Inspection on 03/01/07 for Dapplemere

This inspection was carried out on 3rd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Dapplemere 20/08/07

Dapplemere 22/05/06

Dapplemere 26/01/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Dapplemere Shepherd`s Lane Chorleywood Hertfordshire WD3 5HA Lead Inspector Hazel Wynn Key Unannounced Inspection 3rd January 2007 10:00 X10015.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 Dapplemere DS0000064417.V325726.R01.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. 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. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dapplemere Address Shepherd`s Lane Chorleywood Hertfordshire WD3 5HA 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) 01923 282119 01923 282119 Pressbeau Ltd Manager post vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (15), Terminally ill over 65 years of age (7) of places Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd May 2006 Brief Description of the Service: Dapplemere is a two storey period house to which a modern extension has been added. The extension provides seven nursing places, all in single occupancy bedrooms, whilst the original building offers 15 individual places for elders. There is no lift and the original building is constructed on several levels, which means that residents are required to have a degree of mobility. The home is located in a rural setting a short drive of a junction for the M25 and Chorleywood railway station. The fee range is £600 plus the amount of the Registered Nursing Component granted. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the afternoon/evening of 3rd January 2007. The inspector observed staff interaction with service users. A tour of the building was undertaken and records examined. The medication and records were checked during this inspection. The inspector met with service users, the manager and staff. The home was being well run. What the service does well: What has improved since the last inspection? What they could do better: The home is still looking to recruit a manager as the current manager is being promoted and has therefore not registered; a recent recruitment drive had led to an offer of post but the applicant had found a position whilst waiting to hear. The requirement to have a registered manager in post remains unmet. A DVD player is recommended as an aid to training for staff. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3: No service user moves into the home without having his/her needs assessed and been assured that needs will be met. Standard 6, does not apply to this home because it does not provide intermediate care services. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection, the manager was arranging to carry out an assessment for a prospective service user and explaining to the family that she could not offer a placement without first carrying out the assessment and being able to give assurance that the needs of the service user could be met at Dapplemere. The format used for the assessment was seen and this was very comprehensive. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10 The care plans include the health, personal and social care needs of service users and health care needs are fully met. Medication is appropriately managed and safeguards are in place in this respect. Service users are treated with respect and afforded their privacy. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were examined during this inspection and these records showed how health care needs had been met including blood test results and flu injections. The care plans included the personal care needs and guidance for staff to provide support consistently. A copy of any accident records is placed on the service users file. The outcome of the social workers annual reviews were maintained on the file and the in house review of service users needs is carried out monthly as part of the key worker system. Service users Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 10 spoken with said they were very well cared for and that staff were kind and respectful; one service user said staff were “very professional about privacy”. Medication was checked as part of this inspection: all staff who administer medication had received training as seen in the training records. The medication was securely stored at the appropriate temperature. The temperature of the medication room had been recorded daily. Controlled drugs were easily reconciled and the balance in stock accurate and these medications were recorded in a controlled drugs record with dual signatories. There were no gaps in the medication record and the records were clearly recorded. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The lifestyle experienced in the home by services users matches their expectations and preferences in respect of their social, cultural, religious and recreational interests and needs; and service users maintain contact with family, friends, representatives and the local community if they wish. Service users are supported to maintain choice and control over their own lives and they receive a wholesome, appealing, balanced diet with suitable and flexible arrangements for the enjoyment of their meals. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users spoken with said the minister from the local church visits to provide for their religious needs on a regular basis and they can join in the activities provided when they want. The care staff and the part time activities co-ordinator provide the activities for groups and some one to one sessions. The visitor’s book showed a constant flow of relatives and friends visiting the home at various times. Some of the service users said they spend time outside of the home with their relatives and that they felt they had choice and control over their lives. The menu provided healthy choices and appeared well balanced. Service users were enjoying their evening meal during the inspection and said it was very tasty. Some service users ate in the dining Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 12 room and some took their meals in their own room depending on their preference. The dining room is comfortable and the serving of meals is flexible; service users were observed to be taking their meal at staggered times and at their own pace. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Complaints are taken seriously, information received is acted upon and the service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaint file showed one complaint had been resolved in a timely manner and in accordance with the company’s policy and procedure. The training records provided evidence that all staff have attended abuse awareness training and the home has an adult protection policy and procedure that staff can easily access. Service users spoken with said that they felt safe and that staff were very kind and caring, Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 The environment is safe and well maintained and it is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the building was undertaken during this inspection and all areas of the home were clean, pleasant and hygienic; service users spoken with said the home is always kept very clean. Since the last inspection the installation of a lift has been completed and it is now in use. Corridor floors have been levelled and the height of steps have been lessened (the building is listed and planning permission had to be obtained for the work undertaken). There is stair stepping equipment to aid access but generally where there are steps the accommodation in those areas is used by service users whose mobility is not restricted. Radiator covers have been installed to protect service users from accidental burns and provide safe Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 15 central heating. Fire drills have been conducted and the records show that weekly checks of the fire safety system are conducted. Portable appliance tests were carried out in June 2006 to ensure all portable electrical equipment is safe. New carpets have been laid in some areas. The home has a general maintenance plan for the year. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 16 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 39 Adequate staffing levels are maintained and staff are provided with training and are competent to manage their tasks and to provide a safe service to service users. Recruitment procedures at the home are robust and managed in line with the home’s policies and procedures. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were adequate staff on duty and the rota provided evidence that adequate staffing levels are maintained with a minimum of one qualified staff together with trained care staff. The training records showed that all mandatory training had been provided/updated and all staff have been provided with dementia training courses. National vocational qualifications are being progressed. Regular staff meetings are held and the records for these were seen. Regular supervision is provided to staff and a copy of the supervisees notes were held on file. It is recommended that a DVD player be obtained to further facilitate in house training for staff. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 17 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. The home does not yet have a registered manager. However, it is run well and in the best interests of the service users. The financial interest of service users are safeguarded. Staff are formerly supervised. Service users and staff are protected by the home’s policies and procedures and practices in respect of health, safety and welfare. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current manager is not applying for registration and a recruitment drive is in process to procure a new manager who is suitable to be registered. The current manager will continue to manage the home until a new manager is in post and will then oversee the management of the home from a promotional post. A requirement made at the last inspection for a registered manager to be in post therefore remains unmet. Service user and relatives feedback is Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 18 obtained by the home and safeguards are in place to ensure it is run in the best interests of the service users; regular relatives/residents meetings are held. All financial matters are either managed by the service users themselves or by their representative; the home invoices for all charges and extras. Throughout this report evidence has been written about the safeguards in place to promote the health, safety and welfare of service users and staff; policies, procedures, trainings and systems were in place at the time of this inspection for the meeting of this standard. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 19 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 3 X 3 Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP31 Regulation 8(1) Requirement A fit person must be registered to manage the home. The proprietor stated that the registration application process would commence on the day of the inspection. Due to the circumstances of this post being vacant (and satisfactory managment arrangements being in place) a new deadline has been set for completion by 30th April 2005. Timescale for action 30/04/07 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 Refer to Standard OP30 Good Practice Recommendations A DVD player would further assist staff training in that they would use some of the DVD resource discs available in the home’s training library. Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Dapplemere DS0000064417.V325726.R01.S.doc Version 5.2 Page 22 - 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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