Inspection on 10/04/06 for Deepdene

This inspection was carried out on 10th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Deepdene 19/05/08

Deepdene 25/09/07

Deepdene 04/07/06

Deepdene 16/06/05

Deepdene 09/05/05

Deepdene 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Deepdene 1 Deepdene Avenue East Croydon Surrey CR0 5JP Lead Inspector Barry Khabbazi Key Unannounced Inspection 10th and 11th April 2006 8:30am Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 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 Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 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 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. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Deepdene Address 1 Deepdene Avenue East Croydon Surrey CR0 5JP 020 8667 9753 020 8680 3406 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) Surrey Oaklands NHS Trust Mrs Jacqueline Alby Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Deepdene is a residential unit registered to provide care to eight people with Learning Disabilities between the ages of eighteen and sixty-five. All the service users have been assessed as having high dependency needs. The premises is a detached two storey house in a residential road in East Croydon close to Lloyd Park, tram links and within easy walking distance of Croydon town centre. It has eight single rooms, two of which have en-suite facilities, a dining room, lounge, sensory room, kitchen, laundry, and several bathrooms. There is also a large secluded garden to the rear of the building with a patio area and a summerhouse. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Following serious concerns being identified, two additional unannounced inspections occurred on the 16/6/2005 and the 21/7/2005. These concerns were compounded by the lack of management support and the last reports recorded the following: ‘The home has not had a registered manager in post since January 2003. Although there are a high number of unmet existing requirements in this report, the inspector believes that this is due to an inconsistency in management, and now also a lack of senior staff. The inspector believes that many of the requirements can be easily addressed once these posts are filled with permanent staff.’ These staffing issues had been resolved by the time of the last inspection with a manager and deputy in place. The manager is currently undergoing the registration with the Commission. A marked improvement was observed at that time. This was demonstrated by the number of requirements dropping from 24 to 15 with many of those remaining being worked on and therefore moving towards being met. Since that time however, only 4 out of the remaining 15 requirements have been met and the 11 remaining requirements had not progressed any further than at the last inspection. In addition, there are two new requirements in this report. One of which {Care Plans} was previously met, but had fallen back below the required standard. This inspection occurred over two half days to enable a meeting with the manager on the second day, to facilitate discussion regarding the requirements. During this inspection the service users, staff deputy, manager, and director, were met, and two relatives were briefly met. Records, policies and care plans, and the building were examined. One of the indicators of the outcomes for service users, arising from the remaining shortfalls, is that the number of reportable serious incidents at the home remains high with 43 incidents reported in the previous 12 months. What the service does well: It was seen as good practice that medication training occurs annually and additional annual training occurs in ‘as and when medication’, and also in rectal diazepam usage. The move to person centred planning is seen as good practice as this is a more resident focused way of working. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The service users guide is still not satisfactory as it does not contain the views of the residents. This is important so that new residents are clear about how other residents feel about living in this home. Behavioural pyschological guidelines are still out of date and need be reviewed and updated. Addressing this could reduce the number of challenging incidents. The new care plans are not in place for all residents. This could affect staffs’ knowledge of the needs of the residents. The care plans sampled did not contain all of the information required, for example, educational, training, occupational, social, religious, or cultural needs. This could affect staffs’ knowledge of the needs of the residents and how those needs are met. Reviews are still not occurring with the required frequency. This could affect staffs’ knowledge of the changing needs of the residents. Although there had been much progress in early 2005, in providing accessible information regarding the home’s services, some policies and information still needs to be made more accessible to the residents and there has been little progress in this area since the last inspection. Continued Over……… Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 7 Although improvement has been made in producing risk assessments that contain all the information required, these are still not available for all limitations of liberty. Including this information could reduce unnecessary restrictions of liberty for the residents. The home no longer has family meetings. The Commission’s relative surveys show that relatives are not happy that these have stopped. Residents do not receive all the paid holidays they are entitled to. Each resident should be offered a seven-day holiday paid for by the home as a part of the contracted price. This would facilitate more funding and additional holidays for residents that they do not have to pay for. Residents’ rooms do not contain all the furniture required. This may be because a resident has chosen not to or because of risk. However this must be recorded to ensure that residents have all the furniture they are entitled to. Although this has now started, not all new staff have had induction and foundation training within Sector Skills Council training specifications. This could also affect the home’s ability to meet all a resident’s needs. Staff have still not had an annual appraisals that review performance against job descriptions. Although previous progress had been made with regards to the home implementing a quality assurance system and an annual development plan, this has not progressed since the last inspection and this still needs to be finalised. Without this the involvement of the residents and relatives could be limited. Many of the original timescales for the above had previously elapsed and were extended by up to a year and a half. Those new extended timescales also have now elapsed and will therefore not be extended again. {See requirement section}. This home needs to meet requirements in a more timely fashion. The Commission is now considering what action to take to progress these requirements in a satisfactory and timely fashion. 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. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 1 and 2. Although the home provides most of the information needed for potential residents to make an informed decision about moving in to the home, the residents do not have all the information they need. There have been no new service users to facilitate re-assessing Standard 2 on this occasion. EVIDENCE: The Statement Of Purpose now contains all the information required, including details of the experience of staff, the number and size of rooms in the home and the number of baths and toilets, as stated in the last inspection report. The 2004 inspection report contained a requirement for the Service Users Guide to contain the views of the service users. This has still not occurred yet and this requirement therefore remains in force. The original timescale of the 1/12/04 was not met and extended by a year. The timescale will therefore not be extended again. There have been no new service users to facilitate re-assessing Standard 2 on this occasion Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 6, 7, 8, and 9. Residents’ assessed needs, changing needs and how the home meets these needs are not fully recorded. This could affect the home’s ability to meet and show how it has met all a resident’s known and changing needs. Restrictions of liberty and risks are not shown as essential by the use of appropriate risk assessments. Behavioural pyschological guidelines are out of date and need be reviewed and updated. Addressing this could reduce the number of challenging incidents. Information regarding the home’s policies, activities and services, are not made fully accessible to the residents. EVIDENCE: At the May 2005 announced inspection it was identified that behavioural pyschological guidelines were out of date and needed be reviewed and updated. This was also highlighted as needed at an adult protection meeting near that time. The following requirement was therefore set: Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 11 Behavioural pyschological guidelines must be reviewed and updated. This was highlighted as a priority requirement due to the high number of reportable incidents occurring at this home. One individual’s assessment for this had been set up by the time of the last inspection and has since occurred. However, the second was only applied for last week, eleven months after the initial requirement was set. This second one has obviously therefore not occurred yet. No reasonable explanation for waiting eleven months to make the referral was given. Ample time has elapsed to implement this priority requirement and the requirement remains in force as does the original unmet timescale. The May 2005 inspection identified that new care plans were not available for all service users. The following requirement was then set: Care plans must be completed for all service users. The new care plans are still not in place for all service users. The requirement therefore remains in force and as an ample timescale of almost a year was given, the timescale will not be extended. The areas to be covered in care plans were previously met, but had fallen back below the required standard. The care plans sampled did not contain all of the information required, for example, educational, training, occupational, social, religious, or cultural needs. For example, one file sampled did not record cultural needs that the manager confirmed were needs of the resident concerned. The following new requirement is now therefore set. Care plans must contain all the elements required under Standard 6.2, namely those set out under Standard 2.3. and in particular, educational, training, occupational, social, religious, or cultural needs. Files sampled showed at the May 2005 inspection showed that reviews of care plans were not occurring with the required frequency. The following requirement was set at that time: Care plans must be reviewed at least six monthly. Although care management reviews have been occurring annually, the internal reviews are still not meeting the required frequency. The existing requirement remains in force and as the 4 month timescale then set has elapsed by a further 6 months, it will not be extended. Standard 7 requires that staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. Requirements to facilitate and evidence this process have been made under Standard 9 below and one of which remains unmet. Although a minor shortfall in meeting Standard 7 therefore exists, a requirement has already been made under Standard 9 below and will not be duplicated here. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 12 The May 2005 inspection contained the following requirement under Standard 8: The home must provide service users with accessible information regarding its policies, activities and services. Although there had been much progress in early 2005, in providing accessible information regarding the home’s services, some policies and information still needs to be made more accessible to the residents and there has been little progress in this area since the last inspection. This requirement therefore remains in force. The 2004 inspection contained the following requirement under Standard 9: Risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. Improvement has been made in producing a new risk assessment pro forma that contains all the information required under the National Minimum Standards. This now meets the 1st requirement set under Standard 9 regarding risk assessments. However, these now need to be filled in for all limitations of liberty. See the next existing unmet requirement under Standard 9 below. The 2004 inspection report contained the following requirement under Standard 9: The home must produce risk assessments to evidence how safety outweighs choice where any restrictions of liberty are assessed as necessary for the protection of service users. These are still not available for all limitations of liberty, for example locking the front door which effectively locks the residents in the building, limitations to facilities etc. The existing requirement regarding this remains unmet and in force. This was a priority requirement and the original timescale of the 1/9/04 was not met. The timescale was then extended by a further 10 months. The timescale will therefore not be extended again. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 12, 13, 14, 15, 16 and 17 Service users have the opportunity for self-development, are part of the local community and are able to take part in appropriate activities. Service users do not receive all the paid holidays they are entitled to. Addressing this would facilitate more funding, and additional holidays for service users that they do not have to pay for. Service users are appropriately supported to have appropriate family, personal and sexual relationships. Where not appropriate, service users are protected. The food provided is sufficient in quantity, and it is now sufficiently nutritious. This is important to ensure good health. EVIDENCE: Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 14 The service users were observed on both days to be preparing for activities in the community or at day centres. The service users attend Geoffrey Harris House day centre, and access a range of classes and activities designed to promote education and fulfilling activities. The activities include art/ craft, music therapy, cookery and a sensory room. One of the service users had a job delivering the local paper, and the home participates in paper recycling schemes. The home is close to a tram stop and local transport links. The residents also have Freedom Passes for buses and trains. Access to the local community is assisted by the home having its own transport, which includes a mini bus and a car. The local pubs, parks, restaurants, cafes, pools, bowling, and shops are accessed. Staff are available to support residents while accessing the community and this occurs in the evenings as well as during the daytime and at weekends. The last inspection report contained a recommendation under Standard 14, for each service user to be offered a seven day holiday. Holidays are still funded by the service users and not the organisation through the contract as specified under Standard 14. The existing recommendation therefore remains in force. The last inspection report contained a requirement under Standard 15 for plans of care to contain a record of any household tasks that service users participate in, as a part of independence promotion. This has now been implemented. This requirement is therefore now met. The home no longer has family meetings. The Commission’s relative surveys show that relatives are not happy that these have stopped. There is an open visitors policy at Deepdene and the home ask that visitors phone to ensure their family member is going to be in before they visit. The menus were previously not found to be sufficiently nutritious, for example Monday of week 4 of the menu contained no vegetables for the 3 meals of the day and their alternatives. Since that time the menus have been assessed by a dietician and are much improved. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 18, 19, 20, and 21 Residents’ personal care and physical and emotional health needs are generally not met well by this home. Service users are protected by the home’s medication practice and procedures. The residents and their families have not been consulted about their wishes in the event of terminal illness and death. This is consultation is needed to ensure that the residents’ wishes are implemented at these times. The ageing, illness and death of a service user is treated with respect and as the individual would wish. EVIDENCE: Personal care needs are not fully recorded, as care plans have not been completed. See Standard 6 where a requirement has been set regarding this. In addition a new requirement under Standard 6 has been set for care plans to contain all the required information so that staff will know all a service user’s needs and how to meet them. This home has also been involved in a high number of adult protection investigations over the last two years, many relating to alleged inappropriate physical and emotional health care. These all create an additional shortfall under these Standards 18, and 19. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 16 The service users are registered with a local G.P. They are able to access community health facilities such as opticians, chiropodist and district nurses as required. The manager has stated that the service users have an annual health check by their G.P. Service users are supported to attend outpatient appointments and other medical appointments as required. The home has a copy of the British Medical Association guide to medication in place. Medication profiles and medication administration record sheets were seen in records sampled. Medication is kept securely in a locked metal cabinet fixed to the wall. The trust has a policy on the administration of medication and also provides accredited training in this area. The home has now obtained and record the service users’ consent to medication. However, at the May 2005 announced inspection it was identified that behavioural pyschological guidelines for service users were out of date and needed be reviewed and updated. This was also highlighted as needed at an adult protection meeting near that time. The following requirement was therefore set under Standard 9: Behavioural pyschological guidelines must be reviewed and updated. This was highlighted as a priority requirement due to the high number of reportable incidents occurring at this home. This has not yet occcurred and therfore also affects the rating of Standard 20. The following is seen as good practice under Standard 20: Medication training is to a high level. Training occurs annually and additional annual training occurs in ‘as and when medication’, and also in diazepam usage. This should help insure that mistakes in administering medication do not occur. The 2005 inspection report contained a requirement under Standard 21 for the residents and their families to be consulted about their wishes in the event of terminal illness and death, and any wishes must be recorded. This had occurred by the time of the last inspection, with letters requiring a response being sent to all relatives. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 17 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 the following standard(s): The home’s complaints procedures meet the required standard and are accessible to the service users. The home’s policies do now facilitate protecting service users but the current practices do not fully protect service users from harm. EVIDENCE: The complaints procedure is clear and contained all the elements required including a written maximum response time of less than 28 days and details of how to contact the Commission. The last additional inspection report identified some concerns regarding how physical and emotional health needs were being met and identified serious inconsistencies between written incident notifications and other reports. The 2005 inspection report therefore contained the following requirement under Standard 23: The Trust must put systems in place to ensure that incident records accurately match staffs’ verbal statements of events.PRIORITY REQUIREMENT. This has now occurred. The home has since provided training and guidance to staff regarding consistency in filling in incident forms and also daily direy notes. This requirement is now met. The 2005 inspection report also contained the following requirement under Standard 23: The Trust must make the results of the investigation into the swallowing of a pebble incident referred to in this report, available to the lead inspector for this home. This has still not occurred and this requirement remains unmet and in force. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 18 In addition, requirements for risk assessments and behavioural psychological guidelines under Standard 9, and the high number of notifiable incidents (43 in the previous 12 months) and high level of adult protection meetings all also contribute to the shortfall under this Standard 23. All the relevant policies regarding protection are in place. At previous inspections the acting manager was not able to produce the restraints policies and guidance. These policies were not readily available to staff, and the policies and guidance were not known by them. Staff now sign to confirm they have read and understood all relevant protection policies and procedures. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 19 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 the following standard(s): 24, 26, and 30. Although the environment and furniture generally meet the residents’ needs, parts of the environment do not fully promote the residents well being. Residents’ rooms do not contain all the furniture required. This may be because a resident has chosen not to or because of risk. However this must be recorded to ensure that residents have all the furniture they are entitled to. The home is hygienic and clean. This environment therefore facilitates the residents’ health and emotional well-being. EVIDENCE: The environment does not fully protect the residents from harm, especially self harm. However, although a shortfall exists under Standard 24, the Manager and a Director were observed to be directly addressing a specific issue that had arisen for one of the service users, with consultation with their relatives. The inspector will assess the effectiveness of these plans once put into practice and anticipates a requirement will not be needed at that time. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 20 The 2004 inspection report contained the following requirement: Service users rooms must contain all of the items listed in Standard 26.2 unless the service user has made a positive choice not to and this is evidenced in their files or recorded risk assessments show otherwise. This has still not occurred. The timescale of the 1/7/04 was not met and the timescale was then extended by one year and 4 months to the 15/11/05. The timescale will therefore not be extended again. The building was hygienic and clean during this inspection, and the last two unannounced inspections. The laundry facilities at Deepdene are situated in a detached building to the rear of the premises. It is separate from any food preparation areas and has suitable flooring. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 21 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, and 36. The home’s recruitment procedures protect the residents through vigorous staff vetting. The completion of staff induction and foundation training within Sector Skills Council training specifications is not being met satisfactorily. This could also affect the home’s ability to meet all a resident’s needs. The home does not provide adequate supervision for its staff through annual appraisals that review performance against job descriptions. EVIDENCE: The 2005 inspection report contained the following requirement that was met at the following inspection: All elements of Schedule 2 {staff files} must be kept securely on site and be available for inspection. This includes CRB checks and records of staff disciplinary action. This has now enabled the inspector to check recruitment practices which are confirmed as currently meeting the requirements under Standard 43. The 2004 inspection report contained the following requirement: All staff recruited since April 2002 must undertake a six weeks induction {by the 9/2004} and six month foundation training to Sector Skills Council workforce training targets. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 22 This has only occurred for one of the staff concerned, as was the case at the last inspection. The requirement therefore remains in force. The timescale initially set of 1/09/04 was extended at following inspections by a further 11 months to the15/8/05 and will not be extended again. The 2004 inspection report contained the following requirement: Staff must all have annual appraisals that review performance against job descriptions. This has not fully been implemented and this requirement therefore remains in force. The timescale initially set of the 1/12/04 was extended at following inspections by a further 9 months to the 15/9/05 and will not be extended again. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 23 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. The residents now benefit from a better run home due to continuity provided by employment of management and senior staff. Although progress was made during the first half of 2005 with regards to the home implementing a quality assurance system and an annual development plan, this has not progressed since. Without this, the involvement of the residents and relatives could be limited. Although the health and welfare of the residents is generally promoted, parts of the environment do not fully facilitate the residents health and well being. EVIDENCE: This home has not had a registered manager since January 2003 and there has also been no deputy managers for a long periods. In addition the care team leader was acting up to the manager’s post, leaving the care team leader post uncovered. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 24 By the time of the last inspection in January 2006, a permanent Manager, Deputy and 2 care team leaders had been appointed to the relevant posts. The manager is currently going through the registration process. The residents now recieve the continuity of care required to meet their needs. However, this report records a high number of continually unmet requirements with long generous timescales for completion. In addition these timescales for a number of requirements have been extended by a further 6 to 18 months and still remained unmet. The following new requirement is now set under Standard 37: The registered provider and registered manager must ensure that all requirements are met in a timely fashion, and that requirements pertaining to regulations listed under regulation 43 {offences} are met well within the required timescale. The 2004 annual inspection report contained the following requirement under Standard 39: The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home should also ensure that an annual development plan produced and is open to the service users, to allow measurement of achievement in improving quality. The 2005 inspection report recorded that although there had been some progress, this has not fully been implemented, with the residents’ views and an annual development plan still needed. No further progress was identified at this inspection. This requirement remains in force until fully met. The original timescale of the 1/12/04 was not met. The timescale was then extended by 11 months to the 15/11/05. The timescale will therefore not extended again. All of the health and safety policies and procedures relevant to this standard have been seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. The testing of systems required in Standard 42 are also present. These included fire fighting equipment testing, fire warning testing, Portable Appliance Testing, 5-year wiring testing and Bacterial analysis and testing of the water supply. Control Of Substances Hazardous to Health policies and data sheets are present and all these items are locked in the storage cupboard. Although the health and welfare of the residents is generally promoted, parts of the environment do not fully facilitate the residents health and well being. See Standard 24 for details. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 25 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 Standard No Score 1 2 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 2 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 x 2 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 3 2 x 2 x x 2 x Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 26 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 YA1 Regulation 5 12[3] Requirement The Service Users Guide must contain the views of the service users. {Original Timescale of the 1/12/04 was not met and extended by a year}. Timescale not extended again. Behavioural psychological guidelines must be reviewed and updated. PRIORITY REQUIREMENT. {Original set in May 2005 }. Timescale not extended. Care plans must be reviewed at least six monthly. {Originally set in May 2005 }. Timescale not extended. Care plans must be completed for all service users. {Original set in May 2005 }. Timescale not extended. Timescale for action 11/04/06 2. YA6 152b 124b 11/04/06 3. YA6 152b 11/04/06 4. YA6 15 11/04/06 5. YA6 15 Care plans must contain all 11/04/06 the elements required under Standard 6.2, namely DS0000025778.V288600.R01.S.doc Version 5.1 Page 27 Deepdene 6. YA8 124b those set out under Standard 2.3. and in particular, Educational, Training, occupational, social, religious, or cultural needs. {New requirement} The home must provide service users with accessible information regarding its policies, activities and services. {Originally set in May 2005 }. Timescale not extended. The home must produce risk assessments to evidence how safety outweighs choice where any restrictions of liberty are assessed as necessary for the protection of service users. PRIORITY REQUIREMENT.{ Original Timescale of the 1/9/04 not met. The timescale was then extended by 10 months}. Timescale not extended again. 11/04/06 7. YA9 171a 11/04/06 8. YA23 17 The trust must make the 11/04/06 results of the investigation into the swallowing of a pebble incident referred to in this report, available to the lead inspector for this home. { Original Timescale of the 15/8/05 not met}. Timescale not extended. Service users rooms must contain all of the items listed in Standard 26.2 unless the service user has made a positive choice not to and this is evidenced in their files or recorded risk assessments show otherwise. {Timescale of the 1/7/04 not DS0000025778.V288600.R01.S.doc 9. YA26 162c m 11/04/06 Deepdene Version 5.1 Page 28 10. YA35 181a c 11. YA36 182 12 YA37 43 13 YA39 24,1,2,3 met. The timescale was then extended by one year and 4 months}. Timescale not extended again. All staff recruited since April 2002 must undertake a six weeks induction {by the 9/2004} and six month foundation training to Sector Skills Council workforce training targets..{Timescale of the 1/9/04 not met. The timescale was then extended by 11 months }. Timescale not extended again. Staff must all have annual appraisals that review performance against job descriptions. .{Timescale of the 1/12/04 not met. The timescale was then extended by 9 months }. Timescale not extended again. The registered provider and registered manager must ensure that all requirements are met in a timely fashion, and that requirements pertaining to regulations listed under regulation 43 {offences} are met well within the required timescale. {New requirement} The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home should also ensure that an annual development plan produced and is open to the service users, to allow measurement of DS0000025778.V288600.R01.S.doc 11/04/06 11/04/06 11/04/06 11/04/06 Deepdene Version 5.1 Page 29 achievement in improving quality. {Timescale of the 1/12/04 not met. The timescale was then extended by 11 months }. Timescale not extended again. 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 YA14 Good Practice Recommendations Each service user should be offered a seven day holiday. Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Deepdene DS0000025778.V288600.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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