Inspection on 25/09/07 for Deepdene

This inspection was carried out on 25th September 2007.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Deepdene 19/05/08

Deepdene 04/07/06

Deepdene 10/04/06

Deepdene 16/06/05

Deepdene 09/05/05

Deepdene 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 25th and 28 of September 2007 09:30 th Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 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.V350639.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V350639.R01.S.doc Version 5.2 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 and Borders Partnership NHS Trust Mrs Jacqueline Alby Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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. Fees currently range from £1388/week. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. The manager and deputy were away on the first day of the inspection so a second visit was arranged to meet the deputy manager so that staff files could be seen. During this inspection the residents were met, the deputy manager was interviewed, and records, policies, care plans and the building were examined. Previous concerns about the home have been steadily decreasing as requirements are being implemented, and numbers of incidents and adult protection referrals are reducing in frequency. One area of progress is as follows: The home has implemented a requirement for risk assessments to fully evidence why a limitation of liberty is needed before it is implemented. This process has resulted in a re-think of limitations of liberty, and as a result of this the residents are no longer being locked out of their kitchen. Although good progress in meeting previous requirements and raising standards was apparent, some previously identified shortfalls that had been previously met have slipped back down below the minimum standard again. For example staff supervision and residents’ care reviews have again fallen below the minimum standard. The home has made improvements, and although sliding back in some areas, has not yet quite slipped back to the very poor quality service recorded in previous reports. In an attempt to avoid further slippage and maintain the pace of improvement, this home will continue to be closely monitored and receive additional inspections. During this process further action may be taken by the Commission to ensure Standards are met and remain met. What the service does well: It was seen as very good practice that an additional deputy manager post has been created to facilitate improvement at this home, particularly as vacancies and previous gaps in management were identified as affecting quality. Medication training occurs annually and additional annual training occurs in ‘as and when medication’, and also in rectal diazepam usage. New areas of good practice were also identified, for example the new, more accessible pictorial household chores {independent living tasks} rota. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 6 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the information needed for potential residents to make an informed decision about moving in to the home. There have been no new service users to facilitate re-assessing Standard 2 on this occasion. However this Standard was previously met and remains met. EVIDENCE: The Statement Of Purpose 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. The Service Users Guide contains all the elements required including the views of the service users. There have been no new service users to facilitate re-assessing Standard 2 on this occasion. However this Standard was previously met and remains met. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards, 6, 7, and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users know that their assesed needs and their goals are recorded in their individual plans, but can not be confident that their changing needs are known or reccorded. Service users make decisions about their lives with assistance as needed. Restrictions of liberty and risks are now all shown as essential by the use of appropriate risk assessments. This process has reduced the number of restrictions that could be evidenced as essential, and therefore reduced the number of unnecessary restrictions imposed by the home. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 10 EVIDENCE: Following previous requirements, care plans had been updated to contain all the information required under the Standards. This was still the case at this inspection. Following previous requirements the frequency of reviews had improved to meet the minimum standard. However at this inspection the frequency of reviews had fallen below the minimum standard again. The following requirement is therefore re-set under Standard 6: Care plans must be reviewed at least twice a year. As progress in this area is inconsistent, this area will receive additional monitoring and any further action required to maintain standards will be taken. 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 are now met. In addition more accessible information is now being provided to support informed decisions by service users. For example, the service users guide is more accessible and contains the residents own views of the home, menus and many policies are now a more accessible and available in different formats, New areas of good practice were also identified, for example the new, more accessible pictorial household chores {independent living tasks} rota. The last report contained the following requirement: 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. This is now currently met. Restrictions of liberty and risks are now all shown as essential by the use of appropriate risk assessments. This process has reduced the number of restrictions that could be evidenced as essential, and therefore reduced the number of unnecessary restrictions imposed by the home. For example the residents are no longer locked out of their kitchen. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard, 12, 13, 14, 15, 16, and 17. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. 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 engage in appropriate leisure activities and holidays, although the residents do not receive all the placing authority funded holidays they are entitled to. Residents are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. The food provided is sufficient in quantity, and it is sufficiently nutritious. This is important to ensure good health. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 12 EVIDENCE: The residents were observed on the last three inspections, to be preparing for activities in the community or at day centres. The residents attend day centres, 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 until recently participated 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. Plans of care now contain a record of any household tasks that service users participate in, as a part of independence promotion. New areas of good practice were also identified, for example the new, more accessible pictorial household chores {independent living tasks} rota. 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 home menus are based on the likes and dislikes of the home’s service users. The Trust dietician visits the home on a regular basis to check the menus for nutritional value. The menus examined were varied and listed alternatives for those service users who did not want the main dish on offer. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ personal care and physical and emotional health needs are generally met by this home. Residents’ physical and emotional health needs are generally met. Residents’ are protected by the home’s medication practice and procedures. EVIDENCE: Personal care needs are now fully recorded in care plans but are not regularly reviewed{see Standard 6}. Requirements and shortfalls under Standard 6 also create a minor shortfall under this Standard. Personal care is provided in private, and timings of this are also flexible, for example residents can have a bath when they are not booked in for this. Residents’ preferences for how personal care is to be conducted are currently recorded in the ‘my plan’ plan of care and are to be included in the new ‘person centred’ plan of care. The home provides consistency and continuity through the use of designated key workers. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 14 Service users have access to relevant professional support to maximise independence, including access to physiotherapists and occupational therapists. This home had been involved in a high number of adult protection investigations over 2004 to 2005, many relating to alleged inappropriate physical and emotional health care. These reduced in 2006/7 to a more satisfactory level. One resident has been self harming more regularly recently. The general manager was observed to be meeting with the family at the last inspection and records show that strategies have been put in place to facilitate reducing the number of incidents. 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. The home has a copy of the British Medical Association guide to medication in place for staff guidance. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication and the M.A.R sheets are kept securely in a locked metal cabinet fixed to the wall. This home uses a controlled register when controlled drugs are used. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well and there were no complaints since the last inspection. Service users are protected from abuse or self harm through the home’s protection policies and procedures and by these being known. EVIDENCE: The home has a complaints procedure that meets all the elements of this Standard including a minimum response time of less than 28 days, details of the Commission and this is now also available in more accessible formats. The home has a copy of Croydon’s Vulnerable Adults Policy and training in this area is mandatory. The last announced inspection report recorded that the home has a “Responding to Aggression and Violence” policy and procedure, which states that physical restraint, should only be used as a last resort and should be recorded. A new corporate Whistle Blowing Policy and a local Wills Policy has been devised and staff are aware of these. Previous concerns about the home have been steadily decreasing as requirements are being implemented, and numbers of incidents and adult protection referrals are steadily reducing in frequency. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment and furniture generally meet the residents’ needs, and generally the environment does promote the residents well being. Residents’ rooms contain all the furniture required or records demonstrate a resident does not want an item or the item would be unsafe. The home is hygienic and clean. This environment therefore facilitates the residents’ health and emotional well-being. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 17 EVIDENCE: The last report recorded that, The environment does not fully protect the residents from harm, especially self harm. For example bulbs which a resident uses to self harm are still not covered and are easily accessed by the resident. This had now been addressed, see Standard 42 for details. 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. Maintenance for the home is provided on an as required basis by the Trust Works department. The overall condition and décor of the home was reasonable. All residents’ rooms either contain the furniture required or records demonstrate that risk assessment shows that an item would not be safe in the room, or that a resident has chosen not to have a specific item in their room. This requirement is now met. The building was hygienic and clean during this inspection, and the last three 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.V350639.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The required minimum of half of the staff trained to NVQ level 2 has been achieved. This insures a better trained workforce. The completion of staff induction and foundation training within Sector Skills Council training specifications is not being met. This could affect the home’s ability to meet all a resident’s needs. The home’s recruitment procedures do not always protect the residents through vigorous staff vetting. The home does not provide adequate supervision for its staff or annual appraisals that review performance against job descriptions. This provides a poorly supervised workforce. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 19 EVIDENCE: The last report contained the following requirement: At least 50 of staff must have the NVQ 2 in care. This has now been met with 6 out of 12 staff having the required qualification. All elements of Schedule 2 {staff files} are now kept securely on site and are available for inspection. This includes CRB checks, references and records of staff disciplinary action. One shortfall was observed. A minimum of two references are required for all staff. One recruitment file examined contained one reference, but the other was simply a letter stating that the organisation concerned did not provide references but would confirm the dates of employment. This letter can not therefore be accepted as the second reference required and a further reference should have been sought. The following new requirement is now set to address this shortfall: Two references are needed for all staff. {A letter from an employer stating references are not provided by them will not count as one of the required references.} 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. 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 has not been met. 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 has also not been met. The 2 requirements remaining unmet since 2004, indicate a major shortfall under these Standards. The Commission is now considering taking further action to ensure compliance. Previous inspection reports have contained requirements for staff supervision to meet the minimum frequency required. Although these requirements had been previously met, the Standard has fallen again. This now represents a poor record for meeting this Standard in a consistent manner. The following old requirement is now therefore reset: Staff must receive supervision at a rate of at least 6 sessions per year. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, and 42: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents now benefit from a better run home due to continuity provided by employment of management and senior staff and the creation of additional management posts. However, failure to meet requirements and the need to reset requirements that had been previously met but were needed again because standards slipped back, do not represent good management standards. The home has now implemented a quality assurance system and an annual development plan, which includes the involvement of the residents and relatives. 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 Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 21 EVIDENCE: Previous inspection reports recorded that this home had not had a registered manager since January 2003 and there were no deputy managers for a long period. In addition the care team leader was previously acting up to the manager’s post, leaving the care team leader post uncovered. 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. This provided better continuity of care, more timley meeting of requirements and a gradual raising of standards. However, some requirements still continue to remain unmet, in addition, the need to re-set requirements that had been previously met but were needed again because standards slipped back, does represent good management standards. The home has a Quality Assurance system that includes user satisfaction surveys and makes the service users central to the process. The manager has produced his own user satisfaction surveys and the organisation has also produced these since. This information has been analysed together with complaints and residents meetings, and the issues identified where appropriate have been included in the annual development plan. All of the health and safety policies and procedures relevant to this Standard were seen to be present. The testing of systems required in Standard 42 were also present and inspected. These included fire fighting equipment testing, portable appliance testing, boiler and gas testing, and bacterial analysis and testing of the water supply. The last inspection report contained the following requirement under Standard 42: The ground floor toilet’s lock must be replaced. This has now occurred and the requirement is met. The last inspection report also contained the following requirement under Standard 42: The Trust should explore safely covering the sunken bulbs on the ground floor and must respond to the Commission in writing as to its conclusions. This has now occurred and the sunken bulbs are now covered with a wire mesh to prevent access to those who have used them for self harm in the past. The last inspection report also contained the following requirement under Standard 42: The COSHH cupboard must be kept locked. This was again observed to be left open on the first unannounced day of this inspection. The requirement remains unmet and in force. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 22 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 3 2 3 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 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 2 x 3 x x 2 x Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 15[2]b Requirement Care plans must be reviewed at least twice a year. {This is an old Timescale for action 31/12/07 requirement that was previously met, but practice has slipped below the minimum required again} 2. YA34 17 Two references are needed for all staff. {A letter from an 31/12/07 employer stating references are not provided by them will not count as one of the required references.} 3. YA35 181a c 4. YA36 18 5. YA36 18 All staff recruited since April 2002 must undertake a six weeks induction and six month foundation training to Sector Skills Council workforce training targets..{Timescale of the 1/7/07 not met.}. Staff must all have annual appraisals that review performance against job descriptions. .{Timescale of the 1/07/07 not met. } Staff must receive supervision at a rate of at least 6 sessions per year.{This is an old requirement that was previously met, but practice has slipped below the minimum required again} 01/02/08 31/12/07 31/12/07 6. YA42 12[1]a 13[3] The COSHH cupboard must be kept locked. 01/11/07 Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 24 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 fully funded from the contracted price. Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Deepdene DS0000025778.V350639.R01.S.doc Version 5.2 Page 26 - 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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