Inspection on 23/06/05 for Deanbrook

This inspection was carried out on 23rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Deanbrook 20/05/08

Deanbrook 09/05/06

Deanbrook 02/02/06

Deanbrook 22/10/04

Deanbrook 13/04/04

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 Deanbrook Totnes Road South Brent Devon TQ10 9BY Lead Inspector Margaret Crowley Announced 23 June 2005 rd 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. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Deanbrook Address Totnes Road, South Brent, Devon, TQ10 9BY 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 293084 Havencare (Plymouth) Mrs Julie Ann Hunt Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22/10/04 Brief Description of the Service: Deanbrook is a large converted bungalow close to the centre of the village of South Brent. It is owned by Havencare (Plymouth) a voluntary organisation specialising in learning disability care. Deanbrook is registered to provide care for six people with a learning disability who may also have physical disabilitities, including those aged over 65 years. The home caters for people with a high level of needs. The accommodation comprises 5 single bedrooms, one of which is used as the ‘sleeping in’ staff bedroom/ office, and one double bedroom.There is a lounge, dining room and a conservatory which opens onto extensive gardens.There are currently no disabled bathing facilities available. Deanbrook has its own transport which is used extensively and has access to the shops and facilities within the village. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place on 23rd June 2005, over one day. A tour of the premises took place, and records were inspected. All of the service users were seen, but most do not have verbal communication and are unable to comment on the quality of the service provided. Staff on duty were observed in the course of their duties, and 2 staff were spoken with. Discussions took place with Mrs Julie Hunt, registered manager, and Elizabeth Bannister deputy manager, who were present on the premises during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 6 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 Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 7 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) 1, Information is not yet available for prospective and current service users regarding the facilities and services that they can expect, in a form that they can understand. EVIDENCE: A service user guide has not yet been produced in an accessible form for service users. Discussions took place regarding making this available in a pictorial form. There have been no new service users admitted since Deanbrook opened several years ago. Admission procedures are available should a vacancy occur. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 8 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) 6,7,10 All service users have care plans and risk assessments which are reviewed, and ensure that their changing needs are met. Person centred plans enable service users wishes and aspirations to be recorded and addressed. Service users confidentiality is respected by the safe storage of information about them and a confidentiality policy. EVIDENCE: Service users have both care plans and a person centred plans. Records inspected demonstrated that comprehensive assessments and plans were available. Where service users needs are changing due to age, assessments and daily records showed that these are addressed. All service users have person centred plans. These are currently in the process of being reviewed within a new framework. Staff have considerable ability in enabling service users to express personal choice, often through the use of other forms of communication such as signs, symbols and photographs. No service users manage their own financial affairs. The registered manager is the appointee for all of the service users. All service users have their own bank accounts. Clear records were seen of incoming and outgoing payments. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 9 A confidentiality policy has been developed since the last inspection, and staff are aware this. Service users records are securely held in the office. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 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) 12,13,14 Service users enjoy a range of appropriate activities within Deanbrook and the community. EVIDENCE: Each service user has an individual activities plan that is made on a daily basis and reflects their needs, interests and wishes. These are displayed on the wall in the dining room using symbols and pictures that the service user understands. Service users are enabled to make choices by the staff. Extensive use is made of the Home’s minibus to visit the moor and leisure facilities. Two service users currently have day opportunities one or two days per week. Service users participate in the village by using the village shops daily. Some enjoy visiting the pub and having meals out. The high staffing ratio enables service users to go out individually with staff or in pairs. Where an older service user no longer wishes to participate in activities within the community, this is acknowledged and suitable activities such as music and are provided at Deanbrook. Most service users have holidays individually or in pairs, for which they pay. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 11 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) 18,19,20,21 Service users benefit from a personalised system of support. They can be confident that their health care needs will be met and reviewed. There are satisfactory arrangements in place for the management of service users medication. EVIDENCE: There was a good awareness demonstrated of service users healthcare needs and their preferences about how they like their personal support to be delivered. The service users require a high degree of support in all areas of personal care and daily living. Records showed that service users healthcare needs are addressed via services from the primary care team and learning disability specialist services. Where an older service user’s health is deteriorating, they are regularly monitored and reviewed. One service user is included on the falls register and appropriate action has been taken to prevent injuries. There are clear processes in place for the storage and administration of medication. Staff have received accredited training in the administration of medication. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 12 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) 22,23 Procedures are in place to enable service users to complain and to protect them from abuse. EVIDENCE: There have been no complaints since the last inspection. There is a complaints procedure that has been effectively simplified and converted into simple English and symbols. This is displayed in service users rooms. Staff have a good awareness of the service users feelings and methods of communication mean, which enable them to deal quickly with any service user’s concerns. Service users have access to an advocacy service. There is an adult protection procedure and staff have received in–house training in adult protection. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 13 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) 24,27,30 Service users are provided with accommodation that is comfortable, attractive and clean. Bathroom, shower and toilet facilities are no longer adequate for some service users’ needs. EVIDENCE: Service users rooms and communal rooms are well furnished and attractively presented to provide a very homely environment, of a good standard. There are extensive well-maintained gardens that service users enjoy. These provide areas for sitting out and leisure activities. The property was clean throughout and efforts are made to keep the environment hygienic and odour free. Refurbishment of the bathroom and shower room is awaited. The premises do not currently provide suitable facilities for older or disabled service users. The laundry room does not have hand-washing facilities. There is a damp patch on the wall in the hall that is currently being investigated. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 14 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) 32,34,35 Deanbrook has an experienced staff group who provided continuity of care for the service users. Sufficient skilled staff are employed to meet the high level of needs of the service users. EVIDENCE: There is a good range of skills and experience within the staff group. Some have worked in the home for several years and know the service users well. A good proportion of staff are well qualified. There is a staff training programme and staff are encouraged to undertake NVQ and LDAF training. There were sufficient staff on duty to address the high level of needs of the service users. There was one staff vacancy and agency staff are employed if necessary. Records were inspected of staff recently employed and provided satisfactory evidence of the recruitment and the induction processes. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 15 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) 38,41,42 Deanbrook is well managed and has efficient administrative and record keeping systems. Service users live in an environment where health and safety standards are met and maintained. EVIDENCE: There is an open, positive and inclusive atmosphere within Deanbrook. The management and staff provide an environment which is warm and friendly, and where the service users are valued. This was evident during the inspection in the interaction between service users, the managers and the staff. Routine maintenance and safety checks are carried out with clear, efficient systems in place. Fire safety records and accident records were in order. Staff receive mandatory training in health and safety matters, including fire safety, first aid and moving and handling. Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x x x Standard No 22 23 ENVIRONMENT Score 4 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 4 x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x 2 Standard No 11 12 13 Deanbrook x 3 3 Standard No 31 32 33 34 35 Score x 3 x 3 3 Version 1.20 Page 17 D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc 14 15 16 17 3 x x x 36 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 3 Standard No 37 38 39 40 41 42 43 Score x 4 x x 4 3 x Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 18 no 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. 2. Standard OP1 OP27 Regulation 4 23 Requirement The service user guide must be available in a form that service users can understand. Bathroom and shower facilities must be refurbished to meet the needs of older and disabled service users. Handwashing facilities must be provided in the laundry. Timescale for action 23/09/05 23/12/05 3. OP30 23 23/12/05 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 Good Practice Recommendations Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Deanbrook D54-D07 S3684 Deanbrook V221424 230605 Stage 4.doc Version 1.20 Page 20 - 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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