Inspection on 04/07/05 for Dene Place Nursing Home

This inspection was carried out on 4th July 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 24/10/05

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 Unannounced 4 July 2005 @ 9:00am th 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. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Marie Buys CRH - Care Home 32 Category(ies) of DE(E) - Dementia over 65 (1) registration, with number OP - Old Age (32) of places Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - 32 Beds providing nursing care for the elderly people from the age of 60 years. 2 - One of the older people accommodated may be in the category DE(E) Dementia over 65 years. Date of last inspection 25th November 2004 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 house. This establishment provides nursing care for up to 32 service users. There are good road links, but the home is not well served by public transport. Accommodation is generally provided in single rooms, 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 toshare. The home is furnished and decorated to a high standard. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection to be undertaken in the Commission for Social Care Inspection year 2005/2006. This unannounced inspection took place on the 4th July 2005 and lasted for over six hours. None of the staff, service users or management knew of this inspection. The inspector spent the first part of the visit in discussion with the manager, checking the requirements of the last inspection, perusing service users and staff files, and home records. The second part was spent speaking with service users and staff and touring the home and gardens, followed by feedback to the manager on the findings of the inspection. The home has been going through a period of refurbishment, which enhances the lifestyles of the service users and those visiting the home. All records reviewed were found to be up to date and in good order. Service users care plans were found to provides good level of information about each individual and care workers said this enabled them to give the care the service users wishes. What the service does well: What has improved since the last inspection? Newly appointed administrative support for the home in the post of bursar has been helpful to both service users and staff. The old nurses call bell system has been replaced by a more up to date and modern system. Painting the shed and planting of creepers along the area to beautify the shed have improved the view from the windows of service users bedrooms facing the main road. New garden furniture has been bought and installed in the Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 Page 6 gardens. The home has now issued new contracts to service users, which includes the regulatory role of the Commission for Social Care Inspector. A programme of refurbishment has taken place at the home to include the boardroom, the activity room, bedrooms 1 2 and 14 with new carpets, curtains and furniture. A new refrigerator has been purchased for the kitchen to replace the old one; also a new cooling system has been installed in the kitchen to promote the health and safety of the Chef and kitchen staffs. Five new wheelchairs and new profiling beds have been purchased for the use of service users, plus new clothes containers have been purchased for the laundry room. 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 H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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 Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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 2 3 There is clear and consistent assessment of service users’ care needs in place to adequately provide care workers with the information they need to satisfactorily meet the service users’ needs. EVIDENCE: The Statement of Purpose is in need of updating in line with the amended Care Homes Regulations 2001, to include the requirements of Schedule 1. The home now has the new service users contract, which is more comprehensive and contains the confidentiality clause relating to the regulatory role of the Commission for Social Care Inspector. Review of service users files demonstrated that pre assessment of service users needs are carried out prior to admission into the home. From the full assessment it was seen that service users social, health and cultural needs are assessed and documented. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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. Care workers and service users share a close and respectful relationship. This has been evidenced by the positive interaction observed by the inspector. EVIDENCE: The service users files looked at by the inspector revealed full assessment of needs were undertaken, and service users are involved in deciding the care needed to meet the identified needs. Care plans are dated and signed both by night and day staff. Generally the views of the service users spoken to on the day of inspection were that they felt the staff listen and act on their wishes and that they were treated with respect. Review of service users’ medication charts demonstrated that medication was administered at the times stated. Medication Record Sheets are signed and dated. Service users spoken to confirmed they received their medication at the due time. It was also noted that medications entering the home are signed and dated. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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 standard(s) 12 14 15 Social activities and meals are both well managed, creative and provide daily variation and interests for service users. EVIDENCE: A number of service users living in the home were spoken to and every one said how good the food is and that they welcomed the daily choices. Samples of the menus were reviewed and were found to be balanced and interesting. Mealtime’s arrangements are also flexible to accommodate service users’ preferences. The home employs two part time activities coordinator who covers the week. Activities are varied and not compulsory. One service user spoken to and his activity file supported his statement “I would rather observe than take part”. On the day of inspection service users were observed doing crossword puzzles and some were playing scrabble. There was a lot of laughter and bantering in the room, which the inspector interpreted as contentment with their surroundings and the staff. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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 standard(s) 16 18 Service users are confident that their concerns are listened to and acted upon. All staffs have undertaken training in protection of Vulnerable Adults. EVIDENCE: Service users spoken to said they were confident they could make a complaint should they wish to do so and that they would be treated fairly. The home has a comprehensive complaints policy and procedure, copies of which are left on the table in the entrance hall for the use of service user and anyone visiting the home. A copy of the complaints procedure is also included in the service users guide, which is in each service users bedroom. On this inspection the complaints record book showed one complaint was received in the home since the last inspection and this was resolved within the complaints policy timescales. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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 standard(s) 19 20 21 22 Continued improvements to the home and gardens have provided service users with a safe and comfortable surrounding which is pleasing to visitors to the home also. EVIDENCE: The home and gardens are well maintained and with the recent investment service users are assured of a safe and comfortable home indoors and out doors. One service user spoken to say she enjoys the garden in the summer months and usually tries to go outside most days but not today as it is raining. The home provides suitable toilets and washing facilities for the comfort of the service users. The home has recently bought a number of new wheelchairs and profiling beds for the comfort of the service users and care workers. The home has a passenger lift installed which is serviced on a regular basis. Service records of Hoists lift; wheelchairs and assisted baths are all up to date. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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 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) 27 28 29 The procedures for the recruitment of staff are robust and provide safeguards to offer protection to service users. The deployment of staff on the day of inspection appeared satisfactory to meet the needs of the service users. EVIDENCE: All staffs at the home have been POVA checked and 95 have had their CRB check completed. A random review of staff files demonstrated the home complies with the Care Home Regulation 2000 requirements on staffing in the home. On checking the staff rota it was shown that on a given twenty-four hour period an appropriate number and skill mix of staff adequately covers the home. The home has recently updated the recruitment and selection policy that sets out clear guidelines on recruitment and retention, and principles of fair employment based on the Equal Opportunities Policy. The inspector viewed letters of declaration from three agencies declaring that all staff referred to this home has been POVA checked as suitable to work with Vulnerable adults and are also CRB checked. The home operates a training matrix from which it was evident what courses staff had attended and when staffs were due for updates. Review of staff files supported the information contained in the matrix. Staff spoken to supported the information contained in their training records. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 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 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 33 The home benefits from strong leadership; with good guidance and direction to staff to ensure service users receive consistent quality care. This results in practices that promote and safeguard the health, safety and welfare of the service users EVIDENCE: The registered manager, who has completed the registered manager’s award course, is a registered nurse who understands the disease processes associated with old age runs the home. The manager complies with the Code of Practice published by the General Social Care Council, setting out standards expected by persons employing social care workers. Staffs spoken to on the day of inspection were unanimous in their comments about the manager, saying she operates an open door policy and they felt able to approach her. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 Page 15 The home operates a yearly self-monitoring system using an objective and verifiable method of quality assurance system involving service users and relatives. This is achieved through an internal audit conducted by an independent firm of auditors. The results of the march 2005 survey has recently been received and shows a marked improvement on last years result. Service users and relatives satisfaction with the service went up by 26 . Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 Page 16 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 2 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 3 x x x x x Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 Page 17 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 1 Regulation 4 Requirement Statement of purpose to be updated in line with the requirements of the amended Care Homes Regulations 2001. Timescale for action 4.10.05 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 reccommendations were made on this inspection. Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 Page 18 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 Dene Place Nursing Home H58 H09 S17607 Dene Place V225722 040705 Stage 4.doc Version 1.40 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!