Inspection on 23/05/06 for Deepdene Care Centre

This inspection was carried out on 23rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Deepdene Care Centre Deepdene Care Centre Hill View Reigate Road Dorking Surrey RH4 1SY Lead Inspector Lesley Garrett Key Unannounced Inspection 23rd May 2006 10:00 X10015.doc Version 1.40 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 Care Centre DS0000065717.V296011.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 Older People. 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 Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deepdene Care Centre Address Deepdene Care Centre Hill View Reigate Road Dorking Surrey RH4 1SY 020 8343 9336 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) Life Style Care Plc Philippa Marie Savage Care Home 66 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (44) of places Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/11/06 Pre-Registration site visit Brief Description of the Service: Deepdene Care Centre is situated close to Dorking town centre and the local amenities. It was opened in January 2006 and is owned by Life Style Care PLC. It is a two-storey building with a total of sixty-six bedrooms and all are single with en-suite facilities. On each floor there is communal bathrooms, two sitting rooms and a dining room. There is a lift to access the upper floors. The grounds are well maintained with some CCTV cameras for security and there is a small car park for visitors. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to 2007. The service is newly registered. Lesley Garrett lead inspector for the service, carried out the inspection over six hours. Philippa Savage, registered manager, represented the establishment. A tour of the premises took place and the inspector saw all of the service users and spoke to some of them in more detail. A pre-inspection questionnaire and feedback from a service user survey (using comment cards) was used to write this report. Records were also sampled as part of the inspection process including care plans and policies and procedures. This was a positive inspection and the inspector would like to thank the service users, staff and manager for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? This is the first key inspection of a newly registered service. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 6 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 Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using evidence including a visit to the service. All service users have a pre-admission assessment and this was all well documented in the individual files. The home does not provide intermediate care. EVIDENCE: The Registered Manager told the inspector that pre-admission assessments are carried out on all service users prior to their admission to the home. The inspector saw examples of these assessments, which were comprehensive and contained all the information necessary to enable the staff to compile the necessary care plans for the service users. The home does not provide intermediate care. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users individual plans of care are comprehensive and demonstrate that their health needs are met. The home has policies and procedures in place for the safe handling of medications and no issues around privacy and dignity were raised. EVIDENCE: The inspector sampled some service users plans of care and found them to be comprehensive and detailed. They were generated from the pre-admission assessment and also contained a variety of risk assessments and evidence that they were reviewed every month. The service users, relatives or representatives were also involved in the care plans and evidence seen of their signatures. The home has good access to other health care professionals. The General Practitioner visits weekly and as required. The manager stated that the health care team was a good support to the home. The dentist, opticians, audiologist Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 10 and chiropodist visit. Tissue viability training has taken place and the home has access to a tissue viability nurse specialist. The continence link nurse has also visited and assessments for the service users have taken place and nutritional assessments are also in place for service users. The home uses a monitored dose system to administer their medication and this is delivered to the home. A medication audit had taken place by the commission prior to the home opening and all relevant policies and procedures were in place. The inspector sampled some medication administration charts, which were appropriately completed. The home had no controlled drugs on the day of inspection and the medication fridge was empty but daily temperature recordings were taking place. The inspector saw a privacy and dignity policy and the manager stated that this topic is covered during induction. All the rooms are single en-suite and all service users are seen, by visiting professionals, in their own room. The inspector noted staff knocking on the doors prior to entering the room. The service users have access to the homes telephone to use in private if they wish but they are also able to have telephones in their own bedrooms. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has begun to develop an activities programme and families and friends are welcomed to the home. Service users are offered a well balanced diet and are encouraged to exercise control over their lives EVIDENCE: The home has employed a full time activities co-ordinator who has been at the home for six weeks. She is beginning to develop a programme of events but due to the small number of service users is able to accommodate individual needs on a daily basis. The manager stated this included walks into the town as one service user in particular enjoys the farmers market. Art, knitting, watching videos and shopping are some of the activities. A pat dog visits regularly and the mobile library comes to renew books in the home every three months. There are no visiting restrictions in the home and the inspector had the opportunity to speak with some visitors during the inspection. They told the inspector that they were made to feel welcome and a cup of tea is always made for them. The manager stated that more contact needed to be made Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 12 with the community but a local vicar had been contacted and had visited the home. The manager told the inspector that the philosophy of the home is choice and the inspector witnessed this during the inspection. The service users can eat in the dining room or in their room if they wish. The chef told the inspector that he gave the service users a choice of food for all meals. The service users have all been given a choice of what room they would like. Service users finances were managed appropriately by their relatives/representatives although the home provides some assistance with sundries. The administrator looks after this account and all money are kept separately and an individual record is kept of the transactions. The inspector had the opportunity to meet with the chef and assistant. He has been here since the home opened. There is a four-week rotation of menus and there is a choice for all meals. The chef told the inspector that the service users enjoyed traditional food and he makes homemade soups, cakes and biscuits. The service users that the inspector spoke with were complimentary about the food and one service user stated ‘he makes the most wonderful soups’. Fridge and freezer temperatures are recorded and a weekly audit in the kitchen is carried out. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints and protection of vulnerable adults policies in place and training has taken place in respect of these areas. EVIDENCE: The inspector saw the homes complaints policy. This is displayed in reception and each service user has a copy in their room. The manager has had no complaints since the home opened. The home also has the February 2005 copy of Surrey Multi Agency Protection of Vulnerable Adult policy. The manager and all staff have had training and the manager also told the inspector that a Surrey adult protection manager has visited the home to meet with the manager. There have been no issues since the home opened. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained internally and externally and is clean and free from offensive odours. EVIDENCE: The home was registered in January 2006 and was subject to a site visit prior to opening. The décor is still of a high standard and there is a regular review of the internal decoration by the maintenance man. The development company looks after the gardens for the first year and they will mow the lawns and keep this area tidy. The grounds are small but accessible by the service users. The home has CCTV cameras, which is directed to the outside of the building and reception and does not intrude on the daily life of the service users. The home was clean and free from offensive odours. The manager employs one housekeeper for cleaning and she also does the laundry as the home has so few service users. The laundry is large and the housekeeper had knowledge Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 15 of infection control issues and is about to have some training in this area. The washing machines have sluicing facilities and red alginate bags are used. Paper hand towels and soap dispensers were freely available in all areas. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels in the home are sufficient to meet the needs of service users. The home is able to demonstrate that service users are supported by trained and qualified staff that is able to carry out their role competently. The home ensures that adequate checks are completed prior to staff working in the home, which ensures that service users are protected by the homes recruitment policy and procedures. Staff training is carried out on a regular basis. EVIDENCE: There are adequate numbers of staff on duty for the number of service users. The inspector looked at the rotas and numbers were consistent. The manager stated that the home was still actively recruiting and the numbers will increase as more service users are admitted to the home. 50 of the care staff has the NVQ level 2 qualifications and the home has not needed to use agency nurses since opening. An induction programme is in place for all new recruits and all are registered with the skills for care. The inspector sampled some recruitment folders and found that all necessary paper work was in place. The home has a full time training co-ordinator who is responsible for delivering and accessing all training needs for the home. All new staff has induction and Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 17 mandatory training such as manual handling, food hygiene, fire. They all have a training and development plan that the inspector saw and there is a training plan for the year displayed on the notice board in the staff room. On the day of inspection all the registered nurses were receiving training on medication. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a new manager who has been at the service since it opened. There is evidence to show that the home is run in the best interests of the service users. Financial interests are safeguarded and the health, safety and welfare of service users are protected through their policies and procedures. EVIDENCE: The registered manager was appointed prior to the home opening and training shortfalls noted prior to opening have been addressed. There was a recommendation that she attend dementia training, which has now been achieved. It is the homes intention to send out quality monitoring forms yearly to seek the views of the service users. This has not been done yet as the home is Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 19 newly opened. The inspector saw all heads of department complete regular audits and the schedule for completion of these. Monthly visits are also completed by the homes senior manager responsible for that service. Financial interests of service users are safeguarded the sundries account is organised by the administrator. Adequate records are kept. Manual handling training has taken place for all staff and first aid training will also be available. Food hygiene training and infection control training has taken place and is on a rolling programme as new staff are recruited. The home has a full time maintenance man who showed the inspector the records of his regular tests that take place. Fire alarms are tested weekly and fire training takes place every six months. He also checks wheelchairs every week and hi-lo beds are checked every month. All certificates were seen prior to the home opening and there have been no changes. Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Deepdene Care Centre DS0000065717.V296011.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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