Inspection on 24/10/05 for Dene Place Nursing Home

This inspection was carried out on 24th October 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

Dene Place Nursing Home 04/06/07

Dene Place Nursing Home 04/07/05

Dene Place Nursing Home 25/11/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Dene Place Nursing Home Ripley Lane West Horsley Leatherhead Surrey KT24 6JW Lead Inspector Mavis Clahar Announced Inspection 24th October 2005 09:00 X10015.doc Version 1.40 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 Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 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 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. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dene Place Nursing Home Address Ripley Lane West Horsley Leatherhead Surrey KT24 6JW 0113 381 6100 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) buysmupa.com BUPA Care Homes Limited Marie Buys Care Home 32 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (32) of places Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 32 beds providing nursing care for elderly people from the age of 60 years. One of the older people accommodated may be in the category DE(E) Date of last inspection 4th July 2005 Brief Description of the Service: Dene Place is owned and operated by BUPA who are the Registered Providers. The home is a large period-detached house situated in grounds owned by the National Trust, surrounded by farmland, in a village location in Leatherhead Surrey. The home benefits from a large well-maintained garden with wheelchair accessible path that runs along the out side of the house. The home provides nursing care for thirty-two service users. There are good road links but the home is not well served by public transport. Accommodation is usually provided in single bedrooms, a proportion of which has en-suite facilities. The home has five bedrooms, which are available for double occupancy, or in the event of a couple wanting to share. The home is furnished and decorated to a high standard. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection to be undertaken in the Commission for Social Care Inspection year March 2005 to April 2006. This announced inspection took place on the 24th October 2005, and lasted for five hours. The home received an unannounced inspection on 4th July 2005. Mrs Alison Walron a Registered Nurse with many years nursing experience has been appointed manager for the home and has been in post since 12th September 2005. The inspector noted that this inspection was well advertised in the home, and this was supported from the generous amount of pre inspection questionnaires returned from relatives, visitors and visiting professionals to the home. The inspector would like to thank everyone for all their comments, which enabled her to make a thorough inspection of the home. The first part of the inspection was spent touring the home, speaking with service users and staff. It was noted that fluids and the call bells were out of reach of the service users, but staff very quickly rectified this. On a whole the service users were happy with the home but two service users expressed some dissatisfaction. This was later discussed with the Manager and the deputy manager and the service user was reassured in the presence of the inspector that changes would be made to her bedroom as soon as the care taker was free. The manager immediately to the satisfaction of the service user dealt with the other concern. The second part of the inspection was spent reviewing service users care records which were all up to date and providing a good level of information about the individual to allow care workers to give the appropriate care to the service users. This was followed by the inspector giving feed back to the manager about the findings of the inspection. What the service does well: Good assessment and documentation of service users care needs from which the care plans are drawn with the cooperation of the service users. The inspector observed good interaction between the care workers and service users, which was respectful but not intrusive. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 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. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 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 the following standard(s): Standard 6 does not apply to this home. EVIDENCE: Standard 1 2 and 3 were assessed on the last inspection. For information on these standards please refer to the report of 4th July 2005. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 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 the following standard(s): 10 Evidence gathered demonstrated this standard is well met. EVIDENCE: Speaking with service users and from the results of the pre inspection questionnaires it was evident that the home place service users privacy and dignity in high esteem. The inspector noted that care workers knocked on service users doors and asked permission before they entered the service users bedrooms. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 13 Service users links with their family and the community is good and this enriches their lives. EVIDENCE: Service users informed the inspector that they have regular contact with their families. One service said “my daughter lives in the midlands and she comes regularly once per week to visit me”. Another service user informed the inspector “my son comes regularly on a Monday, but I will not be getting dressed up for him”. The Manager informed the inspector that one service user has formed a friendship with a local villager and regularly goes to tea in the village. Relatives sometimes take service users out to lunch and to visit Wisley. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 16 Service users are confident their concerns are listened to and acted upon. EVIDENCE: The home has a robust complaint procedure, which is closely adhered to. One complaint was documented in the complaints log since the last inspection and this was dealt satisfactorily with within the complaints procedure time frame. During the inspection a service user raised a concern about the rearrangement of her bedroom, and this was discussed with the service user and plans agreed to rearrange the bedroom again so that the service user would not loose the view she had come to enjoy from her window. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 26 Continuous improvement in this home has maintained the appearance of this home creating a comfortable and safe environment for the service users. EVIDENCE: The home is clean and tidy and appears well maintained. There were no offensive odours present at the time of inspection. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 13 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 All grades of staff are not yet up to date with moving and handling. EVIDENCE: It was noted from the training matrix that the majority of the Registered nurses were have not yet completed their yearly update on moving and handling. The inspector was informed that the manual handling coordinator was aware of this and that dates are being discussed. Food hygiene, COSH, Health and Safety, POVA abuse, First Aid and Fire training are all up to date. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 14 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 38 The new manager is supported well by senior staff in providing clear leadership throughout the home, with all staff spoken to demonstrating an awareness of their roles and responsibilities. EVIDENCE: The home does not become involved with service users finance. All service users in this home have undergone pre admission assessment to ensure the home is able to meet the assessed care needs of the service users. The home uses the minimum data set to assess, identify and plan nursing care needs. Risk assessments are carried out as required with documented guidance on how to minimise the risks. The inspector was informed that communication between service users and carers is an ongoing process in the home as service users views are highly valued, sought and acted upon. Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 15 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Dene Place Nursing Home DS0000017607.V250080.R01.S.doc Version 5.0 Page 16 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard 8 8 Good Practice Recommendations Jug with water and a glass should be placed within easy reach of all service users. All service users must have easy access to nurse call bells at all times. 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