Inspection on 04/07/06 for Deepdene

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 4 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 10/04/06

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 2nd Key Unannounced Inspection 4th July 2006 9:00am Deepdene DS0000025778.V304163.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.V304163.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.V304163.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 Borders and Partnership NHS Trust Mrs Jacqueline Alby Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th April 2006 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.V304163.R01.S.doc Version 5.2 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 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.’ These staffing issues had been resolved by the time of the last inspection with a permanent manager and deputy in place. A marked improvement was observed at that time. This was demonstrated by the number of requirements dropping from 24 to 15. Since that time, the inspector has met with the area manager to discuss requirements and an additional deputy post has been created. At this inspection only 3 out of the previous requirements remained unmet. This represents a major improvement. There is 1 new requirement and 1 new recommendation in this report. Additional unannounced inspections occurred from April 2005 to March 2006. An unannounced key inspection occurred in April this year. This follow-up inspection in July however was announced to allow the service manager to be present to help move requirements on, and to discuss where improvement is still needed. During this inspection the residents, staff, deputy manager, manager and service manager, were 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 although the number of adult protection meetings has reduced satisfactorily, the number of reportable serious incidents at the home remains the highest out of all the Surrey Borders homes inspected by the Croydon Commission for Social Care inspection office. This situation will continue to be monitored and connected recommendations have been set under Standard 23. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? An additional deputy manager post has been created to facilitate improvement at this home. The service users guide now contains 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 have now been reviewed where required and updated. This could reduce the number of challenging incidents. The new care plans are now in place for all residents. This should improve staffs’ knowledge of the needs of the residents. The care plans sampled now contain all of the information required. This should improve staffs’ knowledge of the needs of the residents. Reviews are now occurring with the required frequency. This should improve staffs’ knowledge of the changing needs of the residents. There has been much progress in providing accessible information regarding the home’s services, some policies and information. Residents’ rooms now contain all the furniture required or records identify that where this is not the case it is either because the resident does not want it or there is a risk assessment clarifying why the item is not safe in the residents room. Progress had been made with regards to the home implementing a quality assurance system and an annual development plan, this has now been finalised and includes the involvement of the residents and relatives. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 7 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. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 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.V304163.R01.S.doc Version 5.2 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. Quality under Standard 1 is good. This judgement has been made from evidence gathered both during and before the 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. 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, as stated in the last inspection report. The 2004 inspection report recorded that the Service Users Guide contained all the elements required except for the views of the service users. The following requirement was then set: The Service Users Guide must contain the views of the service users. This has now occurred, and this requirement and Standard 1 are now fully met. The home is also further developing methods of improving communication with those residents who have communication difficalties. There have been no new service users to facilitate re-assessing Standard 2 on this occasion Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 10 Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users know that their assesed and changing needs and their goals, are recorded in their individual plans Service make decisions about their lives with assistance as needed. Information regarding the home’s policies, activities and services, is made more accessible to the residents. Restrictions of liberty and risks are not all shown as essential by the use of appropriate risk assessments. 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.V304163.R01.S.doc Version 5.2 Page 12 Behavioural pyschological guidelines must be reviewed and updated. At this inspection it was assertained that behavioural pyschological guidelines had been reviewed or were being re-assessed by the psycologist. This requirement is now met. 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 now place for all service users. The requirement is now also met. 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. Files sampled at this inspection showed that both reviews are now occurring on a six monthly basis. This requirement is now also currently met. 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. 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. There has been much progress in providing accessible information regarding the home’s service. For example, the complaints procedure, service users guide, fire procedures, menus, household chore lists, have been translated in to more accessible documents with the use of pictures for the above and a taped version of the service users guide has been produced. This requirement is therefore also now met. 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. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 13 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. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the 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 not receive all the fully 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. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 15 EVIDENCE: The residents were observed on the last two inspections, to be preparing for activities in the community or at day centres. The residents 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 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. 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.V304163.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the 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. The ageing, illness and death of a resident is treated with respect and as the individual would wish. EVIDENCE: Personal care needs are now fully recorded. In addition care plans now contain all the required information so that staff will know all a resident’s needs and how to meet them. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 17 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. Residents’ 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 have now reduced 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 number of incidents however remain high indicating that the residents’ needs in this area could be better met. This area will therefore be monitored between now and the next inspection to assess effectiveness of the strategies employed. Requirements will be made at if necessary following the monitoring period. See also Standard 23 where a general recommendation regarding the high number of general incidents has been set. 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.V304163.R01.S.doc Version 5.2 Page 18 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 ensure 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.V304163.R01.S.doc Version 5.2 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 the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home’s complaints procedures meet the required standard and are accessible to the residents. The home’s policies do now facilitate protecting service users but the current practices do not fully protect service users from harm. EVIDENCE: There had been one complaint from a neighbour. The complainant told me that their complaint had been addressed in a professional and timely manner. 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. 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.V304163.R01.S.doc Version 5.2 Page 20 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. This had occurred by the April 2006 inspection. The home has provided training and guidance to staff regarding consistency in filling in incident forms and also daily direy notes. This requirement is currently 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 had occurred by the April 2006 inspection and this requirement is now met. 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 have now reduced to a more satisfactory level. This home has a high number of reportable incidents that affect the well-being of the residents. Although requirements under Standard 6 for behavioural pyschological guidelines to be reviewed and updated have been met, the number of reportable incidents remains high. The following recommendation is now set to address this: The manager should review incidents to identify patterns and trends, and then put strategies in place to reduce the number of reportable incidents that affect the well-being of the residents. The high number of notifiable incidents, also contribute to the shortfall under this Standard 23. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 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 the following standard(s): 24, 26, and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Although the environment and furniture generally meet the residents’ needs, parts of the environment do not fully 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. EVIDENCE: 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{see Standards 19 and 23 for details}. Although this creates a shortfall under Standard 24, monitoring of this is now in place under Standard 19 and a recommendation has been set under Standard 23. Further requirements are therefore not currently needed here. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 22 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 now occurred. 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.V304163.R01.S.doc Version 5.2 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 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. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. A little less than half of the staff are adequately trained {to NVQ level 2.}. 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 protect the residents through vigorous staff vetting. The home does not provide adequate supervision for its staff through annual appraisals that review performance against job descriptions. EVIDENCE: 5 out of 12 care staff currently have a NVQ2 or above. This is just short of the 50 required. The following requirement is now therefore set: At least 50 of staff must have the NVQ 2 in care. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 24 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 34. 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 was extended to the 15/7/06 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 to the 15/7/06 and will not be extended again. The 2 requirements remaining unmet since 2004, now indicate a major shortfall under these Standards. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 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 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. Quality in this outcome area adequate. This judgement has been made from evidence gathered both during and before the 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. 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. EVIDENCE: Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 26 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 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. The residents now recieve the continuity of care required to meet their needs. However, the last report recorded 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 was therefore set under Standard 37 at the last inspection: 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. Since that time, the area manager has met the inspector and agreed to be present at this inspection to provide additional information. Nine previous requirements have been met, and an additional deputy manager’s post has been created to facilitate meeting the improvements required {the latter is seen as very good practice}. This requirement is now therefore currently met. 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. By the time of this inspection, the residents’ views had been obtained and added to the annual development plan where appropriate. This requirement is therefore currently fully met. 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. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 27 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.V304163.R01.S.doc Version 5.2 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 Standard No Score 1 3 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 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 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 3 3 3 3 3 x 3 x x 2 x Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 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 YA9 Regulation 17(1)a 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. {Original Timescale of the 1/9/04 not met.}. At least 50 of staff must have the NVQ 2 in care. 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. Timescale for action 11/07/06 2. 3. YA32 YA35 18 18[1]a c 15/09/06 15/07/06 4. YA36 18 15/08/06 Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 30 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. 2. Refer to Standard YA14 YA23 Good Practice Recommendations Each service user should be offered a seven day holiday. The manager should review incidents to identify patterns and trends, and then put strategies in place to reduce the number of reportable incidents that effect the well-being of the residents. Deepdene DS0000025778.V304163.R01.S.doc Version 5.2 Page 31 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. 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