Inspection on 25/06/08 for Deer Park Care Centre

This inspection was carried out on 25th June 2008.

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

Other inspections for this house

Deer Park Care Centre 05/09/06

Deer Park Care Centre 21/11/05

Deer Park Care Centre 09/05/05

Deer Park Care Centre 28/09/04

Deer Park Care Centre 14/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Deer Park Care Centre Deer Park Care Centre Detling Avenue Broadstairs Kent CT10 1SR Lead Inspector Mark Hemmings Key Unannounced Inspection 25th June 2008 09:00 Deer Park Care Centre DS0000023393.V366909.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 Deer Park Care Centre DS0000023393.V366909.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. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deer Park Care Centre Address Deer Park Care Centre Detling Avenue Broadstairs Kent CT10 1SR 01843 868666 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) deerpark-manager@btconnect.com Phoenix Care Homes Ltd Kate Hayward Care Home 38 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (38) of places Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residential Care for older people with mental health difficulties is for residents aged 50 years and over. Residential Care for people with Dementia is restricted to two (2) Service Users whose dates of birth are 26/10/25 and 13/08/22. 5th September 2006 Date of last inspection Brief Description of the Service: The Deer Park Care Centre (the Service) is registered to provide accommodation and personal care for 38 people who are over 50 years of age and who have difficulties with parts of their mental health. Two people who have problems with their understanding can be accommodated. The premises are a detached purpose built property. The accommodation is on the ground and the first floors. All of the people who live in the Service can have their own bedroom. Each bedroom has as a television point. All of the bedrooms have a private wash hand basin and 24 also have their own toilet. The bedrooms, bathrooms and toilets are connected to a call bell system. There is a passenger lift that gives step-free access around the building. The gardens are mainly laid to lawn with flowerbeds and shrubs. There is plenty of off-road car parking. The Service is located in a residential area. There is a bus stop nearby. There are a couple of local shops that are within walking distance. Ramsgate town centre and its main line railway station is about fifteen minutes walk away. People who might want to move in can get information from several sources. There is a Service Users’ Guide. This is a brochure that outlines the main things available in the Service. There is also a document called a Statement of Purpose. This gives a more detailed account than does the Guide. The Registered Provider ensures that a copy of the most recent Inspection Report from the Commission is available for people to read. The range of fees charged currently for each person’s residence in the Service runs from £499.30 to £540.00 per week. The actual amount charged depends upon the source of funding used and the level of personal care required. The fees include all accommodation, meals, personal care, laundry and in-house entertainment. They do not cover things such as hairdressing. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this Service is 1 Star. This means that the people who use this Service experience adequate quality outcomes. The commission since 1 April 2006, has developed the way it undertakes its inspection of care services. This inspection of the Service was an unannounced “Key Inspection”. The Inspector arrived at the Service at 09.00 and was in the Service for about eight hours. It was a thorough look at how well the Service is doing. It took into account detailed information provided by the Registered Provider in his self assessment. This is called the Annual Quality Assurance Assessment (AQAA). Further, it considered any information that the commission has received about the Service since the last inspection. During the inspection visit, we looked at a selection of the records and documents kept in the Service. We spoke with the Manager, the deputy manager, the Financial Controller, five support workers, the cook and the activities coordinator. Also, we spoke with five of the people who live in the Service and spent time in the company of others. We examined parts of the accommodation and grounds. What the service does well: There is a relaxed and homely atmosphere. The people who live in the Service say that members of staff are kind and attentive. People say that they receive the support and assistance they need and that this is in line with their expectations. People are helped to maintain their health. Medicines are handled and given out safely. People are served with good quality meals. There are opportunities for people to do things that interest them. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There is a shortfall in the arrangements used to dispense a medicine that can be used as and when it is needed. This could result in the medicine not being used in the correct or in a consistent manner. Some of the exterior woodwork is in a poor condition. This makes parts of the building look rather run down. The up to date fire risk assessment can not be found. There is only the out of date one to see. This might lead to potential hazards going unnoticed. The Department of Environmental Health has recommended an improvement in the kitchen that is overdue. There is a shortfall in the complaints procedure. This means that people might not realise that they can approach us at any time if they are concerned about something. The Registered Provider has not acted promptly to tell the Department of Health about someone who was dismissed for being abusive to one of the people who live in the Service. This means that other registered providers will not be informed about the dismissal if the person in question applies for employment. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 7 On some occasions not all of the rostered support worker shifts are being filled. This reduces the amount of time available to provide people with individual assistance. There are some shortfalls in the training programme. This means that support workers are not being given all the opportunities they need to develop and to refresh their range of skills. The quality assurance system does not collect enough information. Also, it does not tell people what is going to be done to introduce suggested improvements. This means that the people who live in the Service do not have a clear say in how they want things to be. There are shortfalls in the electrical installation. This could increase the chances of a power failure or of someone having an accident. Not all members of staff are having regular fire safety training updates. This might result in someone doing the wrong thing if there is a fire safety emergency. 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. Deer Park Care Centre DS0000023393.V366909.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 Deer Park Care Centre DS0000023393.V366909.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. Information is collected about the assistance needed by people who move into the Service. EVIDENCE: The Manager completes an assessment of each prospective person’s needs for assistance. This is done before a decision is made about whether or not the Service is a suitable place for the person’s residence. The assessment is completed in consultation with the person concerned. Other people are also involved such as family members and care managers (social workers). We looked at the assessments that have been completed for two people. They contain useful information about things such as their mental health and their ability to get about. Support workers say that this information is shared with them so that they can assist people as soon as they move in. Deer Park Care Centre DS0000023393.V366909.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): Standards 6, 7 and 9. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. There are individual plans of support that say what assistance each person has agreed to receive. People are helped to manage their personal spending money. People are supported to take reasonable risks. EVIDENCE: People say that the support workers offer them all the assistance they need. There is a written individual plan of support for each person. These are important documents. This is because they form one of the means by which people can be informed about and can agree to the assistance they will receive. Also, the plans are a source of information for staff. This then helps them to provide support in a consistent manner. We looked at three of these plans. The way the plans are written is rather cumbersome. There is a lot of Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 11 paperwork and this might put people off from making a contribution to what is written in their name. The Annual Quality Assurance Assessment recognises that more should be done to actively involve people in deciding the plan of their support. Having said that, the plans as they stand currently do contain useful information about a number of important subjects. For example, things such as special communication needs and how to help if the person becomes anxious. We asked four of the support workers to tell us about these things. They have a good and consistent understanding of the information in question and about what they need to do. The plans are kept under review to make sure that they are up to date The Registered Provider does not administer anyone’s financial affairs for them. People either do it themselves or have someone such as a family member to act on their behalf. The Annual Quality Assurance Assessment says that people will continue to be helped to take care of their own affairs. This will include helping them to open up their own bank accounts. The Registered Provider does hold some people’s personal spending monies in order to help them budget. The Manager says that this is done with the agreement of the people concerned. None of the people say anything to the contrary. We looked at one set of the records that are kept of the various transactions involved. These give a clear account of where the money is going and there are receipts for the purchases made. The Financial Controller keeps an eye on the records to make sure that everything stays in order. People are helped to be sensible about taking risks. This means that support workers consult with them about things they would like to do and then suggest ways to go about them. This includes activities such as smoking indoors and going out into town shopping. Deer Park Care Centre DS0000023393.V366909.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): Standards 12, 13, 14, 15, 16 and 17. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. People have the chance to do interesting things. They can spend their days as they wish. Good quality meals are served. EVIDENCE: People are free to do things that interest them. There is an activities coordinator. Her job is to offer each person opportunities to do occupational and recreational things. She runs a small day centre in the Service where people do various crafts and where they can play games such as pool. The Annual Quality Assurance Assessment says that the range of activities offered to people has increased and will continue to do so. The activities coordinator also accompanies people out for walks in the neighbourhood. She also has the Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 13 use of a vehicle and so can take people out further afield. She has also organised trips to London, Paris, Hastings and Brighton. Some people want to be much more active than do others. We looked at the records for one person who does like to be out and about. These show that between 1 May 2008 and 21 May 2008, they went out for walks and rides on seven occasions. Indoors, they did things such as embroidery, artwork, ballgames and bingo. We asked four people about the things that they do. All of them say that they are satisfied with the present arrangements. People say that the pace of daily life in the Service is relaxed and unhurried. While they have considerable choice about how to spend their day, there are broad expectations about some of the things they will do. For example, they are expected to adopt reasonable personal practices such as not going to bed too late. People are assisted to keep in touch with members of their families, if this is necessary and if it is their wish. Family members and friends are welcome to call to the Service at any reasonable time. The Manager in consultation with the person concerned, keeps in touch with family members so that they know how things are going. People say that they receive good quality meals and that they have enough to eat. They consider meal times to be a relaxed and pleasant experience. There is a choice of dish available at each meal time. The cook says that people are helped to have a balanced diet that does not have too much fat and sugar. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 14 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): Standards 18, 19 and 20. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. People are helped to support themselves. This includes using health care services. There is a shortfall in the way one medicine is being handled. EVIDENCE: People are supported in ways that are right for them. Support workers are courteous in their manner and they respect each person’s individuality. People say that they take it for granted that they can rely upon support workers to be there when they are needed and to be approachable. People are assisted to maintain their health. Support workers keep a tactful eye open so that they can see when someone is becoming unwell. They arrange for medical assistance to be promptly received. Since the last inspection, people have been supported to consult with various doctors, with district nurses and with specialist services such as the diabetes clinic. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 15 People are free to manage their own medicines when this is appropriate. None of them have chosen to do this at present. There is a system to check medicines when they are received into the Service to make sure that they are right. They are stored securely and in an organised manner. There is a procedure that support workers follow to make sure that the right medicine is given to the right person at the right time. We looked at six sets of the records that have to be kept each time a medicine is dispensed. They were correct. We also looked at three medicines in more detail to see if the administration record matches the remaining stock level. We found the balance to be correct. A doctor has said that Person A can have Medicine 1 as and when it is needed. The circumstances for the use of the medicine have not been explained in writing. This might result in confusion about when to use it. Also, the person concerned has not been actively consulted about taking the medicine. These oversights need to be put right. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. There is a gap in the information contained in the complaints procedure. There is a shortfall in how people’s wellbeing is safeguarded. EVIDENCE: There is a written complaints procedure. This explains how the people who live in the Service and other interested parties can go about raising a concern. As a first step it is often best for people to try to sort out concerns informally with the Registered Provider. However, as an alternative they can contact us direct. The procedure does not explain this alternative. The Manager says that this will be corrected by 1 August 2008. There is a record book that is used to list all complaints that are received. Also, it describes what has been done to sort them out. We looked at the entries made since our last inspection. Things are a bit muddled because some of the dates are not correct. However, there is information about what has been said and what has been done. This shows that the matters have been appropriately looked into and that as necessary other agencies have been involved. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 17 There is a written statement of the Registered Provider’s commitment to promoting the wellbeing of the people who live in the Service. It says what things might suggest a cause for concern and then it tells support workers what steps they can take. For example, it says that they should contact someone senior without delay. Since the last inspection there has been an occasion when a former member of staff acted inappropriately towards one of the people who live in the Service. We looked at the records of how this matter was investigated and resolved. They show that the Registered Provider dealt correctly with most of the matter. The support worker was immediately suspended. Statements were taken from witnesses and following a disciplinary hearing the person concerned was dismissed. The Registered Provider should have informed the Department of Health about the dismissal. This is so that the person could be considered for addition to the provisional safeguarding list. This is a list of people who are not allowed to apply to work in care settings with people who may be vulnerable. The Registered Provider has not done this. The day after our inspection, the Manager made the necessary contact with the Department of Health. The Registered Provider now needs to follow this up to make sure that the necessary provisional listing is made. The people who live in the Service say that they feel safe living in the Deer Park Care Centre. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 18 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): Standards 24, 29 and 30. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. People live in a generally comfortable setting. The up to date fire safety risk assessment can not be found. The kitchen is clean but there is an improvement that remains outstanding. The laundry is well equipped. EVIDENCE: From the outside, the gardens are well tended and most parts of the building are in reasonable repair. However, there are some wooden window frames and railings that have begun to rot. They look unsightly. Also, the paintwork on some of the planking near to the gutters is peeling away. On the inside, most areas of the accommodation are homely. This does not include the bathrooms and toilets. These are bare and stark. The Annual Quality Assurance Assessment says that various improvement have been made to the Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 19 accommodation. These include the redecoration of four of the bedrooms and the re-carpeting of some of the hallways. The Service is fitted with an automated fire detection system. This provides a high level of fire safety protection. The Registered Provider has prepared a fire risk assessment. This has been done to ensure that the fire safety system works as intended. The copy we looked at is dated 26 October 2005. It says that there are no problems. The Manager says that the assessment has been updated since then. However, she could not find a copy of the newer document for us to see. She says that it will be found and that it will be sent to the Kent Fire and Rescue Service. This needs to be done so that the fire officer can be kept up to date with how the fire safety system is being used. The Manager says that this will be done by 1 August 2008. The kitchen is clean and well organised. It has a normal range of equipment. However, the refrigerator that is used to store the partly prepared tea time meal is too small. When we looked inside it the space was over filled with some items having to be squeezed in. The local Department of Environmental Health last inspected the kitchen on 22 October 2007. The report says that the kitchen in general is running well. However, it says that a protective mesh needs to be fitted to the extractor hood above the stove. The timescale given was 1 November 2007, but we noticed that it has still not been done. The Registered Provider needs to get this sorted out as soon as possible. We spoke with the cook. She has a good knowledge of safe food handling. For example, she knows about the importance of preparing certain foods separately from others. She takes sensible steps to ensure the cleanliness of the kitchen and of the store rooms. About half of the people who live in the Service need extra help in the bathroom because they have difficulties with their mobility. There is a bath hoist in one bathroom and a walk-in shower unit in another. The assistance each person needs has been assessed and support workers know what they need to do. The laundry is equipped with a washing machine and dryer. People are encouraged to do their own laundry, but in practice most rely upon support workers to organise this for them. The arrangements used work well. Each person has a sufficient supply of clean and presentable clothes from which to choose. There are new regulations that have been introduced to ensure that used water does not leak back into the main pipe-work. The Registered Provider needs to check with the local water supply company to make sure that the pipe-work is alright. This needs to be done by 1 September 2008. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 20 Deer Park Care Centre DS0000023393.V366909.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): Standards 32, 33, 34 and 35. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. On most days there are enough staff. Security checks are completed on new members of staff. There are some gaps in the training support workers receive. EVIDENCE: On most days there are four support workers and one senior support worker on duty during the day and the evening. At night time, there are two support workers present. On weekdays there are also housekeepers, the cook, the activities coordinator and the handyman/gardener. We asked some of the support workers about how the roster works out in practice. They think that four support workers is enough. However, they do have concerns about the “frequent” occasions when this number reduces to three. The Manager says that this is because it is often difficult to fill last minute absences. Also, it is because there is a limit to how much overtime people can do. The Registered Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 22 Provider needs to review this matter to make sure that sufficient support workers are available to fill the various shifts. The cook prepares the lunch time meal. She then starts to get the tea time meal ready. The support workers have to finish this off and serve it. This means that one support worker has to be in the kitchen for quite a lot of time and so is not available to provide direct assistance for people. The Registered Provider also needs to review this arrangement. There is an on-call system. This means that someone senior can be contacted for advice out of office hours. The Registered Provider completes a number of security checks for new support workers. This is done to ensure that they are trustworthy people who are suitable to have unsupervised access to the people who live in the Service. We examined two sets of records for support workers who have been appointed recently. The necessary checks have been completed. New support workers receive introductory training before they work without direct supervision. After that, they are provided with ongoing training. This is designed to develop further their ability to provide a high quality residential care experience. We looked at the range of the training provided. There are some shortfalls. For example, there is no training that focuses directly upon the nature of mental health conditions and there is none that deals with helping people who develop difficulties with their understanding. The Annual Quality Assurance Assessment does not pick up these problems. It says that the Service has “an excellent training system”. The Manager says that she is now going to review the skills and knowledge of each of the support workers. The results of this exercise will then be used to plan the provision of training in the future. She says that this review will be completed by 1 January 2009. We asked two support workers points of detail about their work. For example, the nature of mental illness and how this relates to people’s needs for support. We also asked about particular features of how this support needs to be delivered. They have a good knowledge of these subjects. Deer Park Care Centre DS0000023393.V366909.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): Standards 37, 39 and 42. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. The Service is reliably managed. The quality assurance system does not collect enough information. There are shortfalls in some of the health and safety arrangements. EVIDENCE: The Manager holds both of the formal qualifications that are required. These are important. This is because they are designed to help her to ensure that people get the support they need. Various things are done to ensure good team work. These include staff meetings. Also, there are handover meetings at Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 24 the beginning and end of each shift. These are held so that support workers can tell each other how things are going and can decide what needs to be done next. Several things are done to consult with the people in residence about how well the Service is running. These include informal discussions and the completion of more organised questionnaires. We looked at one of the questionnaires and noted that the person concerned is very satisfied with her home. There are also house meetings. These are held every two or three months. We looked at the records of the meetings held on 20 January 2008, 16 March 2008 and on 20 May 2008. We noted that on the first occasion one person asked to have cheese on toast. The matter was raised again at the next meeting with the person being told that this could not be done because there is no grill in the kitchen. At the third meeting, the person quite reasonably questioned the value of making a contribution since the cheese on toast issue still had not be resolved. There is no organised system to plan a response to suggested improvements and to promptly tell people what is going to be done. The consultation system does not include members of staff. The Registered Provider is going to sort this out. This will be done in time for the results to be notified to us in 2009, when the Registered Provider submits his next Annual Quality Assurance Assessment. Regular checks are completed to ensure that the Service’s fire safety equipment remains in good working order. This includes a weekly test of the fire alarm bells and periodic more detailed checks completed by a contractor. There are unannounced fire drills. There is an annual fire safety lecture. However, if someone misses it they have to wait for the next one to come round. We looked at the records of who has attended these lectures in 2007 and so far in 2008. The Annual Quality Assurance Assessment says that there is a suitable system of fire training. However, we noted that seven support workers have not received the training. This needs to be put right. This is so that there is a reliable system to make sure that all members of staff know how to use the Service’s fire safety procedure. The electrical wiring system was inspected on 24 January 2007 and the Annual Quality Assurance Assessment says that everything is in order. However, the report says that there are 11 matters that “require urgent attention” before the installation can be considered to be safe-worthy. Parts of the report are missing so we can not tell what needs to be done. The Manager says that some or all of the points have been addressed. However, there is no written evidence to confirm this account. This will now need to be sorted out. There is a current certificate that shows that the gas fired appliances used in the Service are in a safe-worthy condition. We looked at the records that are kept of accidents in the Service. There is nothing in their frequency or nature that is a cause for concern. The Manager Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 25 keeps a check on what has happened. This is done so that she can take steps if there is a particular problem that is resulting in accidents such as falls. The Manager checks the premises and the accommodation to ensure that there are no hazards that might be a problem. We looked at the records of the two most recent reviews that were completed on 9 July 2007 and on 20 February 2008. These show that a number of relevant things are being considered such as the possible dangers posed by hot water and heated surfaces. The Manager says that she has not come across any particular hazards that need further action. We did not notice any. Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 26 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 X 33 2 34 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 2 X Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 27 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 YA20 Regulation 13 (2) Requirement The Registered Provider must consult with Person A about and must make suitable arrangements for the dispensing of Medicine 1. The Registered Provider must ensure that all of the improvements to the Service’s electrical wiring installation are completed. (This Requirement is outstanding from the previous two inspection reports. At the last inspection the Registered Provider was required to address the matter by 08/09/06). 3. YA42 23 (4) The Registered Provider must ensure at least once in every period of six months, that all members of staff are competent to operate the Service’s fire safety procedure. 01/08/08 Timescale for action 01/08/08 2. YA42 12(1)(a) 01/09/08 Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 28 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 Deer Park Care Centre DS0000023393.V366909.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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