CARE HOME ADULTS 18-65
Denecroft Denecroft 1 Denmark Road Guildford Surrey GU1 4DA Lead Inspector
Helen Dickens Unannounced Inspection 28th November 2005 01:00 Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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 Denecroft DS0000013625.V269517.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 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. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Denecroft Address Denecroft 1 Denmark Road Guildford Surrey GU1 4DA 01483 301315 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) denecroft@seeability.org SeeAbility To Be Confirmed Care Home 6 Category(ies) of Dementia (2), Learning disability (6), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Sensory impairment (6) Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The age/age range of the persons to be accommodated will be: 30 years to 65 years. The 6 (six) adults with learning disabilities (LD) accommodated may also have a sensory impairment (SI). Of those 6 (six), up to two may have an additional mental disorder (MD). Of those 6 (six) up to two named individuals may also Dementia (DE) Date of last inspection 7th July 2005 Brief Description of the Service: Denecroft is a large detached property situated in a pleasant residential area of Guildford. It is close to local facilities and amenities. The service provides personal care and accommodation for up to six adults with learning disabilities, visual impairment and challenging behaviour. The current residents are all female. All residents have single rooms, and some have en-suite facilities. The accommodation is on two floors and there is no lift to the upper floor, however, current residents do not require this at present. There is a terraced area and car parking to the rear of the property. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and a half hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the Service. Laura Newcombe, manager of the service, represented the establishment. Fewer Standards were assessed on this visit as most of the key Standards were assessed at the July inspection. A tour of the premises took place and the inspector met all residents and spent time with two in particular. Three members of staff were also spoken with. A number of records and files were examined, as were the results of the annual survey of relatives, residents and care managers. This was a positive inspection. The inspector would like to thank the residents at Denecroft for their extremely warm welcome and assistance throughout the inspection. She would also like to thank the Manager and staff for their time, assistance and hospitality. What the service does well: What has improved since the last inspection?
Most of the requirements and recommendations from the last inspection have been met including the finalising of the policy on ageing, obtaining the up-todate copy of the Surrey multi-agency procedures for the protection of vulnerable adults, and reviewing the call alarm systems within the home. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 6 Some decorative work has been carried out in the hallway, the stairs and landing areas, which improves the look of the premises. A new fridge/freezer has also been purchased for the kitchen. A new emergency situations folder has been devised which is outlined later in the report. The home have started their work on providing residents with ‘health action plans’ and one has been completed, with others in the pipeline. Some of these will be in a ‘talking’ format to suit each resident’s own particular communication needs. New communication and information methods are being devised for residents and the inspector was particularly impressed by the ‘talking photo album’ which is described later in the report. ‘Communication books’ are being compiled which each set out an area of independent living which residents engage in. For example, local shopping (with photos of the actual shops frequently used by residents), public transport and leisure activities. Residents feature in some of the photographs. 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. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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 Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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): EVIDENCE: Please see previous report. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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 and 9 Resident’s can be confident that their support plans reflect their changing needs and goals. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Three support plans were sampled and these showed a good overview and sufficient detail regarding resident’s support needs. As is the case in all SeeAbility homes in this county, there is a good level of detail and information on resident’s needs in relation to their eyes and vision. Plans also describe resident’s personal care support needs, communication needs, and their goals. All residents have access to the in-house SeeAbility rehabilitation worker, and some also have specialist help, for example from the ‘Behavioural Team’. It was noted that recommendations from one resident’s local authority Review in August had already been dealt with. Staff enable residents to take reasonable risks and there were numerous examples of resident’s being encouraged to be independent. Residents are encouraged to help with cooking and jobs in the house, and to go out into the local community with the appropriate support. Risk management strategies
Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 10 were in resident’s files. The need for additional risk assessments around the home was identified and this is highlighted under Standard 42. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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): 15 Staff support residents to maintain family and friendship links, and to make new friendships with people who do not necessarily have their disability. EVIDENCE: Staff at this home are knowledgeable about resident’s existing family and friendship links. One key worker gave a good overview of a resident’s large family network and friendships. A talking photo album had been devised and, at the push of a button, each photo is introduced by that person’s voice, giving a greeting to the resident. The key worker also described a new friendship which was developing with someone who does not have this resident’s disability. Staff were not aware of any intimate personal relationships but said these would be encouraged, with appropriate information and guidance. Residents are supported to take advantage of local community facilities such as pubs and restaurants and therefore it is more likely they will be able to make friendships outside the home. Staff consider resident’s friendships to be very important. One resident who had moved from this home to another some distance away was enabled to keep in touch with her friends from Denecroft. Resident’s enjoyed their visits to the other home as it meant they could travel by train which the manager
Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 12 said was very popular. Another resident may be moving in the short to medium term and plans for her to keep in touch with her current friends at Denecroft were already being considered. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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): 20 The administration of medication is well organised at Denecroft and resident’s are protected by the home’s policies and procedures. EVIDENCE: One member of staff has been given overall responsibility for managing the medication at Denecroft and it was observed to be well organised and methodical. All staff who administered medication had received training, and this is up-dated annually. The records of visits made by the community pharmacist were all on file and the recent inspection in October noted that the ‘medicines policy was excellent.’ Recommendations were made at this pharmacy visit which staff said are in the process of being actioned – most of these concern clarifying instructions with the GP. A Requirement will be made in this respect. During the CSCI visit the inspector asked if the home could provide written instructions for staff regarding the administration of ‘as required’ medications such as pain killers – this ensures residents will be given medication in a very consistent way. This guidance is best provided by the GP. There are no controlled drugs at this home. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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 and 23 Residents are safeguarded by the home’s policies and practices in relation to complaints and protection. EVIDENCE: The complaints procedure has been adapted to suit residents needs though the main way for resident’s to make complaints is direct to staff who understand their communication needs. This can be done on a daily basis to their key worker or any member of staff. Resident’s monthly meetings would also give the opportunity to raise issues. One complaint has been raised since the last inspection and the manager highlighted this and discussed it with the inspector. The home has now obtained the up-dated Surrey multi-agency procedures for the protection of vulnerable adults. The manager has been on the corresponding local authority course. One member of staff was asked about the actions to take in the event of an allegation being made and she knew that her own actions should be to make the resident safe, and immediately report it to her manager. She said she was also doing some more detailed work on this issue as the final unit in her NVQ2. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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 Residents live in a homely and comfortable environment. Some minor repairs need attention in order to meet this standard in full. EVIDENCE: Resident’s rooms at Denecroft are homely and accessible. There are no residents who need a wheelchair indoors but recently when one was required on a temporary basis, the ground floor was fully accessible to that resident. The high ceilings at this home make the rooms light and spacious. The premises are comfortable, bright and cheerful. Denecroft is clean and tidy, and free from offensive odours throughout. Furnishings are of a good quality and domestic in appearance. Residents have helped choose colour schemes in their own rooms, and in communal areas. The home is close to local facilities and amenities. On the day of the inspection there were some minor maintenance issues which needed attention. One bedroom door and the fridge had their handles missing and the handyman had been asked to repair these. One bathroom had sealant peeling off around the bath - the manager said this whole bath was being replaced, but not in the short term; therefore the peeling sealant needs to be repaired. The soap dispenser had fallen off the wall and was waiting to be put back. The small toilet upstairs needs to have the walls painted and the floor
Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 16 needs to be cleaned or replaced to remove paint which has been trodden into the floor covering. One bedroom window needed privacy screening and the manager was currently exploring the options. The outstanding issues on the fire safety officers recommendations and additional risk assessments will be dealt with in the final section. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 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): 35 Resident’s individual and joint needs are met by appropriately trained staff. EVIDENCE: The home has a training and development plan which is part of their general annual development plan. All staff take part in a structured induction programme, which includes an introduction to learning disabilities and visual impairment. SeeAbility provide equalities training to all staff which is called ‘Values and Positive Lifestyles.’ Trainers with visual impairments teach the ‘Disability equality and human rights course’ to staff. The manager said the training needs assessment has previously identified training which needed to be sourced externally, such as Makaton training, and training in dementia. SeeAbility have funded these courses. The majority of staff have either already got, or will have by December 2005, at least an NVQ2. The manager has just completed the Registered Managers Award. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 18 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 and 42 Residents benefit from the management approach of this home, and have a say in how the home develops. Health and safety are generally good but some further work is needed to meet this Standard in full. EVIDENCE: Resident’s benefit from a well run home and the current manager has just completed the Registered Managers Award. The home meets its stated purpose, aims and objectives. However, the manager must complete her application with CSCI and ensure that the home complies with the Care Standards Act and Regulations (37.3vi.) in order to fully meet this Standard. The ethos, leadership and management approach of the home creates an open, positive and inclusive atmosphere. The manager communicates a clear sense of direction and the processes for managing the home are open and transparent. The manger encourages staff to be creative and the new ‘communication books’ devised by one member of staff were a good example of this. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 19 Quality assurance is managed centrally by a Quality and Performance Manager. An annual survey is sent to residents, relatives and care managers in the placing authorities; the collated responses were available to be inspected. The home uses a number of other methods to get feedback from residents and this includes one to one sessions with key workers, and resident’s monthly meetings. There is an annual development plan for the home. There are many areas of good practice in relation to health and safety at Denecroft and it is considered everybody’s responsibility. The hazardous substances cupboard was locked and baffle handles have been fitted to the laundry doors. SeeAbility have reviewed their arrangements for emergency call bells and these will be purchased and fitted before the end of this financial year. There is currently a waking night staff member on duty to ensure the needs of residents are met at night. The home’s vehicle has weekly (and sometimes more frequent) maintenance checks, which are carefully documented by the staff member responsible for the vehicle. An emergency situations folder has been compiled by another member of staff which brings together actions and risk management strategies for the home’s most likely emergencies including fire, the night time checks which are carried out, the disaster recovery plan and emergency contact numbers. The kitchen was clean and tidy and fridge and freezer temperatures regularly recorded and within safe limits. The home records, on arrival, the temperature of frozen food which is delivered. Information on the safe storage of food within the fridge was provided for staff, and all items in the fridge were correctly stored. Cold meats, pates and spreads which had been opened were labelled and dated. Not every item of perishable food which had been opened was labelled and the home was asked to review this. The inspector noted a number of toiletries in the bedrooms and bathrooms and asked the manager to carry out risk assessments to identify potential hazards to resident’s safety, and to take appropriate action. It was also noted that hand washing facilities were not adequate in some areas. One soap dispenser had come off the wall, and a ‘communal’ bar of soap was being used. Another area had no soap at all. The laundry room had the ‘bag’ from the dispenser, but no dispenser. A member of staff said she went next door to get soap to wash her hands, as she didn’t like to the use the ‘dispenser’ soap. The manager was asked to review all the hand washing facilities. The issue regarding the fire officer’s recommendations has still not been resolved and the home has used a health and safety consultant to advise them. Negotiations with the fire service are continuing. A further requirement will be made in this regard. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 4 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Denecroft Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X 2 X DS0000013625.V269517.R01.S.doc Version 5.0 Page 21 Yes 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 YA24 Regulation 23(2)(b) Requirement Timescale for action 15/12/05 2. YA20 3. 4. YA37 YA42 5. 6. YA42 YA42 The manager must send an action plan to CSCI stating when the maintenance issues outlined in the report will be remedied. The action plan should include the bedroom and fridge door handles, the sealant on the bath, decoration of the upstairs toilet and removal of paint from the floor, and the privacy screening for one bedroom. 12(1)(b) To ensure correct treatment for residents, the home must act on the advice of the community pharmacist (14.10.05). 8(1) The manager must complete her CSA registration with CSCI as soon Section 11 as possible. 13(4)(a)(c) The manager must carry out risk assessments on the availability and storage of toiletries and other potentially harmful substances around the home. 13(4)(a)(c) The manager must review handwashing facilities as highlighted in the main report. 13(4)(a)(c) The home should review its decision not to implement the recommendations of the fire
DS0000013625.V269517.R01.S.doc 15/12/05 15/12/05 05/12/05 05/12/05 28/12/05 Denecroft Version 5.0 Page 22 safety officer and provide a risk assessment on this subject to CSCI. 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 YA5 YA20 YA42 Good Practice Recommendations The contracts between the home and each resident should be in a format which is accessible to each resident. The home should provide written guidance for staff on the administration of painkillers which are given ‘as required’. The home should date-label mayonnaise and sauces etc in the fridge, where these items have a time-limited use after opening. Denecroft DS0000013625.V269517.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office 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
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