Inspection on 14/04/05 for Deepdene House

This inspection was carried out on 14th April 2005.

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

Other inspections for this house

Deepdene House 21/12/07

Deepdene House 11/04/06

Deepdene House 11/10/05

Deepdene House 25/11/04

Deepdene House 01/07/04

Deepdene House 26/02/04

Deepdene House 30/10/03

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Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Deepdene House 55-57 Stanthorpe Road Streatham London SW16 2EA Lead Inspector Lynne Field Unannounced 14 April 2005, 2:30 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Deepdene House Address 55-57 Stanthorpe Road, Streatham , SW16 2EA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8769 6297 Mr Sam Vindalon NA Care Home 20 Category(ies) of PC Care Home only registration, with number of places Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25/11/04 Brief Description of the Service: Deepdene House is a private care home that at the time of this inspection provides up to 23 places for adults with mental health problems and aims to rehabilitate them. The home is made up of 2 interconnecting Victorian houses with a large rear garden. There is parking at the front of the houses and on street. Accommodation at the present time is both single and double rooms. Deepdene House is situated in a quiet suburban street within easy walking distance of Streatham High Street, which has good transport links as well as leisure, community and shopping amenities. On the day of the inspection there were four service user vacancies. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection that was unannounced, lasted about 2 hours. It followed a complaint sent to CSCI and concentrated on looking at this complaint. There was not a manager at the time of the inspection but the registered provider was acting manager until the new manager takes up the post at the beginning of May. The inspectors found the registered provider open and approachable. The Inspection methods included discussion with approximately five service users; interviews of a team leader, the registered provider; examination of records and a tour of the building. The home was in the process of being refurbished, which included making four rooms that were double rooms into single ensuit rooms. This will effectively reduce the number of service users to 19. Few of the standards have been inspected at this inspection but most were met at the last inspection. The timescale for action on several of the previous requirements had not been exceeded at the time of this inspection and these will be assessed at the next inspection. What the service does well: What has improved since the last inspection? Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 6 The registered provider has demonstrated commitment to raising standards within the home. A programme of redecoration and refurbishment has begun. Double rooms are now being converted into single ensuit bedrooms, which will give greater privacy and dignity. The home has continued to make good progress with regard to care plans, risk assessments and reviews. 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 House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) NA These Standards was not assessed at this inspection. The finding of the previous inspection was that these Standards were met. EVIDENCE: Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 In the last year progress has been made in making sure reviews are held annually, six-monthly or more frequently if required; there has been input from other professionals involved with the service user such as CPNs and the Psychiatrist. Families are involved in these reviews and in care planning if the service user agrees to this. EVIDENCE: Individual care plans were seen and it was noted these had been reviewed at appropriate intervals and this was recorded. One CPN, who the Inspector had contacted, told the Inspector he was pleased with the progress the service users in his care had made when they were at the home. Service users said they had monthly key worker meetings and notes from these meetings were kept. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 14 The home had recently assessed the range of activities being offered in the home, which includes television, videos, a pool table and a table tennis table. The home used the results of the assessment to create a fuller activities programme, which include a baking group and a current affairs discussion group, but this is still limited. EVIDENCE: Several service users were spoken to said they enjoyed the baking group as they thought it was useful to learn how to cook for themselves. However, several service users said the only activities they participated in was going to day centres for a couple of afternoons a week. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The home administers and records the medication in an appropriate way, which ensures service users medication needs are met. EVIDENCE: A sample of archived and current medication records was inspected. These were appropriately signed and records confirmed that when a service user refuses medication, the relevant code is entered on the medication record chart. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 &23 Complaints are taken seriously by the home. One complaint has come directly to CSCI alleging that family visitors had been discouraged from visiting. The inspector could find no substantial evidence that suggested the registered provider had prevented relatives from visiting service users. Several service users were spoken to at random who said they could have visitors. The inspectors were shown a policy, which outlined visiting times and procedures. EVIDENCE: The home has a clear complaints procedure and follows the vulnerable adult procedure. Staff and service users are aware of the complaints book and would report any complaint to the acting manager or, if the manager were not available, to the team leader. Service users said they felt they could complain and they would be listened to. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24.25,2627,28 and 30 The home is clean and communal areas are well decorated. Bathrooms and toilets are homely. In the past service users have shared bedrooms but this now being addressed by making these double rooms into single ensuit rooms. The home is in the process of a refurbishment, which is raising the standard of decoration through out the home. Service users are encouraged to keep their rooms clean and tidy as part of developing their independent living skills. EVIDENCE: The refurbishment program has been started and the shared bedrooms are being phased out. Two previously double rooms are being converted to single ensuit rooms and another two are being converted to include ensuit and small kitchens. Service users in these two rooms will be helped to develop independent living skills with the view to them moving into the community. The communal areas are comfortable, bright and homely. The hall stairs and landing are to be decorated. Carpets in the communal areas have been replaced and new chairs are being bought. Bathrooms and toilets are clean and smell fresh. Service users said they had lived here for several years and were happy and comfortable there. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) NA These Standards was not assessed at this inspection. The finding of the previous inspection was that these Standards were met. EVIDENCE: Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 & 39 The registered provider is managing the home until the new manager has started. The registered provider has offered a consistent approach to the management of the home. Service users needs are met by providing a consistent approach to the management of the home. Health & Safety issues are immediately addressed when they arise. EVIDENCE: The registered manager has recently left his post. A new manager has been appointed and is due to start in a few weeks time. During the time there hasn’t been a registered manager, the registered provider has been acting as manager. He has many years experience as a manager and provider as well as being an RMN. There were some good systems in place to ensure service users and staff’s health and safety, for example food hygiene and maintenance of the home. Service users said they felt safe in the home and didn’t want to move on. They said when they had their key worker sessions they were able to say what they felt and it was acted on as well as listened to. Recently following an incident with a service user, a risk assessment was carried out and the fire Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 16 door to the roof, which is also the fire escape exit, was alarmed which alerts staff to the fire door being opened. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 N/A 3 Standard No 11 12 13 14 15 16 17 x 3 x 3 x x x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Deepdene House Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x x x G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 18 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 YA5 Regulation 5(1)( c) Requirement Timescale for action 30/07/05 2. YA16 16(2)(i) 3. YA42 13(4)(a The registered person must ensure that both parties sign the service user license agreement. This is the subject of a previous requirement that has been reinstated. 30/07/05 The registered provider must ensure the service users have the ingredients available to be able to make themselves a variety of hot or cold snacks at all times. The registered provider must supply the CSCI with an action plan of how the home will achieve this. This is the subject of a previous requirement that has been reinstated. The registered provider must 30/07/05 ensure that COSHH regulations are adhered to. This is the subject of a previous requirement that has been reinstated. 4. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 19 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 The Inspector recommends the subject of funding for holidays is discussed fully at service user reviews with individual care managers. Deepdene House G52-GO2 22723 Deepdene 228623 140405 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Ground Floor 46 Loman Street Southwark SE1 0EH 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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