Inspection on 05/09/06 for Deer Park Care Centre

This inspection was carried out on 5th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Deer Park Care Centre 25/06/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Deer Park Care Centre Deer Park Care Centre Detling Avenue Broadstairs Kent CT10 1SR Lead Inspector Sandra Crosby Unannounced Inspection 5th September 2006 10:00 Deer Park Care Centre DS0000023393.V307734.R02.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.V307734.R02.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.V307734.R02.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) 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.V307734.R02.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. 21st November 2005 Date of last inspection Brief Description of the Service: The Deer Park Care Centre is a large detached property with accommodation on two floors. There are 38 single bedrooms 24 of which have en-suite facilities. All bedrooms are connected to a call bell system and have a TV point. There is a shaft lift at the home. The gardens are mainly laid to lawn with flowerbeds and shrubs. There is ample car parking space at the home. The home is located not far from the seafront at Dumpton Gap and a local bus service is available. There are a couple of local shops within walking distance and Ramsgate town centre is about fifteen minutes walk or by bus takes about five minutes. The philosophy of care aims at providing a caring and homely atmosphere, which respects the individuality, dignity and rights to privacy of each Service User. It is based upon the establishment of a positive relationship between Service Users, their families and staff, and upon the creation of a noninstitutional regime, that enables Service Users to lead a fulfilled life and to achieve the highest potential that their condition permits physically, socially, emotionally and spiritually. Information received from the Registered Provider in July 2006 states that the fees are the contract price of £477.55. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was an unannounced key inspection carried out over two days on Tuesday 05 September 2006 between 10.00 and 14.30 and on Friday 08 September 2006 between 09.30 and 14.30. During the inspection the Inspector spoke with Service Users, the Registered Manager, members of the care staff, the cook and laundry person. Records were seen and an accompanied tour of some areas of the premises was made. The atmosphere of the home was welcoming, calm and relaxed, and the home was clean and orderly at the time of the inspection visit. Service Users Comment Cards were received and indicated positive comments about the home. The Pre-inspection Questionnaire completed by the home prior to inspection and the information provided by Service Users and staff at the time of the inspection, has been used in this report. Discussion with the Registered Manager resulted in some of the issues raised at the inspection visit being addressed immediately, together with confirmation being given that action would be taken in relation to all issues raised. The home continues to show commitment towards meeting the National Minimum Standards. What the service does well: The home promotes and develops independent living skills. A wide range of activities is currently being undertaken at the home, arts and craft, swimming, external exercise session, together with trips out. Several Service Users have been enabled to attend Thanet College. Staff members are multi skilled, and staff communication is good with daily handovers and regular staff meetings. The home is well run by a competent experienced supportive Registered Manager, who works well informing and consulting with other professional services and endeavours to provide best practice. The home has achieved Investors in People status, and the plaque is on display by the main entrance. Adaptations and equipment at the home suit the needs of the Service Users. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Deer Park Care Centre DS0000023393.V307734.R02.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 Deer Park Care Centre DS0000023393.V307734.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide provide Service Users and prospective Service Users with the information they need to make a decision about moving into the home. To ensure that service users are appropriately placed at the home a thorough assessment is undertaken, and Service Users move into the home knowing that their needs can be met. EVIDENCE: A Statement of Purpose/Service User Guide seen at previous inspection visits has been compiled in keeping with the information required in the National Minimum Standards and the Care Home Regulations Evidence was seen as part of the Service User Plan documentation that preassessment information provided by the Social Services Care Manager was used to compile a Service User Plan. The Registered Manager needs to ensure that the pre-assessment documentation when completed is signed and dated. Previous information provided indicates that trial visits are offered, together with a ‘settling in’ period following admission. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 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 the following standard(s): 6,7,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know that their personal goals are reflected in their individual service user plans, and that potential risks are managed. Service Users know that their views are listened to and that their records will be kept securely maintaining confidentially. Staff were seen supporting Service Users needs, mainly in a respectful manner that protects privacy and dignity. EVIDENCE: Four Service User Plans were seen and each Service User has an individual Service User plan. Support needs are detailed with actions taken by staff to support these needs. Potential risks are identified and the home takes steps to eliminate these risks where possible without restricting Service Users independence. There was evidence that plans are regularly reviewed to reflect any changes in a persons needs. Formal reviews are held regularly to ensure that the home continues to meet service user needs. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 10 There are lots of examples where Service User’s are enabled to take responsible risks and these are reflected in Service User’s Plans and assessed through the risk assessment process. Some people go out independently and there are procedures in the event of a Service User being missing. Staff had a good understanding of Service User needs. This was evident from the positive relationships and interactions between Service Users and staff (that have worked at the home for some time) witnessed by the Inspector. Records are kept secure when not in use, in the office. Those records seen during the inspection were up to date. There is a policy regarding confidentiality. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users have opportunities for personal and social development and are enabled to develop life skills within their individual capacity. Links with the community are good and support and enrich Service Users social and educational opportunities. Service Users have opportunities for personal and social development and are enabled to develop like skills. Life long learning is supported by the home. Daily routines respect service users rights, responsibilities and individuality. Service Users know the relationships they form will be supported by the home. The meals in this home are good offering both choice and variety and catering for special diets. EVIDENCE: Although the full time activities co-ordinator was on leave at the time of the inspection visit, resources on site enable Service Users to participate in a range of activities, including cooking art and computing. Positive comments in Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 12 relation to the range of activities provided were received from relatives/visitors. Communication with family and friends is supported by the home. Service Users have unrestricted access to communal areas and the grounds of the home. The atmosphere was relaxed and unhurried, interactions between staff and Service Users was respectful and positive. The Inspector spoke with one of the cooks. The choices of food for the day were on display on the notice board in the dining room. The food records were seen and indicated that a varied and nutritious diet was provided with alternatives choices always available. Service Users spoken with said what they had had for dinner and that they liked the food. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is offered in a way to protect Service Users privacy and dignity and promote independence. The health needs of Service Users are met, and the medication system at this home is well managed promoting good health. EVIDENCE: The medication records were seen and on the whole indicated that they were appropriately signed for and up to date. A couple of issues were discussed with the Registered Manager and she agreed to address these issues. Medication storage was not seen at this inspection visit. The home works closely with health professionals and specialist equipment is provided as necessary. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system in place, and there are policies and procedures in place to protect Service Users from abuse, neglect and selfharm. EVIDENCE: The home has a complaints policy, and the Registered Manager confirmed that there had been no complaints made. It was seen that although action had been taken in relation to any complaints made, there was no written record of this, and the Registered Manager agreed to address this issue. All staff members complete a detailed induction that includes the protection of vulnerable adults. The home has an adult protection policy. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good providing Service Users with a homely environment. Service Users bedrooms suit their needs and lifestyles. The home was clean and hygienic at the time of the inspection visit. EVIDENCE: The home was clean and orderly on the days of the visit. The furnishings, fittings, adaptations and equipment were mainly to a good standard, however it was discussed that again some armchairs could do with replacing. The Registered Manager said that four new armchairs had been purchased. It was indicated during the accompanied tour of the home that the premises are suitable for its stated purpose, and meets the needs of the current group of Service User’s. All bedrooms are single occupancy, and bedrooms are personalised. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 16 A number of liquid soap dispensers were seen to be empty, and the Registered Manager when discussed immediately asked a member of staff to check the dispensers and refill as necessary. It was noticed that some of the bedding and towels were in need of replacing, and the Registered Manager said that this was included in the business plan for the home. It was suggested that an audit be carried out, and for bedding and towels to be replaced as necessary as soon as possible. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members are multi skilled ensuring good quality care and support. Service users are protected in the main by the homes recruitment procedures. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: Staff retention in relation to the core staff group of the home is good, and some staff members have been at the home for a long time and are experienced with the Service User group. At the time of the inspection visit it was indicated that currently there is not always sufficient staff on duty to meet the needs of the Service Users at all times. Following discussion with the Registered Manager it was said that the home is in the process of recruiting staff, and a number of phone calls referring to advertisements were taken at the time of the inspection visit, and interview dates and times agreed. Staff files were seen, and although a thorough recruitment procedure is undertaken it was found that again there was no evidence of the POVA First check having been carried out. This was discussed and on the second day of Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 18 the inspection visit evidence was provided that the home had now started to undertake this procedure. Evidence was seen of completed induction programme documentation. Staff training is ongoing at the home, and staff are continuing to undertake the NVQ. It was indicated that Supervision is undertaken with appropriate written records kept. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has a clear vision for the home that, she has effectively communicated to the service users, staff and stakeholders. The Registered Manager is supported well by senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Service Users benefit from a well run home. Service Users rights and best interests are safeguarded by the homes record keeping, policies and procedures. The health, safety and welfare of Service Users are promoted and mainly protected. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 20 EVIDENCE: The Registered Manager has many years experience and the necessary qualifications for running the home. She has a good relationship with staff, and Service Users, promoting an inclusive supportive management style. The Registered Manager was observed communicating a clear sense of direction, and she spoke with understanding of service user needs. The organisation makes a commitment to equal opportunities, and has obtained Investors in People status. Although the Inspector was unable to speak with the administrator for the home at this visit, previous visits have indicated that the home is financially viable and appropriate records are maintained. The home has the required public liability insurance cover. A requirement was made at the last inspection visit in relation to clarification as to whether the home has a current electrical certificate. No action has been taken in relation to this, and following discussion it was agreed that this issue would be addressed without further delay. Although a number of monthly Regulation 26 visits had been undertaken with written records kept, it was found at this visit that these were not up to date by two months, and it was again requested that these visits be maintained, and appropriate records kept. An induction programme is in operation for all new staff, however if was found that this was not being followed up with the required Foundation training, and the Registered Manager agreed to implement this training package as soon as possible. It was found that in at least two bathrooms the hot water temperature was over the required level of 43C and there was no evidence of regular recording of the water temperature. This was discussed with the Registered Manager who agreed to address this issue. Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 3 3 2 2 Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 22 NO 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 YA20 Regulation 13 Timescale for action The registered person shall make 08/09/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home A record of all complaints made 08/09/06 by Service Users…. about the operation of the care home and the action taken by the registered person in respect of such complaint The home has an effective staff 08/09/06 team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health The registered person operates a 08/09/06 thorough recruitment procedure - POVA First Check Previous timescale 22/11/05 The registered person ensures 08/09/06 that there is a staff training and development programme which meets the Sector Skills Council DS0000023393.V307734.R02.S.doc Version 5.2 Page 23 Requirement 2. YA22 17(2) Sch 4 11 3. YA33 18 4. YA34 7,9,18,19 5. YA42 19 Deer Park Care Centre 6. YA42 12(1)(a) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’ – Implement foundation training The registered manager ensures 08/09/06 so far as is reasonably practicable the health, safety and welfare of service users and staff - Provide an appropriate electrical certificate for the home – maintain appropriate hot water temperatures Previous timescale 22/11/05 The Responsible Person to carry 08/09/06 out regular Regulation 26 visits with written records kept at the home Previous timescale 22/11/05 7. YA43 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA3 YA26 YA30 Good Practice Recommendations Ensure that pre-assessment documentation when completed is signed and dated Audit the bed linen and towels, and replace as necessary Ensure the liquid soap dispensers are refilled as necessary Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. Extracts may not be used or reproduced without the express permission of CSCI Deer Park Care Centre DS0000023393.V307734.R02.S.doc Version 5.2 Page 25 - 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. 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