Inspection on 21/12/07 for Deepdene House

This inspection was carried out on 21st December 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Deepdene House 11/04/06

Deepdene House 11/10/05

Deepdene House 14/04/05

Deepdene House 25/11/04

Deepdene House 01/07/04

Deepdene House 26/02/04

Deepdene House 30/10/03

Similar services:

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 Ornella Cavuoto Key Unannounced Inspection 21st December 2007 10:00a Deepdene House DS0000022723.V347514.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 House DS0000022723.V347514.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 House DS0000022723.V347514.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deepdene House Address 55-57 Stanthorpe Road Streatham London SW16 2EA 020 8769 6297 0208 916 2301 ludmila.iyavoo@deepdenecare.org Ludmilia.iyavoo@deepdenecare.org Deepdene Care Ltd 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) Edna Dura-Ray Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2007 Brief Description of the Service: Deepdene House is a private care home that at the time of this inspection provides up to 20 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. Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was present for the duration of the inspection and assisted in the inspection process. Prior to the inspection service user surveys were sent out of which ten were completed and received back. The Annual Quality Assurance Assessment (AQAA) document that was also sent out to the service by CSCI prior to their inspection was returned and completed to a good standard. This provides information on how the service has performed to meet standards and areas where it can improve. This will be referred to in the report. Five service users were spoken to during the inspection and two were case tracked. One of the care support workers was also spoken to. Other inspection methods included a partial tour of the building and inspection of care records. Since the last inspection the home has undergone a lot of staff changes that has had an impact on the day- to- day running of the home. This was evident through the inspection with the home acquiring an increased number of requirements from the last inspection that was held although the quality of service overall remains of a good standard. What the service does well: What has improved since the last inspection? Only three requirements were specified at the last inspection, one had not been met at this inspection whilst due to changes in circumstances within the home a decision was made not to restate the other requirements. Deepdene House DS0000022723.V347514.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. The summary of this inspection report can be made available in other formats on request. Deepdene House DS0000022723.V347514.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 House DS0000022723.V347514.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): 1,2 &5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users do not currently have all the information they require about the home. Service users that move into the home have had their needs fully assessed. Service users are all issued with a contract when they move in. EVIDENCE: The home has a comprehensive statement of purpose and service user guide in place that in the main provides all the information needed apart from details about the fees charged by the service that should be included specifically in the service user guide. This is required under a new regulation introduced in September 2006 (See Requirements). Four personal files were looked at that belonged to service users that had moved into the home since the last inspection was held. All the files included evidence that detailed information and assessments from the referring local authorities had been obtained prior to the service users being admitted to the home. The home also undertakes its own detailed needs and risk assessment of those service users that are referred to the home before they move in to ensure that their individual needs can be met. A licence agreement that had been signed by the service user, their social worker, and a representative from the home was included in all the personal Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 9 files that were checked. This outlined the terms and conditions of their stay with the home. Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 10 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): 6,7& 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are drawn up with service users that are comprehensive addressing all areas of need. Service users are involved in making decisions about their lives. Individual risks presented by service users are assessed and well managed. EVIDENCE: Care plans for four service users were looked at. These were comprehensive and had addressed individual presenting needs relating to their mental health as well as areas of physical health, social and personal support. Care plans had been signed by service users and there was a ‘comments’ box included on the care plan for them to write their personal views. Six monthly reviews had been held as specified within National Minimum Standards (NMS) with any progress made and changing needs reflected within individual care plans. There was evidence from notes of key worker sessions held with service users that they had been supported to make decisions about their own lives. Regular house meetings are held. The minutes of these were seen and it was evident Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 11 service users had discussed and were able to provide feedback and have input on different aspects of the running of the house. In addition, information about independent advocacy services was available for service users. All service users whose files were looked at had detailed risk assessments in place that addressed risks presented by individual service users’ needs, for example in relation to their mental health and physical health. It was evident from personal files that the home does aim to allow service users to take risks as part of supporting them to live independently within a risk a management framework and within restrictions placed on service users under the mental health act. All the risk assessments apart from one had been reviewed six monthly. Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15,16 &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 generally been involved in fulfilling and valued activities and are involved in the local community. In-house group activities and leisure activities away from the home to encourage service users to socially interact have not taken place on a regular basis. Service users have been able to maintain contact with family and to develop friendships and relationships. The home has promoted service users’ independence and individual choices. Meals provided at the home have not always been sufficiently nutritious and varied. EVIDENCE: Service users had been supported to access opportunities to enable them to continue their education or training, for example one service user was attending college to do creative writing whilst another was doing English. Another service user had been supported to attend a work- based project to gain employment skills. In addition, some of the service users attended day centres locally where they were engaged in valued and fulfilling activities such Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 13 as cooking sessions. One service user spoken to reported how they attend a weekly healthy living group at the day centre they attended. Service users spoken to confirmed that they were part of the local community and used facilities such as the local shops, church, library, gym, cinema and restaurants. All the service users had freedom passes to enable them to use local public transport. In respect to in- house activities it was identified at the last inspection that despite the home having a weekly programme in place this was not taking place. It was reported that service users did not want to join in but it was assessed that there needed to be more staff available to encourage and motivate service users to engage in these activities. At this inspection, it was evident that scheduled weekly activities, which included exercise classes, a baking and cookery group amongst others were still not taking place. Service users spoken to reported how there was not much to do during the day and there were no activities. In terms of leisure activities away from the home, one service user reported how they had gone to the cinema but this was a long time ago and that staff were too busy to accompany them to go places. Other service users spoke of how they considered that there was not always a sufficient number of staff working and consequently staff on duty did not have the time to spend with them but that they would like more interaction with staff. This was discussed with the registered manager who acknowledged there had been a high turnover of staff in the last few months and this had caused staffing issues (For further details see Standard 31). Measures need to be taken to ensure activities can be carried out with service users and the previous requirement is restated in this report (See Requirements). There was evidence from service users’ personal files that they had contact with family and friends. Service users spoken to confirmed this with one service user relating how they visit their mother and brother regularly and another service user commented how family members would often visit them at the home. The home’s routines and house rules were identified as promoting independence and individual choice. The majority of responses within surveys that were received from service users indicated that they were able to do what they wanted at all times and at weekends. This may also be dependent on whether service users are subject to restrictions imposed under the Mental Health Act. During the inspection service users were observed as coming and going from the house and that they had the choice to spend time with other service users or to be alone and spend time in their own rooms. Service users had a key to the front door of the house as well as one for their own individual rooms. Also, they spoke of how they are involved in household tasks such as tidying their own rooms and helping in the preparation of meals. Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 14 Feedback from service users about the meals provided at the home was varied with some service users stating they were not happy about the food. It was also noted that concerns about meals had been discussed at service user meetings. The home has meal audits and the aim is to complete these with service users daily although this had not been done. At present care support workers are responsible for cooking lunches whilst the home is using an agency cook as the full time cook has been off sick for the past month. One service user reported that lunches could be basic and repetitive. Records that were seen of lunches that had been provided over the previous few days confirmed this. Also, a lunch -time was observed and the food provided was not very substantial consisting of sausages, tomatoes and cucumber or tuna coleslaw. It was reported bread was always provided on the tables for service users to make sandwiches. In addition, it was evident that lunches being cooked were not the same as those specified by the menu. In respect to evening meals these had been provided in line with the menu but were also repetitive. In discussing the menu with the registered manager they acknowledged that it needed to be reviewed. This needs to be addressed in consultation with service users to take into account their preferences and to ensure the menu is more balanced and meals provided are nutritious (See Requirements). Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 15 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&20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have not all received personal support in the way they prefer. Health care needs of service users have been met. Staff have not consistently adhered to medication policies and procedures to protect service users. EVIDENCE: Service users living at the home are able to carry out their own personal care although some of them require prompting and encouragement. Where service users needed support this had been addressed in their individual care plans and risk assessments Surveys received back indicated that service users generally considered they were treated well by staff. The home aims to operate a key worker system to ensure service users receive consistency and continuity. However, as mentioned in respect to Standard 14 the home has had problems with staffing in recent months and records indicated that there had been a period of two to three months recently where key worker sessions had not been held regularly with service users. One service user expressed concern that one to one sessions had been cancelled with them. It is advised that measures are taken to ensure consistency in the regularity of key work sessions for service users at all times (See Recommendations and Standard 31 for further details). Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 16 There was evidence within service users’ personal files that their physical and emotional health needs including their mental health had been addressed. Each service user had records of medical appointments attended and contact with health professionals that included community psychiatric nurses (CPN), psychiatrists, district nurses, GPs, opticians, dentists, chiropodists. In respect to medication, a list of signatories of those staff that had received training on medication and consequently who were permitted to administer medication was in place. It was reported that staff had received both internal and external long distant training from Bromley College. Service users are supported by the home to take responsibility for their own medication where appropriate. At the time the inspection was held, there were three service users self- administering although self- medicating monitoring forms are completed for all service users to record their progress towards self administration specifically whether they attend the office unprompted or prompted for their medication. Decisions regarding self- administration are made with the involvement of all the professionals involved in the individual service user’s care as part of a CPA. They sign an agreement form of which evidence was seen and they progress through different stages in respect to the amount of medication they are given responsibility to take. Weekly spot checks should also be carried out although it was identified these had not been regularly completed for two of the service users whose records were checked. In addition, in looking at a sample of medication records and checking stocks, errors were identified where records had been signed but medication had not been given. The home does carry out monthly audits but it is advised that these are carried out on a more frequent basis (See Requirements and Recommendations). Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 17 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): 22 &23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users generally considered their views were listened to and would be acted upon. Service users had not been completely protected from abuse. EVIDENCE: The majority of surveys received from service users stated that they knew how to make a complaint, who they would speak to if they were not happy and that generally they considered staff at the home listened and acted on what they said. Service users spoken to during the inspection reported how they all felt able to raise their concerns with staff and one service user commented that at the service user meetings ‘you can say what you want.’ However, individual service users stated they did not always consider concerns raised were acted upon to their satisfaction, for example regarding meals (For further details see Standard 15). It was noted that informal complaints about the food had not been logged and action taken to address these recorded. It is advised this is carried out, as it would also assist to identify any recurring themes or patterns of complaints. The home had not received any formal complaints since the last key inspection. (See Recommendations). There had not been any adult protection investigations undertaken in relation to the home since the last inspection. There was evidence that more established members of the staff team had completed training in this area but staff that had started working at the home within the last six – eight months had yet to receive training in this area and there were no evidence of measures being taken to ensure this was arranged. It was evident in speaking to one care support worker who had yet to receive training that although they Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 18 had some insight into issues relating to abuse they needed to increase their awareness and knowledge in this area (See Requirements). Service users finances were not checked at this inspection. Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 19 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): 24,25,28 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that they find safe and comfortable. Service users’ bedrooms suit their needs. Service users have ample communal spaces to use but some replacements of furnishings are required. The home was clean and hygienic. EVIDENCE: A partial tour of the premises was undertaken. Generally, the home was found to be safe, homely and generally well maintained apart from some furnishings and repairs required in one of the communal areas (For further details see Standard 28). Seven service user’s bedrooms were seen including one of the rooms that were shared. Service users had made a positive choice to share. All the bedrooms were sufficiently spacious, comfortable, had all been personalised and were adequately furnished. The shared room had screening in place to ensure service users’ had their rights to privacy maintained. Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 20 The lower ground floor of the home had a number of different communal spaces including a large dining area and separate lounge areas one for smokers and the other for non -smokers. The smoking lounge was very spacious but it was noted that the tiled floor was cracked and broken in several places and this needed to be repaired or the flooring replaced. Also, the sofas, which were all covered with throws were very uncomfortable and one was very old and shabby and clearly needed to be replaced. The main kitchen was also situated on the lower ground floor and there was also a small kitchenette for service users to be able to cook for themselves and make snacks. The garden that can be accessed through the lounges was paved (See Requirements). The home was clean and hygienic on the day the inspection was held and free from any offensive odours. Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 21 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): 31,32,34 &35, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 50 of the staff had obtained a relevant qualification or were working towards one but the home needs to ensure there are sufficient levels of staff at all times to meet service users’ needs. The home’s recruitment practices and procedures have not completely protected service users. Not all staff have been appropriately trained to meet needs of service users. EVIDENCE: There was evidence that 50 of the care support workers had either completed or were working towards completion of a National Vocational Qualification Level 2. As mentioned in respect to Standards 14 and 18 the home has experienced staffing issues as a result of a high number of staff leaving over the past few months and this has affected the level of support provided to service users in some areas. On the day the inspection was held there was only one care support worker who works as part of the bank staff on duty with the registered manager and the deputy manager. It was reported a care support worker had rung in sick and there had been difficulties in obtaining someone else to cover. The care support worker was required to prepare the lunch leaving limited time Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 22 to spend with service users. The registered manager reported there is a policy that agency staff can only be used for the cook or domestic staff. Although, the registered manager stated that additional staff were in the process of being recruited it is important that measures are taken to ensure that there are sufficient levels of staff provided to meet service users’ needs at all times (See Requirements). In terms of recruitment four staff files were checked that belonged to staff that had been recruited since the last inspection. There was evidence that up to date Enhanced Criminal Record Bureau (ECRB) checks had been obtained. In addition, all staff files included two references and appropriate identification had been obtained as required by regulation. Records of the interview process undertaken were also available. Yet, it was noted for two of the staff that employment gaps had not been addressed and reasons for these obtained and noted down. This needs to be addressed (See Requirements). Staff files that were checked included evidence of training certificates and qualifications. A training plan that included courses completed by other more established staff working at the home was also seen. It was identified from these that there were gaps in training for staff in respect to mandatory topics including manual handling, food hygiene and fire safety. The care support worker that prepared lunch on the day of the inspection had not completed a food hygiene certificate. Also, there was no evidence available to demonstrate that measures had been taken to ensure training in these areas had been arranged. The provider did acknowledge within the AQAA for the home that this was an area for improvement and gave staff turnover as a reason for difficulties in addressing this matter. However, measures need to be taken to ensure staff receive training so that individual and joint needs of service users can be met. There was evidence that staff recruited had received a basic induction. The operations manager reported that an induction that met with Skills for Care specifications was to be introduced in February 2008 (See Requirements). Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 23 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): 37,39 &42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In the main the home is well managed and is run in the best interests of service users with systems in place for self- monitoring but not all these have been implemented. Generally, the health and safety of service users and staff have been protected and promoted but some areas are in need of improvements. EVIDENCE: The registered manager is very qualified and experienced. They have recently completed a course in psychotherapy and have achieved the Registered Managers Award (RMA). They have worked at Deepdene house for just over six years and they are very familiar with the needs of the service users and running of the home. Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 24 In respect to Standard 38 a previous requirement regarding on call arrangements of the home is not to be restated. The registered manager reported that on call arrangements are alternated between themselves, the deputy manager and a senior care support worker and all on call contacts are monitored. The home aims to carry out audits to ensure that standards within the home are maintained, for example in relation to the meals provided and the medication although as mentioned in relation to Standard 15 these had not been regularly completed for meals. Feedback from service users about aspects of the day- to- day running of the home had been obtained from service user meetings that had been held. The home’s AQAA had been comprehensively written and contained relevant and clear information supported by evidence. It was also specified within the home’s AQAA that the operations manager carries out unannounced monthly audits although these were not checked at this inspection. In addition, although at this inspection there was some evidence to indicate that customer satisfaction surveys had been completed with service users as part of self –monitoring, subject to a previous recommendation the results had not been compiled in a report to be made available to service users and other interested parties including CSCI. Any aims or outcomes for service users should also be outlined within a development plan or the home’s business plan. It is advised that relatives where appropriate and professionals should also be asked for their views on the service (See Requirements & Recommendations). External health and safety risk management consultants perform three monthly health and safety audits in the home covering the building and fire safety. After each audit an action report is produced specifying any areas that need to be rectified. Maintenance certificates for gas safety and portable electrical appliances were in place and the fire alarm system had been checked. However, it was noted from personal files that were seen that there had been several incidents that had occurred involving individual service users that the home had not provided notification to CSCI as required by regulation 37. This needs to be addressed (See Requirements). Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 X 5 3 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 3 25 3 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation Requirement Timescale for action 30/04/08 2. YA14 3. YA17 4. YA20 5A(2)(a)&(b)& The registered provider must 5B(2). ensure that as required by regulation a break down of fees charged by the home is detailed within the homes service user guide. 16(2) n The registered person must review the arrangements regarding the programme of activities in the home, including how service users are consulted about activities, and how group activities can be arranged. Consideration must be given to identify funding to support this. (Previous timescales of 01/02/06 & 01/07/06 not met). 16(2)(i) The registered person must ensure that the menu is reviewed in consultation with service users to obtain their individual preferences and views and that meals are provided which are nutritious and varied and in adequate quantities. 13(2) The registered person must ensure that that all staff DS0000022723.V347514.R01.S.doc 31/05/08 31/05/08 31/05/08 Deepdene House Version 5.2 Page 27 5. YA28 23(2)(b)&(c) 6. YA33 18(1)(a) 7. YA34 19 & Sched 2 8. YA35 18 (1)(c) 9. YA39 24 adhere consistently to medication policies and procedures specifically that all staff ensure that medication is administered to service users prior to signing medication records. Also, that for those service users self administering that weekly spot checks as specified are carried out and these are recorded. The registered person must ensure that the flooring in the communal lounge for smokers is repaired or replaced and that the sofas are replaced as part of maintaining the environment of the home to an acceptable standard for service users. The registered person must ensure that there are sufficient levels of staff within the home at all times to meet the needs of service users. The registered person must ensure that as part of recruitment and to protect service users that any gaps in employment are addressed with prospective employees and reasons given are recorded. This information should be kept in staff files. The registered person must ensure that all staff receives training in respect to mandatory topics and this is updated as required to ensure service users’ individual and joint needs can be met. The registered person must ensure that where customer satisfaction surveys are completed with service users the results of these surveys are complied in a report and DS0000022723.V347514.R01.S.doc 30/06/08 31/05/08 31/05/08 31/05/08 31/05/08 Deepdene House Version 5.2 Page 28 10. YA42 37 made available to service users and other interested parties including CSCI. A development plan in which identified aims and outcomes for service users are outlined should also be drawn up. The registered person must ensure that where incidents occur in the home that relate to regulation 37 that these are reported to CSCI and other relevant parties. 31/05/08 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 YA18 Good Practice Recommendations The registered person should arrange for a review to be undertaken to ensure that the home is appropriately addressing issues relating to service users’ gender and sexuality. (Not checked at this inspection) The registered person should try to ensure measures are taken so that service users receive key worker sessions on a consistent and regular basis. The registered person should try to carry out medication audits on a more frequent basis than monthly to address any areas where staff are not adhering to medication policies and procedures and prevent errors from occurring. The registered person should try to ensure that all informal complaints are recorded and action taken to address these are specified as part of identifying any patterns or themes. The registered person should try to ensure the views of relatives where appropriate and professionals are obtained as part of self-monitoring when carrying out customer satisfaction surveys. 2. 3. YA18 YA20 4. 5. YA22 YA39 Deepdene House DS0000022723.V347514.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 House DS0000022723.V347514.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!