Inspection on 31/08/05 for Dean House

This inspection was carried out on 31st August 2005.

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

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

Other inspections for this house

Dean House 01/10/07

Dean House 26/04/06

Dean House 08/12/04

Dean House 17/08/04

Dean House 19/04/04

Dean House 18/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Dean House 34-38 Reddenhill Road Babbacombe Torquay TQ1 3RQ Lead Inspector James Rose Unannounced 31 August 2005 st 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dean House Address 34-38 Reddenhill Road, Babbacombe, Torquay, Devon, TQ1 3RQ 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) 01803 313117 NO FAX Mr Adalino Colombini Mrs Sally-Ann Colombini Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19/04/05 Brief Description of the Service: Dean House is a two story terraced building that is situated in the residential area of Babbacombe, it is within walking distance of local shops and amenities and the Babbacombe downs. A bus service is available locally to the town centre of Torquay. The home offers 24-hour residential care to adults with a learning disability. The Registration for the home is for 12 service users of both sexes, the age range of the current persons receiving care is from approximately 40 years to 65 years. Accommodation is offered in single rooms over two floors. A stairlift is provided for persons with additional mobility issues and toileting and bathing aids are also available. There are three communal lounges and meals are taken in a separate dining room. An activities room is also available. At the rear of the property there is a courtyard garden with seating provided and on road parking is possible at the front. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 4 hours on 31st August 2005. A complete tour of the building was undertaken and four residents were asked in private for their views of life at Dean House. Samples of care records were examined. The deputy manager assisted throughout the inspection. What the service does well: What has improved since the last inspection? The home continues to provide a good service to residents and the programme of maintenance for the building continues. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Appropriate comprehensive assessments are undertaken to ensure that the home can meet the needs of residents. EVIDENCE: Two assessments were examined in detail during the inspection and these were found to be comprehensive and covered all the needs of the person concerned. Health needs were well covered and the individual aspirations of the person. Prospective residents were encouraged to visit the home and use the services available to ensure that they would like to live at this home. One of the assessments carried out concerned a person that came from some distance away. A day visit was undertaken followed by a weekend and then a complete week, this approach ensured that when they moved in it did not hold any surprised for them and that the services available suited them. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 A suitable detailed care plan is available for each resident in the home. Service users are supported to make their own decisions and assisted to live an independent lifestyle through a risk assessed approach. EVIDENCE: Three service user plans were examined during the inspection, these contained details of residents needs and how these needs were met by the home. Good detail was recorded of health needs and the way support was provided by the home. The area covering the aspirations of the residents were discussed and the deputy manger has decided to develop this area further over the next two months. Care is taken by the home to ensure that the individual resident understands their care plan and all have signed to demonstrate their agreement. Four residents were consulted during the inspection process and they all felt that they received a good service and had no needs that were not met at the home. Residents were confident and well able to express their views. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16 and 17 Residents were able to access a comprehensive range of activities in the local community that were to their choice and they are able to have appropriate relationships with family and friends. A healthy balanced diet was provided by the home, which was enjoyed by residents, and choice was always available. EVIDENCE: Residents are encouraged to make full use of the facilities available in the local community; they use the swimming pool, theatre, cinema and attend local dances and clubs. Some residents like to go to church. Residents have been supported and can now use the public transport system and shop independently in Torquay. All activities undertaken are appropriately risk assessed to ensure residents safety. When asked residents could not suggest any other activity they would like to undertake that is not currently available to them. The home has an unrestricted visiting policy and residents confirmed that they can have visits from family and friends and can also make visits as they wish. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 11 Residents are consulted about what foods they would like to eat and the home runs a weekly menu that is changed regularly with the agreement of all residents. Any new foods introduced are explained to residents individually. Choice is always available to residents and drinks and snacks are available at all hours. The four residents consulted during the inspection advised that they like the meals at the home and felt consulted about the food provided. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20 The care team at the home provide a sensitive approach to the way support is given to residents and this is always achieved with the residents’ agreement. The recording of the administration of medication continues to be incomplete; this has the potential to put residents at risk. Residents that are able can self medicate subject to a risk assessment approach. EVIDENCE: Four service users were consulted in private during the inspection and they all confirmed that they liked the way service was delivered to them and felt that they could change things if they wanted to. Good access was available to healthcare professionals when required. Residents felt consulted about issues that affected them and effective monitoring was in place of residents’ emotional and physical health. It was clear from observations made during the inspection that residents were treated with respect by their carers and good natured banter was also apparent. One resident said “ I like it here and I certainly would not want to go anywhere else”. Residents are able to self medicate subject to a risk assessment approach to ensure that this is appropriate. The recording of the administration of Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 13 medication was inspected and the issue record was incomplete. The unexplained gaps are going to be investigated by the deputy manger as the registered manager is on holiday. The recording of medication is essential and an incomplete record has the potential to put residents at risk, this issue was raised at the last inspection and the requirement raised at that time has been repeated in this report. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Residents felt that their views were taken seriously by the home and were confident that if they raised an issue it would be resolved for them. EVIDENCE: The home has available a clear complaints policy and procedure and residents know how to use it if necessary. The residents consulted on the day of the inspection were confident that if they raised an issue it would be acted on and a resolution found. No complaints have been raised since the last inspection and no complaints were received during the inspection process. The home has a clear adult protection policy and procedure available complete with an alerters guide and a video used to train carers with guidance given by management. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 Dean House provides a safe, comfortable well maintained environment. The building is homely; some improvement is needed to ensure residents’ privacy is maintained. EVIDENCE: A complete tour of the home was undertaken at the inspection, residents rooms were homely and were well personalised, decoration had been undertaken to the choice of the resident concerned. All the bathrooms and toilets were seen and it is acknowledged that repairs to the tiling had been completed in one of the bathrooms. A requirement was raised in the last report calling for an appropriate lock to be provided to the ground floor shower room, this has not been achieved and the requirement has been repeated here. The home was found to be clean throughout and a high standard of hygiene was evident. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34,35 and 36 The home has a core of well trained experienced staff. However some basic training is missing for new carers to enable them to fulfil their job description and the home does not meet the standard for staff supervision. EVIDENCE: The home has an established core of carers that are experienced and are committed to providing a good service to the residents. A new carer has joined the care team since the last inspection and her personnel file was examined. It was understood that the CRB and POVA checks had been sent for but were not yet in place, under these conditions the carer concerned should fill a constantly supervised role and have a named supervisor; this was understood by the deputy manager. It was noted that some training courses had been booked for this person but no in house induction had been recorded. It is essential that all care staff should have a comprehensive induction programme with detailed recording undertaken to ensure that the processes concerned are completed and understood. Only one reference was available for this person, which falls below the expected standard. The supervision arrangements for carers were not up to date and a requirement has been raised in this report for this purpose. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 17 Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Residents were confident that their views were valued and underpinned the serviced provided at the home. Health and safety issues were seen as important by the management of the home although currently there are some gaps that require urgent attention. EVIDENCE: Residents are consulted regularly by the management of the home about the service provided and changes requested are acted on. The management also has a comprehensive quality assurance system that has a detailed questionnaire. The last time this was used was over twelve months ago and it is a recommendation in this report that this should be repeated in the near future. Health and safety issues are seen as important and all equipment is regularly serviced and appropriate fire precautions are undertaken. Current recruitment practices are below the standards needed for the safety of residents. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 19 Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 2 x x 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dean House Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 13 Requirement The registered provider must ensure that staff adhere to the homes medication policy and procure (previous timescale of 20.04.05 not met) The registered provider must ensure that an appropriate lock is fitted to the ground floor shower room. (previous timescale of 14.05.05 not met) The registered provider must obtain two written refences for all new carers. The registered provider must provide structured induction training within six weeks of appointment The registered provider must provide formal staff supervision a minimum of 6 times per year. Timescale for action 01/09/05 2. 27 23 09/09/05 3. 4. 34 35 19 19 30/09/05 30/09/05 5. 36 18 30/09/05 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 39 Good Practice Recommendations It is recommended that the registered provider should D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 22 Dean House repeat the quality assurance questionaire process. Dean House D54-D07 S18344 Dean House V241914 310805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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