CARE HOME ADULTS 18-65
Deepdene 1 Deepdene Avenue East Croydon Surrey CR0 5JP Lead Inspector
Barry Khabbazi Unannounced Inspections 16 June 2005 8:15am & 21 July 2005 10:00am 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. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Deepdene Address 1 Deepdene Avenue, East Croydon, Surrey, CR0 5JP 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) 020 8667 9753 020 8680 3406 Surrey Oaklands NHS Trust N/A Care Home 8 Category(ies) of Learning Disability (8) registration, with number of places Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 14 June 2004 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 G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report refers to two unannounced inspections on the 16/6/2005 and the 21/7/2005. These both started before 9 a.m to enable all the residents to be met before some residents went to their day activities. During this inspection the staff were also met and the acting manager was interviewed. Records, policies and care plans, and the building were examined. The home has not had a permanent 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. To this end, 8 of the 28 requirements set, were highlighted as prioritised urgent requirements at the last announced inspection and required to be met by the time of this inspection. Although 4 requirements had been fully met by the time of this inspection only 1 of the 8 prioritised urgent requirements were met by this time. These serious concerns must be addressed urgently by the home and will be monitored for compliance during further additional inspections. A failure to improve practice in these areas and recruit suitable permanent staff will result in further action being taken by the Commission. What the service does well:
Although this inspection report highlights that there is still much improvement that needs to occur at this home, it is recognised throughout this report that the acting manager {Care team leader} has done much to improve practice in this home. 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. Good practice suggestions There is a summerhouse at the bottom of the garden. It is suggested only at this stage, that, moving the summerhouse nearer to the home would facilitate better supervision. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 6 It is suggested only at this stage, that the Whistle Blowing Policy be collated into one document and the restraints procedure be collated into one document, to assist staff awareness of these procedures, as staff have been regularly confused about these procedures and where to find these policies. See Standard 23. 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 and is not available in other more accessible formats. This is important so that new residents are clear about how other residents feel about living in this home. It is however recognised that a new version is currently with the printers. Although training has been now booked, staff still can not communicate effectively with the residents in their prefered term of communication {Makaton}. Addressing this could reduce the number of challenging incidents. Behavioural pyschological guidelines are out of date and need be reviewed and updated. Addressing this could reduce the number of challenging incidents.
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 7 The new care plans are not in place for all residents. This could affect staffs’ knowledge of the needs of the residents. Reviews are not occurring with a satisfactory frequency. This could affect staffs’ knowledge of the changing needs of the residents. The daily notes are not sufficiently detailed and do not reflect how needs in the care plan were met on that day. This could be seen as reflection of the lack of staffs’ knowledge of the needs of the residents and evidence that these needs are not being met. Although there has been some progress in providing accessible information regarding the home’s services, some policies still need to be made more accessible to the residents. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty and in addition do not contain all the information required, and in particular, details of how training and other options have been explored. 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. Although the food provided is sufficient in quantity, it is not always sufficiently nutritious and individual resident’s nutritional needs were not assessed by a dietician. This is important to ensure good health. It is recognised however that a dietician has since started to assess these needs. The residents and their families have not been consulted about their wishes in the event of terminal illness and death. This consultation is needed to ensure that the residents’ wishes are implemented at these times. Incident records do not always accurately match staff’s verbal statements of events. This is needed to ensure that bad practice is identified and that future incidents can be reduced. 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 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 and support for its staff through appointing permanent staff to its deputy manager post and care team leader posts. The residents do not recieve continuity of care required to meet their needs as the managers {since 2002}, and other staff are currently appointed on a temporary basis. Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, this still needs to be finalised. Without this the involvement of the residents and relatives could be limited.
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 8 Further work needs to be done to ensure the residents’ safety in the building. Any suspected asbestos containing products within the home need to be professionally identified, then labelled, sealed and left, or safely removed as risk assessment indicates, and fire extinguishers must be kept safely where they are to be used and not all stored in the main office. 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 G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 9 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 Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 10 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, 2, 3, and 5. 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. Staff can not communicate effectively with the residents in their prefered term of communication {Makaton}. Addressing this could reduce the number of challenging incidents. The residents’ rights are enhanced through their contract with the home. 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 required at the last inspection. The last inspection report contained a requirement for the Service Users Guide to be produced in a format that is suitable for the service users. The new service users guide has been designed but is yet to be printed and implemented. This requirement will remain in force untill fully met. The last inspection report contained a requirement for the Service Users Guide to contain the views of the service users. This had not occurred and this requirement therefore remains in force.
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 11 The home has not had a new resident start for at least 3 years. It was therefore not possible to assess Standard 2 fully at this time. The preferred communication method for many of the residents is Makaton signing. Although training in this area is planned, most staff at the home currently do not have a suitable knowledge of this method of communication. The following requirement was therefore set at the last announced inspection to address this shortfall: The home must ensure that staff can communicate effectively with the residents in their preferred term of communication {Makaton}. Training in Makaton signing has been set up but has not happened yet. The last inspection report contained a requirement for the home to provide the service users with a standard form of contract for the provision of service and facilities in respect of each service user. This had occurred by this year’s announced inspection and this requirement is now met. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 12 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, 8, and 9. Residents assessed needs, changing needs and how the home meets these needs are not fully recorded. This could effect 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 more fully accessible to the residents. EVIDENCE: At the last 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 a recent adult protection meeting. The following requirement was therefore set: Behavioural pyschological guidelines must be reviewed and updated.
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 13 Although this have been set up it has not occurred yet and the requirement will remain untill fully implimented. The new care plans are not in place for all residents. The following requirement has been set and remains in force: Care plans must be completed for all service users. Files sampled showed that the reviews are not occurring with the required frequency. The following requirement has been set and remains in force: Care plans must be reviewed at least six monthly. Files sampled showed that the daily notes are not sufficiently detailed and do not reflect how needs in the care plan were met on that day. The following requirement has been set and remains in force: Daily notes must be more detailed and reflect how needs in the care plan were met on that day. 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. There, risk assessments are required to be amended to refer to the above parameters and therefore evidence the above process fully. Although a minor shortfall in meeting this standard therefore exists, a requirement has already been made and will not be duplicated here. Although there has been some progress in providing accessible information regarding the home’s services, policies and activities still need to be made more accessible to the residents. The last inspection report contained the following requirement: The home must provide service users with accessible information regarding its policies, activities and services. This has started for activities and menus but these need to be printed and more accessible documents are still needed for some policies. This requirement will remain in force untill fully met. The last 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. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty, for example locking the front door which effectively locks the residents in the building. The existing requirement regarding this will remain in force until fully met. The last inspection report contained the following requirement: 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. This has
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 14 not occurred. The existing requirement regarding this will also remain in force until fully met. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 15 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, 15, 16 and 17 Residents have the opportunity for self-development, are part of the local community and are able to take part in appropriate activities. Residents do not receive all the paid holidays they are entitled to. Addressing this would facilitate more funding, and additional holidays for residents that they do not have to pay for. Although the food provided is sufficient in quantity, it is not always sufficiently nutritious. This is important to ensure good health. EVIDENCE: The last inspection report contained a requirement 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 not occurred and the existing requirement remains in force. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 16 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 re-cycling schemes. 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. At the last announced inspection, menus were sampled and were 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. The acting manger also confirmed that a dietician had not looked at this menu or had not assessed the residents’ individual nutritional needs. The following requirement was then set: The home must ensure that the food provided is sufficiently nutritious and ensure that individual service users nutritional needs are assessed by a dietician. A dietician has now evaluated the menus and was visiting again on the day of this inspection. The requirement will remain until the dietician has reported and their recommendations have been implemented. The last inspection report contained a recommendation for each service user to be offered a seven day holiday. Holidays are still funded by the service users and not the organisation. The existing recommendation remains in force. 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. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 17 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 Residents’ personal care and physical and emotional health needs are generally not met well by this home. Although medicine administration records were recorded accurately at this inspection, there were errors identified at the last inspection and a high level of diligence in this area must be maintained to fully protect the residents’ health. The residents and their families have not all 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. 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. 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. 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 following two requirements were set.
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 18 1, Surrey Oakland’s Trust must put systems in place to ensure that incident records accurately match staff’s verbal statements of events. 2, The home 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. Neither of these have been met and both remain in force. However, it is recognised that this particular report has only just been sent to the providers. The 2004/5 inspection reports contained a requirement for the home to obtain and record the service users’ consent to medication. This had occurred by this years announced inspection and this requirement is now met. During the last anounced inspection errors were observed in medicine administration records for the 7th of April 2005. The following requirement was set: Medicine administration records must be recorded accurately. This hade been addressed by the time of this inspection and this requirement is now met. This area will however continue to be monitored. The last inspection report contained a requirement 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 has not occurred and this requirement remains in force. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 19 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 Complaints are generally managed well and there were no complaints since the last inspection. The home’s policies and procedures relevant to this Standard are now known to staff and therefore facilitate protecting residents from abuse. EVIDENCE: The last inspection report contained the following requirement: The complaints procedure must clarify that the Commission can be contacted at any point during the complaints procedure, and not only following the internal stages as the current local procedure infers. This has now been implemented, and this requirement is now therefore met. At the last announced inspection 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. The following requirement was set for the second time: Restraints Policies and guidance must be made available to staff, and these policies and guidance must be known by them. Staff have now signed to confirm they have read and understood all relevant protection policies and procedures. This requirement is currently met. However as this requirement has been made a number of times this area will be monitored for consistent compliance at future inspections. The last inspection report contained the following requirement: A policy prohibiting staff from individually benefiting from residents’ wills, or being involved in making residents’ wills, must be made available to staff, and these policies and guidance must be known by them. Staff have now signed to
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 20 confirm they have read and understood this policy. This requirement is therefore currently met. Following a adult protection investigation last year, a requirement for all of a residents’ records to be held on site, and for a period of not less than three years following the resident leaving was set. This has since been implemented. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 21 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, 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: Please see the environmental requirements under Standard 42 for details of how the environment does not fully promote the residents’ well being. The last 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 not occurred and this requirement remains in force.
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 22 The building was hygienic and clean during the announced 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. The building has an asbestos roof, which has been investigated by Trust works department. The washing machine is capable of washing clothes at high temperatures, and also has a sluicing cycle. The home has policies and procedures regarding the disposal of clinical waste and Control of Substances Hazardous to Health. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 23 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) 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 and support for its staff through its appointment of permanent staff to its manager, deputy manager and care team leader posts. EVIDENCE: Last year’s inspection reports contained the following requirement: 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 occurred and this requirement is now met. Last year’s inspection reports also 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. This has not fully been implemented and this requirement therefore remains in force.
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 24 Last year’s inspection reports contained the following requirement: All staff must have an individual training and development profile. This requirement had been met by this year’s announced inspection. The last 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. This home has not had a registered manager since January 2003 and there is currently no deputy manager. In addition the care team leader is acting up to the manager’s post, leaving the care team leader post uncovered. The following requirement was set at this year’s announced inspection to address this lack of senior staff to facilitate satisfactory supervision: The home must provide adequate supervision and support for its staff by appointing to its deputy manager post and care team leader post. {A long standing existing requirement remains under Standard 37 regarding appointing to the manager’s post.} Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 25 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) 37, 39, and 42 The residents do not benefit from a well run home due to a lack of continuity of management and senior staff. Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, this still needs to be finalised. Without this, the involvement of the residents and relatives could be limited. Although the health and welfare of the residents is generally prompted, parts of the environment do not fully facilitate the residents health and well being. EVIDENCE: The last two annual inspection reports contained the following requirement: The registered provider must ensure a permanent manager is appointed to the home. This requirement remains unmet and in force. This home has not had a registered manager since January 2003 and there is currently no deputy manager. In addition the care team leader is acting up to the manager’s post, leaving the care team leader post uncovered.
Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 26 A requirement regarding senior staff has also been set under Standard 36. The excessive use of temporary managers and staff over the last two years, has also prompted the following requirement: The Trust must ensure that employment of any persons at the care home on a temporary basis will not prevent service users from such continuity of care as is reasonable to meet their needs. The 2004/5 annual inspection report contained the following 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 is produced and is open to the service users, to allow measurement of achievement in improving quality. This has not fully been implemented, with the residents’ views and an annual development plan still needed. This requirement remains in force until fully met. The 2004/5 announced inspection contained the following 3 requirements. 1, An up to date 5 year wiring certificate must be sent into the Commission. 2, An up to date Portable Appliance Testing certificate must be sent into the Commission. 3,All fire doors must only be held open by approved fire responsive door closing devises. All the above three requirements were met by the time of this year’s announced inspection. The fire retardant material on the back of the three doors to the lounge was suspected to be an asbestos containing product. To meet current ‘Asbestos at work’ regulations, the following requirement was set at last year’s inspection: The home must consult the ‘Health and Safety Executive’ {regulation 23[5]}, and provide evidence, that any suspected asbestos containing products within the home have been professionally identified, then labelled, sealed and left, or safely removed as risk assessment indicates, and under Health and Safety regulations. {See also, Regulation 4 of the Control of Asbestos at Work Regulations 2002.} Although there was an assessment of suspected asbestos containing products available at this inspection, it did not show any assessment of the product on the back of the doors identified in this report. The requirement will remain until evidence of these products being assessed and tested is available. Fire extinguishers had been removed from their designated places and stored in the main office. These were therefore not available throughout the building. The following requirement was set at the last announced inpection to address this. Fire extinguishers must be kept safely where they are to be used and not all stored in the main office. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 27 Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 28 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 2 x 2 x 2 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 1 2 2 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x 2 x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 2 3 2 2 Standard No 31 32 33 34 35 36 Score x x x 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Deepdene Score 3 2 2 2 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 29 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 1 Regulation 5[2] [4] Requirement The Service Users Guide should be in a format that is suitable for the service users. {Timescale of the 31/1/04 not met}. The Service Users Guide must contain the views of the service users. {Timescale of the 1/12/04 not met}. The home must ensure that staff can communicate effectively with the residents in their preferred form of communication {Makaton}. - PRIORITY REQUIREMENT. Behavioural pyschological guidelines must be reviewed and updated. - PRIORITY REQUIREMENT. Care plans must be reviewed at least six monthly. Care plans must be completed for all service users. Daily notes must be more detailed and reflect how needs in the care plan were met on that day. The home must provide service users with accessible information regarding its policies, activities and services. {Timescale of the 1/12/04 not met}. Timescale for action 31/1/04 2. 1 5 12[3] 1/12/2004 3. 3.5 12[3] 4 15/7/2005 4. 6 15[2]b 12[4]b 15[2]b 15 12[1]b 15/7/2005 5. 6. 7. 6 6 6 15/9/2005 15/8/2005 15/8/2005 8. 8 12[4]b 1/12/2004 Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 30 9. 9 17[1]a 10. 9 13[7] 11. 16 15 12. 17 12[[1]a 13[1]b 13. 21 12[3] 14. 23 17 15. 23 17 16. 26 16[2]c m 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. {Timescale of the 1/9/04 not met}. - PRIORITY REQUIREMENT. 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. {Timescale of the 1/9/04 not met}. Plans of care must contain a record of any household tasks that service users participate in, as a part of independence promotion. {Timescale of the 1/12/04 not met}. The home must ensure that the food provided is suficiently nutritious and ensure that individual service users nutritional needs are assessed by a dietician. The service users and their families must be consulted about their wishes in the event of terminal illness and death, and any wishes must be recorded. The home must put systems in place to ensure that incident records accurately match staff’s verbal statements of events.PRIORITY REQUIREMENT. The home 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. Service users’ rooms must contain all of the items listed in 15/7/2005 1/9/2004 1/12/2004 15/8/2005 1/12/04 15/7/2005 15/8/2005 15/11/200 5
Page 31 Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 17. 35 18[1]a c 18. 36 18[2] 19. 36 18[1]a 20. 37 18[1]b 21. 37 8[1]bi[2]a b 22. 39 24,1,2,3 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 met}. 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}. Staff must all have annual appraisals that review performance against job descriptions. .{Timescale of the 1/12/04 not met}. The trust must provide adequate supervision and support for its staff by appointing to its deputy manager post and care team leader post.- PRIORITY REQUIREMENT. The trust must ensure that employment of any persons at the care home on a temporary basis will not prevent service users from such continuity of care as is reasonable to meet their needs. The registered provider must ensure a permanent manager is appointed to the home. PRIORITY REQUIREMENT. {Timescale of the 1/12/04 not met}. 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 15/8/2005 15/9/2005 15/7/2005 15/8/2005 15/7/2005 15/11/200 5 Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 32 23. 42 13[3] 13 [4]a,b,c 24. 42 12[1]a measurement of achievement in improving quality. {Timescale of the 1/12/04 not met}. The home must consult the ‘Health and Safety Executive’ {regulation 23[5]}, and provide evidence, that any suspected asbestos containing products within the home have been professionally identified, then labelled, sealed and left, or safely removed as risk assessment indicates, and under Health and Safety regulations. Fire extinguishers must be kept safely where they are to be used and not all stored in the main office.- PRIORITY REQUIREMENT. 15/9/2005 15/7/2005 25. 26. 27. 28. 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 14 Good Practice Recommendations Each service user should be offered a seven day holiday. Deepdene G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 33 Commission for Social Care Inspection 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 G53 S25778 Deepdene V227446 160605 stage4.doc Version 1.30 Page 34 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
