Inspection on 18/04/05 for Dehnlea Rose

This inspection was carried out on 18th April 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dehnlea Rose 15/05/06

Dehnlea Rose 18/11/04

Dehnlea Rose 23/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOMES FOR OLDER PEOPLE Dehnlea Rose Lambly Hill Virginia Water Surrey GU25 4BF Lead Inspector Sandra Holland Unannounced 18 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dehnlea Rose Address Dehnlea Rose Lambly Hill Virginia Water Surrey GU25 4BF 01344 843221 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Welmede Housing Association Ltd Byfleet House, 2 Guildford Road, Chertsey, Surrey, KT16 9BJ Mrs Bibi Humeanee Jehangeer Care home only (PC) 6 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (MD(E)), 1 of places Learning disability (LD), 1 Physical disability (PD), 5 Learning disability over 65 years of age (LD(E)), 1 Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 5 Service users within the category LD(E), one of whom may also be in the categories PD(E) & MD(E). One service user may be in the categories LD & PD 2 The age/age range of the persons to be accommodated will be: 58 TO OVER 65 YEARS OF AGE Date of last inspection 18 November 2004 Brief Description of the Service: Dehnlea Rose is a large detached bungalow located in the village of Virginia Water and was purpose built to accommodate up to six older adults with physical and learning disabilities. All service users have single bedrooms and the use of a communal lounge / dining room which has access to the garden. There is a large enclosed rear garden on two levels and car parking is available to the front of the property. The service is owned and run by Welmede Housing Association and the staff team are employed by the North Surrey primary Care Trust (NSPCT). Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and three quarter hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Mrs. S. Holland, Lead Inspector for the service. Mrs. H. Jehangeer, Registered Manager was present representing the service. A full tour of the premises was undertaken and all four of the service users and four members of staff were spoken to. A number of records and documents were examined, including care plans, staff personnel files, medication administration records and policies and procedures. This was a positive inspection and the service users, manager and staff are thanked for their hospitality, time and assistance during the inspection. What the service does well: What has improved since the last inspection? The cost of weekly charges and any extra costs are now included in the service users guide. The bathing facilities in the home have been improved by the installation of a specialist bath with integral hoist and optional spa feature. The bathroom has been renovated and presents as a very comfortable space in which to bathe. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 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. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5. A service users guide and statement of purpose are available to prospective service users or their representatives to inform them of the services offered. Prospective service users and their relatives and friends are welcome to visit the home before moving in and assessments have been undertaken for those people already living in the home. EVIDENCE: A comprehensive statement of purpose and service user’s guide were seen and contained all the required information to enable prospective service users to make an informed choice about where to live. Assessments of service user needs have been carried out to ensure that these can be met, and where able, these have been signed by the individual service users. The home manager advised that the family of a prospective service user who is in hospital had recently visited the home and she is in the process of arranging for the prospective service user to visit the home prior to his final discharge from hospital. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Care plans have been drawn up for each service user. Service user’s health care needs are met and medication administration appeared to be accomplished satisfactorily. Service users are satisfied with the service provided. EVIDENCE: Service user care plans, which were drawn up on admission, were seen to be comprehensive but had become out of date and no longer accurately reflect current service user needs. Risk assessments relating to specific needs were seen and these also need to be updated. The involvement and attentions of various health care professionals was evident from the care plans, including district nurses, general practitioners, dieticians, opticians and occupational therapists. The manager confirmed that service users also go out to appointments for dental or chiropody treatments. Medication administration records and storage facilities were examined and were seen to be managed appropriately. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 10 Staff were seen to interact with service users appropriately, to treat them with dignity and respect and positive relationships were evident. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14. Service users were satisfied with daily life in their home and enjoy the external activities that they attend. All service users maintain contact with either friends or family, attend a variety of local community facilities and are helped to exercise choice and control over their lives EVIDENCE: Service users spoken to expressed satisfaction with the service provided and of their enjoyment of activities, both in house and externally, although frustration with individual physical limitations was expressed by a service user. Service users confirmed that friends and family are welcomed in the home. Where service users are able they accompany staff on shopping trips to help make selections. All have been consulted regarding colour schemes for redecoration planned shortly and are involved in service user meetings to express views and choices, for outings or holidays for example. Care plans do not record service users current preferences, religious, cultural or recreational interests and needs. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. A complaints procedure is available in an easily understood format and service users and staff know who to speak to if they have concerns. EVIDENCE: Service users spoken to confirmed that they knew how to make a complaint and who they should speak to if they were worried in any way. Staff spoken to stated that they were aware of the whistle-blowing policy and had attended training for the Protection of Vulnerable Adults (POVA). Required vetting checks for staff were seen to be in place. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The standard of the environment is good, providing service users with an attractive and homely place to live. EVIDENCE: A tour of the home was undertaken and it was seen to be well maintained, comfortably furnished and homely in style. It appeared clean, tidy, fresh and hygienic. A very small number of areas requiring improvement, have been identified and the manager stated that plans are in hand to redecorate the home in the near future. The rear garden is accessible via a door and a ramp from the lounge and the garden is safely enclosed with a secure gate. Each service user bedroom is fitted with a wash hand basin and sufficient toilets are provided within easy reach. The bathroom has recently been refitted with a specialist bath with spa system, integral hoist and cleaning system. A wheelchair accessible shower room is also available. Specialist equipment that is required has been obtained and some of these items were seen in use. Service user’s bedrooms have been personalised with Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 14 pictures, photographs and other items and a service user willingly showed me his room. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30. Only one member of staff was at the home at the start of the inspection. Staff working at the home are employed by the North Surrey Primary Care Trust, who also undertake recruitment. A variety of appropriate training has been accessed for staff. EVIDENCE: It was of concern that one member of staff was left alone in the home with service users at the time of the inspection. Staff personnel files were seen to contain most of the required documentation, including appropriate checks to protect the service users. One file for a longstanding member of staff did not have photographic evidence of identification. Training records were seen and covered courses including food hygiene, Protection Of Vulnerable Adults (POVA), medication administration and fire procedure refresher training. Staff spoken to confirmed attendance at the training. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 36 and 38. The home manager, who has run the home for a number of years, supervises the staff and has created an open, positive and inclusive atmosphere. Procedures are in place to safeguard service user’s financial interests. The health, safety and welfare of the service users was not fully safeguarded at the time of the inspection. EVIDENCE: The manager stated that she had run the home for more than five years and her approachable and inclusive manner towards service users and staff was seen. An effective system of managing and recording service user’s finances is in place. This was checked and the amounts present found to be correct. Two signatures are required for each entry and were seen to be recorded. Supervision of staff is undertaken by the manager and a small number of supervision records were seen, but others were unavailable. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 17 With regard to the health, safety and welfare of service users, as mentioned at Standard 27, it was of concern that only one member of staff was present in the home at the start of the inspection, although the manager and another staff member returned shortly after. Risk assessments are required in respect of specialist equipment in use, particularly electrically operated equipment. Other risk assessments, for activities for example, were out of date and need to be reviewed. A hazardous substance was seen to be stored in a service user’s bedroom, and this must be kept in a locked provision. Control of Substances Hazardous to Health (COSHH) sheets must be stored with the products to which they refer. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x 3 2 x 2 Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 19 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 7 Regulation 15 Requirement The service users plan must be kept under review and after consultation with the service user, the plan must be revised and the service user advised of any revision. Having regard to service users needs, they must be consulted about their social interests and this to be recorded in their individual plans. The care home must be conducted so as to ensure proper provision is made for the care and supervision of service users. The registered person must ensure that persons working at the care home are appropriately supervised. The registered person must ensure that all parts of the home to which service users have access are so far as reasonably practicable, free from hazards to their safety; that any activities in which service users participate are so far as reasonably practicable free from avoidable risks; unnecessary risks to the health or safety of service users Timescale for action 10 June 2005 2. 12 16 10 June 2005 3. 27 12(1)(b) 18 April 2005 4. 36 18 10 June 2005 20 May 2005 5. 38 13(4)(a)( b)(c) Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 20 are identified and so far as possible eliminated. 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 Good Practice Recommendations No recommendations were made at this inspection. Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dehnlea Rose H58 S13624 Dehnlea Rose V220596 180405 Stage 4.doc Version 1.30 Page 22 - 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. 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