Inspection on 07/08/06 for Denecroft

This inspection was carried out on 7th August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Denecroft 28/11/05

Denecroft 07/07/05

Denecroft 16/11/04

Denecroft 03/08/04

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Thorndene

Insight - Eastchurch

Southfields

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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 HOME ADULTS 18-65 Denecroft Denecroft 1 Denmark Road Guildford Surrey GU1 4DA Lead Inspector Helen Dickens Key Unannounced Inspection 7th August 2006 09:30 Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 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 Laura Newcombe 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.V307192.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The age/age range of the persons to be accommodated will be: 18 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 28th November 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 with a patio and vegetable garden, and car parking to the rear of the property. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to June 2007. The inspection was carried out by Helen Dickens, Lead Inspector for the Service. Lesley Cassidy and Jonathan Menachem, Senior Support Workers, represented the establishment. All the the key National Minimum Standards for younger adults were assessed on this visit. A full tour of the premises took place and the inspector met and spoke with all six residents. All members of staff on duty were also spoken with during the course of the inspection. A number of records and files were examined including residents support plans, recruitment files, and health and safety certificates. 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 staff for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? There have been a number of improvements since the last inspection and all the previous requirements have been met. The outstanding maintenance issues have been remedied, and the privacy screening for one bedroom window has been fitted and is excellent. Advice from the community pharmacist has been fully implemented and all staff have had medication training. The manager has completed her registration with CSCI. The home has reviewed its decision not to implement the recommendations of the fire Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 6 safety officer and further communications with the fire service have taken place; new evacuation arrangements have been made. All residents now have their own health action plans and therefore a better record of health needs and inputs is being kept. New guidelines have been drawn up for the administration of PRN (as required) medication to ensure staff are dispensing this in a consistent way. The bathroom and toilet upstairs have been refurbished with black and white tiling and non-reflective taps on the basin and bath. Most residents have had their rooms decorated and all have had new floor coverings fitted since the last inspection. The carpet and curtains on the stairs and upstairs landing have also been replaced. The back gate is no longer a thoroughfare for visitors which means the residents have better and more secure access to the terraced area. One resident with green fingers has grown (from seed) a number of vegetables which are now planted out in a small vegetable garden. Residents will be able to enjoy home grown tomatoes and runner beans, and admire the sunflowers which were about to bloom. The inspector noted the excellent standard of labelling of opened items in the fridge which improves food safety for residents. As the home has now increased its age range of residents, staff have been on a training course to enable them to be more knowledgeable on the needs and aspirations of young people. It was also noted that the home has introduced and are already using the new common induction standards which will become mandatory for new staff in September 2006. What they could do better: On the day of the inspection there were a few decorative matters which were waiting to be addressed and a requirement will be made in this regard. Staff recruitment and induction records need further work and the home must review the current number of staff on duty as recent staffing levels could compromise the quality of life of residents. The home must ensure that they have sufficient staff with NVQ2 or above as set down in the National Minimum Standards. The home should continue to monitor any gaps in the recording of medication administration and all residents should have a photo on their medication record as per the home’s policy; a recommendation will be made on this matter. The home should also review their current arrangements for menu planning and consider taking advice from a dietician on resident’s meals. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 7 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.V307192.R01.S.doc Version 5.2 Page 8 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.V307192.R01.S.doc Version 5.2 Page 9 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): 2 Prospective service users are admitted only on the basis of a full assessment. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The assessment of the latest resident to be admitted was thorough and was continuing during the initial weeks spent at the home. It included the need for personal support, social and behavioural needs and rehabilitation. Some of the other resident’s original assessments have now been archived but were examined at the inspection in July 2005 and found to be thorough, especially on sight and learning disability issues. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Resident’s assessed and changing needs are reflected in their personal plans and they are assisted to make decisions in their day to day lives. Residents are encouraged to be independent and supported to take risks. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All six support plans were examined and these showed a good overview and sufficient detail regarding resident’s support needs. 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 priority goals and plan. All residents have access to the inhouse SeeAbility rehabilitation worker, and some also have specialist help, for example from the ‘Behavioural Team’. All residents now have a ‘health action plan’ which is detailed under Standard 19. All residents have a key worker and one to one sessions with key workers are recorded and laminated, then added to the residents support plan. Residents were heard to be given choices by staff for example when they wanted to get up and what they would like to have for breakfast. Staff were Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 11 heard to deal discreetly with a resident who needed help with personal care, guiding them to a place which was more private. Residents appeared happy and contented and interacted well with each other and with staff. On Sundays residents are asked what they would like to eat for the coming week and each resident gets to choose their favourite meal on one day of the week. From the tour of the premises it was confirmed by staff that residents had chosen the colour schemes and décor for their rooms, and all had personal items making each room very individual . Residents had free access in the home and now also in the garden. The outer garden gate is now being locked and a notice asks visitors to use the front door. Residents were enjoying the improvements in the garden including the vegetables which one resident had grown from seed at adult education sessions. Staff had fitted ping pong balls to the tops of the vegetable support canes so that residents could feel the canes but not be injured by the sharp ends. Decisions taken by residents are recorded both on support plans and in residents meetings. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 12 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): 12,13,15,16 and 17 Resident’s take part in appropriate activities and are part of the local community. Family and friendship links are encouraged and resident’s rights respected. Residents are offered choice regarding meals and mealtimes. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents support plans demonstrated that residents participated in a variety of activities including adult education sessions and all residents have access to the SeeAbility rehabilitation worker. Certificates displayed in resident’s rooms, together with information in their support plans, showed the opportunities residents had had for learning both life and social skills. They were all encouraged to assist with personal and household tasks and the inspector observed residents helping with hoovering and tidying the kitchen on the day of the inspection. This home is on the edge of Guildford town centre and residents use local facilities including shops and restaurants, and the local theatres in Woking and Aldershot. Some residents were going to dancing Queen (the Abba musical) in Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 13 Woking the following day. They are now also booking for the Buddy Holly story. Resident’s support plans recorded residents needs with regard to relationships, and staff were knowledgeable on each resident’s family and friends. A good deal of effort has been made to enable residents to keep in touch with two past residents who now live else where but have left friends behind at Denecroft; the staff should be commended for this. Residents were observed to be treated respectfully by staff. The home has obtained privacy screening for one resident’s window which does not interfere with the view from inside, but prevents anyone from the outside looking in. Staff were seen to knock on residents doors and observed to interact well with residents. There were many examples of staff speaking to each other but then including a resident who unexpectedly joined in. There were no instances of staff ignoring residents and speaking only with each other. On Sundays residents each chose a favourite meal for one day in the coming week and the menu sheet stated whose choice it was on each particular day. Residents made their choice looking at picture cards showing a variety of foods. On the day of the inspection, residents had quiche and tinned spaghetti for lunch, and boil in the bag fish with potatoes and carrots for supper. Meals are taken in the conservatory overlooking the terrace and lunch was observed to be unrushed and relaxed. There were plenty of vegetables (kept in the fridge during the hot weather) and staff said residents had fresh vegetables every day. The home also buys ad hoc food items, and residents sometimes dine out or have takeaways. The inspector discussed the menus and food budgets both on the day of the inspection and the following day with the manager, and a recommendation will be made in this regard. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Residents receive personal support in the way they prefer and require and their health needs are met. Residents are protected by the home’s arrangements for administering medication. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal support at this home is offered in a sensitive way and staff paid attention to resident’s privacy and dignity. Residents were dressed in clothes which they had chosen and in the colours they liked. Each resident had a designated key worker to work with them. Personal support plans had a good record of each residents needs with regard to their personal support. Staff were observed to work in a flexible way with residents who could get up and go to bed when they wished, and had some choice about other routines in the home. Health needs are well catered for at this home and all residents have a health action plan in place. The newest resident has a health action plan in progress. On the day of the inspection two residents were being supported to visit their GP, and the following day another resident was being supported to Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 15 attend a hospital appointment. Health needs are monitored and particular attention is paid to resident’s eye health. Medication is well organised at this home and one staff member takes responsibility for the overall management including re-ordering. A new staff member interviewed had had practical medication training which included reading through the medication administration policy, observing medication being given, giving medication herself under supervision, and then finally a competency assessment. A record of medication training is being kept and when the up-dates are due. Staff were observed to secure the cupboard between the administration of each resident’s medication and heard to explain what was happening to each resident as they administered their medication. The medication administration policy, guidelines for re-ordering, and previous audits from the community pharmacist were on file. Guidelines for PRN (as required) medication has been introduced and this helps staff to support residents in a more consistent way with PRN medication. The home’s policy is to check medication records at the hand over each day, to ensure there are no unexplained gaps or to follow them up promptly; one gap over the previous weekend had not been picked up and the staff member responsible for medication was following this up. A recommendation will be made regarding all residents having a photograph on their medication record as the newest resident was without one, contrary to the home’s policy. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 16 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 Complaints are taken seriously and residents protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure has been adapted to suit resident’s 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. Residents also have documented one to one sessions with their key workers where concerns can be raised, and a record is kept with each resident’s support plan. Resident’s monthly meetings also give the opportunity to raise issues. The complaints log was examined and no complaints have been recorded since the last inspection. The home has its own policy and a copy of the Surrey Multi-agency policy was also in the home. No protection of vulnerable adults issues had been raised since the last inspection. Staff records checked showed that those who had been employed since July 2004 had had their names checked against the protection of vulnerable adults list. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 17 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 and 30 Denecroft provides a homely, comfortable and safe environment for residents. The home is clean and hygienic throughout. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s rooms at Denecroft are homely and accessible. The high ceilings at this home contribute to making the rooms light and spacious. The premises generally 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; most residents have had redecoration and replacement floor coverings in their rooms since the last inspection. The bathroom and toilet upstairs are being refurbished though this has yet to be completed with regard to some painting and floor coverings. Brushed steel taps have been fitted to the basin and bath to prevent reflections which can cause difficulties for those with sight impairments. The handwashing arrangements in the small toilet and bathroom upstairs had to be reviewed as disposable hand towels had previously been found blocking the toilet. The home now places hand gel in these areas and the Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 18 arrangements are being kept under review. One bedroom window which needed privacy screening has now had this applied and it is totally invisible from the inside so does not impede that resident’s view from their window. The premises are clean and free from offensive odours – the laundry was clean and tidy and had the appropriate facilities for the laundering of clothes. The washing machine has a sluicing programme and the floors are impermeable and therefore easy to keep clean. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 19 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): 32,34,35 and 36 Residents are well supported by current staff but more needs to be done to reach the minimum of 50 of staff with NVQ2 or above. Staffing numbers need to be reviewed. Recruitment is well organised though further work is to meet this standard in full. Resident’s needs are being met but a training and development plan needs to be completed. Residents benefit from having well supervised staff. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were observed to interact well with residents, who turned to them for assistance when needed. Resident’s communication needs were well documented and staff were knowledgeable on these. SeeAbility offers a range of training to ensure staff have the skills to meet resident’s needs including recent specialist training on working with younger people. Staff worked closely with the rehabilitation worker, and in line with support plans, to encourage and assist residents independence. Recently the home has lost three staff with NVQs and therefore the home now has only one NVQ trained staff member apart from the manager. Other staff are currently working towards NVQs and one new member of staff interviewed was keen to sign up. Recruitment is managed by theSeeAbility head office and generally well organised. Four files were sampled and found to be kept in good order; all Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 20 staff files had application forms, CRBs, (and those employed since July 2004 had a pova check), and two references. The home must ensure that all staff have a full employment history (one had a small gap) and the dates of previous employment should cite the month as well as the year of employment, in order that any gaps can be followed up. The staffing levels on the day of the inspection gave some cause for concern. Though residents were not placed in danger, their activities and supervision were restricted by the lack of staff. This was discussed with staff on the day and comments were made about the difficulty in fitting in all their tasks, as priority was being given to needs of residents. The next day the shortage was discussed with the manager – she said two new staff would be recruited after her holiday at the end of August – they were restricting the use of agency staff for cost reasons and agency staff cannot be used at night as they do not know residents well enough. A requirement will be made in this regard. SeeAbility do well on staff training and a good record of the training courses undertaken was available. Courses on visual impairment are compulsory for all staff. The organisation does particularly well on equality and diversity training and the following courses had been attended by staff; 1.Disability equality and human rights 2.Anti-discriminatory practice 3.Values and positive lifestyles 4. Meeting the aspirations of young people (including sexual needs and promoting the independence of younger people). The home has already started the common induction standards which are mandatory from September 06. The induction files of four staff were examined and feedback was given to the manager the following day regarding completing these in a timely fashion; two had not been completed in full despite staff being there for years, and the two recent staff had apparently not progressed very far – the manager said she had some practice observations to type up and it was clear that whilst the home is short on staff, residents have come first and some administrative work may have fallen behind. Staff supervision sessions are held regularly and well documented – most staff have monthly supervision which exceeds the National Minimum Standard of 6 times per year. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 21 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): 37,39 and 42 Residents benefit from a well run home. Quality assurance processes are good. The health and safety of residents is promoted. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager at Denecroft has now registered with CSCI and has experience in managing a in a care setting; she has also completed the Registered Managers Award. She has overall responsibility to ensure the home’s objectives are achieved and that it is properly managed. Quality assurance processes are good. Resident’s meetings give good record of resident’s input into activities; they have been held monthly so far this year and staff take notes as a record. The home are thinking about revising the format and perhaps videoing the meeting which could be played back to residents. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 22 Overall quality assurance is managed centrally by a Quality and Performance Manager at SeeAbility. An annual survey is sent to residents, relatives and care managers in the placing authorities; the collated responses are 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 which are documented on resident’s support plans; there is also an annual development plan for the home. A number of health and safety documents were examined; fridge and freezer temperatures were being recorded as were the temperatures of hot food just before serving. There were vehicle safety checks; both weekly and daily checks being carried out. A first aid box review form was completed and this included checking the box and replacing missing items and renewing those which were out of date. The weekly cleaning rota was seen – this included cleaning the fridges and worktops in the kitchen and checking the expiry of foods and bin all done weekly. Records of recalibration of fridge thermometers, and monitoring of water temperatures was also seen. There was an excellent standard of labelling of food items which had been opened and were being stored in the fridge. Since the last inspection the fire evacuation procedure has been reviewed in consultation with the fire service; the assessment team are coming out to arrange a gadget to enable one resident to hear the fire alarm more clearly. The hazardous substances cupboard was securely locked. The gas safety certificate check was on 5/05/06, and a Legionella safety certificate was dated 24/10/05. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 x Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 24 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 YA32 Regulation 19(5)(b) Requirement The registered person must take steps to ensure that sufficient numbers of trained staff (i.e. NVQ level) are employed within the home. A written statement regarding actions to be taken should be sent to CSCI by 7th September. The registered person must take steps to ensure that there are sufficient staff on duty to meet the needs of residents. A review of staffing levels must be carried out and sent to CSCI. The registered person must ensure that every staff member’s record contains a ‘full’ employment history as set down in the Care Homes Regulations. Dates must include the month, not just the year, when employment was taken up or changed. This should be done retrospectively for those staff whose records are incomplete. Any gaps must be explored and the outcome DS0000013625.V307192.R01.S.doc Timescale for action 07/09/06 2. YA33 18(1)(a) 07/09/06 3. YA34 19(4)(b) 07/09/06 Denecroft Version 5.2 Page 25 4. YA35 18(1)(c ) (i) documented. Confirmation that this exercise has been completed should be sent to CSCI. The registered person must 07/09/06 review all staff induction records to ensure they are complete and properly signed off. New staff induction records must be brought up to date as soon as possible. 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. 4. Refer to Standard YA17 YA20 YA24 YA35 Good Practice Recommendations The registered person should seek the advice of a dietician on the suitability of the current menus at Denecroft. The registered person should ensure that all residents have a photograph on their medication record as per the medication administration policy. The registered person should ensure the bathroom refurbishment is completed in a timely fashion for the comfort and enjoyment of residents. The registered person should complete the work on the the staff training and development plan. Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 26 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 © 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 Denecroft DS0000013625.V307192.R01.S.doc Version 5.2 Page 27 - 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!