Inspection on 31/07/06 for Abbeyfield Dene Holm

This inspection was carried out on 31st July 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbeyfield Dene Holm 19/09/08

Abbeyfield Dene Holm 18/09/07

Abbeyfield Dene Holm 16/08/05

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Abbeyfield Dene Holm Dene Holm House Dene Holm Road Northfleet Gravesend Kent DA11 8JY Lead Inspector Gary Bartlett Unannounced Inspection 31st July 2006 09:30a X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Dene Holm Address 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) Dene Holm House Dene Holm Road Northfleet Gravesend Kent DA11 8JY 01474 567532 The Abbeyfield Kent Society Post Vacant Care Home 47 Category(ies) of Dementia - over 65 years of age (35), Old age, registration, with number not falling within any other category (12) of places Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care of one younger adult with a diagnosis of dementia is restricted to one service user whose date of birth is 19/06/1941. 16th August 2005 Date of last inspection 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’s post is being covered by a person who has applied for registration. Current fees range from £420 to £530 per week. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Dene Holm from 9.30 a.m. until 4.30 pm. During that time the Inspector spoke with some residents, a visitor and some staff. Parts of the Home and some records were inspected and care practices observed. Due to the nature of the service provided on the dementia units, it is difficult to reliably incorporate accurate reflections of those residents’ views of the service in the report. Some comment cards were received prior to the inspection. Responses received from residents’ relatives indicated they were generally satisfied with the standards of care. Responses from health professionals also indicated satisfaction. The Manager and staff gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? The Statement of Purpose and Service Users Guide has been updated. The Home had acquired seated scales for weighing residents who had difficulty Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 6 standing so all residents could have their weight regularly monitored. The service has a revised complaints procedure. Menus are more varied. The sluice and laundry rooms have been separated. Staff training has increased and there are improved systems for monitoring individual staff training needs. A key-worker system is being introduced. 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. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service Residents were provided with the information they needed about the Home. Good pre-admission assessments and the opportunity to visit the Home prior to admission ensured residents were appropriately placed and the Home could meet their needs. The Home did not provide intermediate care. EVIDENCE: Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 9 The Manager said the Statement of Purpose and Service Users Guide had been updated to be accurately descriptive of the aims, objectives, philosophy of care, services and facilities and terms and conditions of Dene Holm. Copies of the Service Users Guide were provided for each resident or their representative. These were not inspected on this occasion. A senior staff member described how it was intended to make these available in other languages, Punjabi was mentioned, and in audio format. Senior staff visited prospective residents prior to admission to make a decision whether the Home could meet the persons’ needs. Information was obtained from relevant health care professionals to assist in assessments. Residents were able to visit the Home before moving in and a visitor said staff had been helpful in assisting their relative to settle. Intermediate care was not offered at Dene Holm. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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, 8, 9 and 10 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service Residents’ health and welfare would be better promoted by care plans being more consistently maintained and risk assessments being written or reviewed when necessary. Residents’ health needs would be better protected by improved facilities for the storage of medicines. EVIDENCE: Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 11 Each resident had a care plan. Three were inspected in detail. Although it was clear efforts were being made to improve care planning, they were not adequate in regard to the detail and consistency of information in some parts. Appropriate records had not always been made or reviewed as a result of some incidents. The staff’s understanding of residents’ individual needs was, in most instances very good. There was discussion about how care plans would benefit from including residents’ strengths and abilities in addition to their frailties and enabling staff to understand residents’ current behaviour patterns by linking them with the their previous experiences. The formal recording of this would give staff possible strategies to use with individual residents. It was important for necessary and current information to be recorded and readily available to staff for them to be able to meet residents’ needs. The Manager said that there were proposals for a new care plan format to be introduced. Since the last inspection, the Home had acquired seated scales for weighing residents who had difficulty standing so all residents could have their weight regularly monitored. The medicines storage room was found to be very small and, at the time, too hot for the storage of some medicines. Although, the directions for some medicines stated they should not be stored at more than 25 degrees C., the thermometer in the room was registering 28.8 degrees C. The temperature of the room had been monitored and recorded. These records showed the room temperature had been consistently too high during the recent hot weather. The floor, parts of the wall and some cupboard fittings needed to be repaired or replaced in order to maintain infection control. Records were available to indicate that all staff administering medications had been trained and signed off as being competent to do so. The Medication Record Administration Record (MAR) sheets inspected had been completed appropriately. Medications were seen being administered in compliance with current guidelines. A senior staff member had a sound understanding of good practice. Records inspected and comment cards received indicated the Home had a good working relationship with the specialist and local health care professionals, supporting residents in their health care needs. From observation and discussion with residents’ and a visitor it was clear that staff treated residents with respect and promoted their privacy and dignity. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service Residents could generally enjoy a fulfilling lifestyle although some wanted more activities. Some residents could be given greater choice and control over all aspects of their lives as their individual abilities allowed. Dietary needs of resident were well catered for with a balanced and varied selection of food that met their tastes and choices. EVIDENCE: Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 13 Residents spoken with were happy with the flexibility the Home offered in regard to meeting personal preferences where practicable, for example what time they got up, went to bed etc. The Home was re-introducing a key worker system, which enabled closer resident/staff relationships where likes, dislikes and needs were shared. Some residents mentioned they would like more activities and outings. The Manager explained they had been reviewing the current arrangements in order to provide more meaningful activities for residents throughout the week. There were not individual programmes included in resident’s care plans for staff to follow. Residents were observed watching television, being encouraged by staff to participate in games or quizzes and some were having their hair done by a visiting hairdresser. Whilst staff were seen to be dedicated to meeting residents’ needs, there was not evidence that the Home was promoting the choices and independence of all residents with disabilities by obtaining the necessary specialist advice or equipment. An example being a resident with a severe sight impediment would have benefited from the resources available via the Royal National Institute of the Blind. Indeed the person stated “I sleep in the evenings, maybe because I am bored..” Family and friends felt welcome and knew they could visit the Home at any reasonable time. The design of the Home provided seating areas within the communal areas of the Home where residents could entertain their visitors, in addition to the privacy of their own room. The Home encouraged individuals and groups from the community to visit the home. Residents spoke favourably of the meals, said they had plenty to eat and enjoyed the choices available to them. The meals were well presented and looked appealing. Lunch was taken in a relaxed atmosphere and staff were seen to offer assistance in a discreet and sensitive manner. The Manager described how the menus had been improved and those seen were varied and alternatives were offered. Residents were offered drinks and biscuits during the day. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service Residents and their relatives could have confidence their concerns and complaints would be listened to and acted on. There were systems to ensure residents were protected from abuse. EVIDENCE: The service had a revised complaints procedure that was up to date, clearly written, and easy to understand. The complaints procedure was widely available. Those spoken with had a good understanding of how to make a complaint and they were clear of what could be expected to happen if a complaint was made. The Manager described how records of complaints were kept and these included details of investigation and action taken and were used to inform future practice. There were procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. Staff spoken with had a sound knowledge of adult protection procedures. The Manager stated that Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 15 any allegation of abuse would be referred to the concerned agencies without delay. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 and 26 Quality in this outcome area was poor. The quality of life and safety of some residents was adversely affected by required improvements to the environment and security. Poor infection control in places placed residents at potential risk. EVIDENCE: Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 17 The accommodation was arranged on 2 floors with self-contained units on each floor. Although some areas had been redecorated there was still a need for some parts of the Home to be redecorated or upgraded. For example, the carpeting in parts of “Pocahontas” was very stained and the undecorated areas tired looking. As one staff member aptly described “rather gloomy”. Although there had been some replacement of furniture, many items were substantially worn. This had a consequent adverse effect on some residents’ quality of life, compromising their comfort and in some instances placed them at potential risk. There was a lack of suitable storage areas for wheelchairs, hoists and other equipment, thereby causing obstruction in some areas. This had also led to some domestic equipment being stored in the first floor sluice room, which was not conducive to the maintenance of infection control. The Home’s ability to maintain infection control was further compromised by damaged or missing tiles in high infection risk areas such as the first floor sluice room, the Salon, a bathroom in “Dickens” and the “Pocahontas” kitchenette. The kitchenette also needed some grouting and sealant to be replaced. The greatest risk to residents was posed by inadequate fencing around parts of the garden and other factors that facilitated possible illegal access to the building. The Manager described how they had been notifying head office of the need to improve the security of the grounds. The need for this had been highlighted by a recent incident in which a resident had repeatedly wandered away from the Home. Commendably, staff were seen to be diligent in monitoring comings and goings via the main entrance. CCTV was used for security purposes. There was an attractive garden that residents could use. Minutes of a recent relatives meeting indicated consideration was being given to levelling the garden to allow residents access to a greater part of it. Some of the garden paths were uneven and had potential trip hazards. The Manager described how an assessment had been made of the furniture and fittings in each resident’s bedroom to ensure they were adequate and met the needs of the resident. Unfortunately this had not included the few old hospital style beds that were not necessary for the residents’ needs and far from domestic in character. Where they were able to use them, residents were provided with keys to their bedrooms. Many residents needed the use of lifting aids to help them and staff received manual handling training. However, it was not evident that an Occupational Therapist had made an assessment of the suitability of the equipment being used, thereby placing residents and staff at potential risk. Some equipment seen, for example wheelchairs, lifting hoists, medicines trolley, was in need of a thorough cleaning. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 18 There had been improvements to ensure pipe work and radiators were guarded or had guaranteed low temperature surfaces to protect residents from the risk of burning, but there were still unguarded radiators. Pre-set valves were fitted at hot water outlets to minimise the risk of scalding. The water supply was periodically checked for Legionella. Emergency lighting was provided throughout the Home. Residents said they thought the lounge rooms to be comfortable. Some of the chairs in the communal areas were against each other, so preventing tables from being placed between them. These would have been particularly useful for residents to use when having drinks. Those parts of the Home inspected were clean and mostly free from unpleasant odours. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service Recruitment processes were robust and offered protection to people living at the Home. The Home was addressing the training of its staff so they had the skills to meet the needs of the residents. EVIDENCE: Resident’s said they liked the staff and thought they worked hard. Records seen indicated that robust recruitment procedures were used and ensured the Home directly employed only staff that had been properly vetted. The Manager stated that agency staff were not currently used. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 20 Residents and visitors said there were always staff available when needed. The Manager was monitoring that staff levels remained appropriate as residents’ dependency levels increased. As mentioned earlier in this report, there was some discussion as to whether the number of hours allocated for activities co-ordination was adequate. Indeed, the minutes of a recent relatives meeting included an invitation for volunteers to assist with activities. The staff rosters inspected did not show any staff to be working long consecutive shift patterns that could compromise staff competency through fatigue and thereby put residents at risk. The Home’s staff were required to undertake an induction programme and there was ongoing training for staff, which had recently included specialist areas such as dementia awareness. A training matrix had been written to ensure staff received the training they needed, rather than making it “available to them”. Data provided by the Manager showed that 32 of staff were trained in NVQ. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service The Home benefited from a Manager who was accessible and supportive. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 22 Residents’ welfare was promoted through regular environmental and equipment safety checks. EVIDENCE: Throughout the inspection, the Manager demonstrated a desire to provide a high quality service and a commendable openness and honesty. Staff and residents and their visitors said they considered the Manager to be very approachable. She had applied for registration and was due to have her “fit person interview” in the near future. The management team had been recently augmented by the appointment of an Assistant Manager. The Manager described how residents and their representatives or relatives were regularly asked for their views about the service. A relatives meeting had been held in July 2006 and another was scheduled for September. Most residents were unable to manage their own finances and a staff member explained that the Home encouraged residents’ families / representatives to give assistance with this. The staff member demonstrated a sound system of holding and recording residents’ cash, which facilitated ease of monitoring. Residents’ relatives did not express any concerns about the Home’s management of monies or valuables held on the residents’ behalf. The Manager said Abbeyfield regularly reviewed all its policies to ensure they complied with current legislation and good practice guidelines. The Manager stated that all records of maintenance and safety checks were up to date. These were not inspected on this occasion. Regular environmental risk assessments were made. The Manager was aware that the records of these needed to be improved in some respects. Records were seen to be kept in a manner that preserved confidentiality. A senior staff member stated there was always staff trained in first aid on duty. Records seen indicated that the Home was ensuring all staff had fire training or participated in fire drills and fire exits were kept clear of obstruction. Staff were seen to be diligent in ensuring COSHH requirements were adhered to and those spoken with had a sound understanding of emergency procedures. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 3 4 X 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 1 20 2 21 X 22 2 23 X 24 2 25 2 26 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 24 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 OP7 Regulation 14(2)(b), 15(2), 17 Schedule 3, Schedule 4 Requirement Timescale for action 01/09/06 2. OP7 13(4) 3. OP9 13(2) “The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review” in that service users’ individual plans and records must be kept and be up to date in that they must be consistent and specific in detail of information. An improvement plan must be received by CSCI by the given timescale. The registered person shall 01/09/06 ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be more comprehensive and recorded in response to incidents and changes in residents welfare. An improvement plan must be received by CSCI by the given timescale. “The registered person shall 01/09/06 make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that appropriate facilities must DS0000023933.V300686.R03.S.doc Version 5.2 Abbeyfield Dene Holm Page 25 4. OP12 12(1)(a) 5. OP12 12(1) 16(2)(n) 6. OP19 13(4) 23(2)(o) be provided for the storage and preparation of medicines. An improvement plan must be received by CSCI by the given timescale. “The registered person shall 01/09/06 ensure the care home is conducted so as to promote and make proper provision for the health and welfare of service users” in that appropriate advice and equipment must be obtained from appropriate sources to promote the independence of all service users, including those with physical impairments or disabilities. An improvement plan must be received by CSCI by the given timescale. “The registered person shall 01/09/06 having regard to the size of the care home and the number and needs of service users consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training”. An improvement plan must be received by CSCI by the given timescale. The registered person shall 27/10/06 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: 1. The Home and its grounds must be made secure from illegal entry and vunerable residents must be protected from wandering from the grounds. DS0000023933.V300686.R03.S.doc Version 5.2 Page 26 Abbeyfield Dene Holm 2. All windows must be made safe. To be completed by the given date if not sooner. 7. OP22 23(2)(m) “The registered person shall not use premises for the purposes of a care home unless suitable provision is made for storage for the purposes of the care home” in that wheelchairs, hoists and other equipment must be stored in designated areas that do not compromise the safety and convenienceof service users and staff. An improvement plan must be received by CSCI by the given timescale. “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 and equipment suitable to the needs of the service user” in that: 1. Hospital style beds must be used only when assessed as being necessary by a relevant health care professional. 2. Where a service user requires the use of lifting aids, a qualified Occupational Therapist must assess the suitabilty of the equipment to be used. An improvement plan must be received by CSCI by the given timescale. 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 DS0000023933.V300686.R03.S.doc 01/09/06 8. OP22 16(2)(c) 13(4)(c) 01/09/06 9. OP22 13(4) 01/09/06 Abbeyfield Dene Holm Version 5.2 Page 27 10. OP25 13(4a) 11. OP26 13(3) their safety in that external paths must be made safe. An improvement plan must be received by CSCI by the given date. “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. To be completed by the given date if not sooner. “The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home” in that: 1. Domestic equipment must not be stored in high infection risk areas. 2. The environment of all high infection risk areas must be made good where required. 3. Equipment, for example wheelchairs, lifting hoists, medicines trolley, must be kept clean. An improvement plan must be received by CSCI by the given timescale. 27/10/06 01/09/06 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 DS0000023933.V300686.R03.S.doc Version 5.2 Page 28 Abbeyfield Dene Holm 1. 2. 3. 4. 5. OP20 OP24 OP27 OP28 OP38 It is recommended that the chairs in the communal areas are sited so tables can be placed between them for residents to use. It is strongly recommended worn furniture be replaced. It is strongly recommended that an assessment be made as to whether there are adequate hours allocated for the co-ordination of activities. It is recommended that 50 of care staff are trained to at least NVQ level 2. It is recommended the records of environmental risk assessments be reviewed. Abbeyfield Dene Holm DS0000023933.V300686.R03.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone 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 DS0000023933.V300686.R03.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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