVQ award by Dec 2005. Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Abbeyfield Dene Holm H56-H06 S23933 Abbeyfield Dene Holm V234281 160805 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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