Inspection on 05/12/05 for Denmark House

This inspection was carried out on 5th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Denmark House 26/11/07

Denmark House 21/06/06

Denmark House 08/06/05

Denmark House 17/11/04

Denmark House 15/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Denmark House 36 Denmark Road Gloucester Glos GL1 3JQ Lead Inspector Mr Peter Still Unannounced Inspection 5th December 2005 13:30 Denmark House DS0000016423.V264946.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 Denmark House DS0000016423.V264946.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. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Denmark House Address 36 Denmark Road Gloucester Glos GL1 3JQ 01452 383888 01452 383888 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) Cathedral Care (Gloucestershire) Limited To be Appointed Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 08/06/05 Brief Description of the Service: 36 Denmark House is a detached Victorian House within walking distance of Gloucester city centre. The home is owned by Cathedral Care (Gloucestershire) Ltd. The home provides accommodation to nine residents with a learning disability who may also challenge the service. Some residents have autistic spectrum disorders. All residents have single rooms, some with en suite facilities. There are spacious communal areas, and large gardens to the rear of the house. The home has a car and a people carrier at its disposal. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three hours. Six residents at the home were spoken with and three members of staff. The senior care worker provided confident and helpful support to the inspection. A tour of the building was completed and some bedrooms were seen. The office for the home was locked and staff did not have the keys so the inspector was not able to see all documentation but did review some key records held in a cupboard in the dining room. The home is reminded that documents required for inspection must be available to the CSCI at all times. What the service does well: What has improved since the last inspection? What they could do better: The home currently had an acting manager and registration will need to be pursued. Team building may be needed to support the transition period. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 6 It was most unusual to find a locked office and the reasons for this will need to be explored since the inspector considers this may be an indicator of lack of trust. Staffing level arrangements must always ensure sufficient staff are available to meet the needs of residents and that staff will not have worked long hours, which may lead to a mistake being made. The acting manager responded to environmental issues identified immediately. 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. Denmark House DS0000016423.V264946.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 Denmark House DS0000016423.V264946.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): 2 Full documentation concerning a comprehensive pre admission process for residents must be available for inspection to ensure review can be undertaken. EVIDENCE: Documentation concerning the admission process was not available to the inspector. The office was found to be locked and when asked, staff said all staff had been told to hand their keys back and that they would not have access to the office or computer. It was likely that a number of documents, which should have been reviewed at the inspection, were in the office. The home currently had one vacancy and it was understood a new resident would be admitted after Christmas. Denmark House DS0000016423.V264946.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, 7 Care plans must be regularly reviewed to ensure needs are met and care planning should be developed. Storage of documentation needs to improve. EVIDENCE: A daily communication book was well recorded. Two Care plans were seen, they were not being reviewed every six months and key workers need to keep these up to date. Care planning needs to be expanded to ensure personal goals and changing needs are reflected in more detail and that there is more evidence about consultation with residents to ensure evidence of choice and decision making to enhance quality of life. The care plan storage files need to be reviewed since they were not working properly and sections were falling out and did not provide ease of reference or use. Two residents knew who their key workers were and talk to them about their needs and concerns. A new member of staff said that at their induction, they had been asked to spend extra time reading care plans to be fully aware of residents need and this was considered to be an excellent step. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 10 Denmark House DS0000016423.V264946.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): 13, 14, 17 Transport must be satisfactory to ensure residents can benefit from a range of leisure activity and local community involvement. Staff must have sufficient time to ensure food can be obtained for the home. EVIDENCE: Whilst residents have access to a car, the main large vehicle has a current steering problem and staff have reported safety concerns. The matter had been raised with the proprietors but had not been responded to, however staff said the new manager is talking to the proprietors about it. Whilst it may be better for residents to use an ordinary car to go out in, staffing is not sufficient to ensure they can benefit from activity or trips out as much as residents may wish. The consequence of not using the large vehicle has been a significant reduction in residents being able to go out and action should be taken to resolve this. One resident talked about being happy at the home and of enjoying the Kingfisher club and drawing, another resident goes out on their own a great deal. A resident from the adjacent home was relaxed and enjoying socialising with residents and was supported by his/her member of staff. During the inspection a group of residents were content as they played a game with staff Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 12 and other residents were either in their bedrooms or lounge, where the inspector observed a potentially difficult situation between two residents very successfully diffused. The member of staff was seen to be sensitive and calming yet confident, which appeared to help the residents feeling of security and staff should be commended for their skill. One resident was observed fully involved, helping to prepare the tasty looking evening meal with fresh vegetables. The inspector was concerned that the freezer and fridge contained very little food and asked questions about this standard. There had been a staffing shortage during the morning and the resident from the adjacent home had needed to come over to Denmark House whilst the member of staff made a quick visit to shops to get food for the day. Normally a complete food shop would have been done on the day of inspection but staff shortage had prevented this. Enquiries about money available for food found that a sum of £330 was provided by the proprietors each week to cover all house hold expenses and activity for eight residents. It was understood this money had not increased within the last three years. Unfortunately due to the difficulty with transport and the need to ensure residents attend their planned activities, on one week £60 of the allowance had to be used to cover taxi fares, resulting in less money available for residents. This will need to be considered further. The home has an excellent area for use as a sensory room. It did not look as if it was being used and staff confirmed this. It will be recommended that this valuable resource should be reviewed to see if new ways could be found to encourage residents to take advantage of it. Denmark House DS0000016423.V264946.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): 19, 20 Greater depth within care plans will increase the home’s ability to promote physical and emotional needs. Systems for the administration and control of medication protected residents. EVIDENCE: Further work with care planning and the development of the key worker role would enhance resident’s physical and emotional needs and provide greater protection. Continuity of care plans was raised at the last inspection. At this inspection, staff spoke of a need to reinforce the importance of staff continuity in the way they work together with residents. It may be helpful to consider this at a staff team meeting. Re establishing the sensory room may help promote residents physical and emotional needs. The senior carer was confident with the process of medication and clear about its administration. A number of points were identified at the last inspection, which required action and the senior carer was able to demonstrate how they had been responded to. The stock for one ‘as required’ medication was checked for one resident and the balance of tablets remaining was correct with the recording sheet. Stock levels of medication were being maintained at a low level. Creams and liquids held in the locked dining room cupboard had not Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 14 been dated on opening and must be but an eye ointment held in the fridge was dated correctly as 10/11/05. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 15 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, 23 More evidence is required concerning resident’s views, having regard for the standard. Staff need to have reinforcement training concerned with adult protection to ensure residents are safeguarded. Documentation concerning regulation 37, complaints and incidents must be available for staff to access. EVIDENCE: Development of care planning and the role of the key worker will help to ensure more evidence is available to show residents views are listened to and acted upon. Quality assurance is a key aspect of this standard and was not seen, it may have been in the locked office and this will need to be reviewed at the next inspected. Documentation concerning incidents and regulation 37 was not available and possibly held in the office. The complaints log was also understood to be in the office. All these items must be readily available to staff. Staff were not able to confirm when they had last received reinforcement training concerning protection of vulnerable adults and this must be provided. The inspector was impressed with staff responses to the protection of residents and it appeared that they knew the steps to take if they had a concern The last inspection indicated there would be training concerning the management of challenging behaviour. Staff spoken with were not aware it had been provided and this should be pursued. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 16 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, 30 Residents enjoy a clean homely and comfortable environment. Following the inspection there was an immediate response to confirm resolution of a small number of environmental issues, to protect residents and staff. EVIDENCE: The home was clean and tidy and residents bedrooms had been personalised. The senior carer confirmed that since the last inspection all bedrooms had been decorated and that residents had been involved. The large welldecorated kitchen was organised and clean. Resident’s help or work in the kitchen and this is a valuable resource. The dining room was also well used. The last inspection noted two smaller sofas beginning to sag and that they should be replaced. This had not been undertaken. The senior carer showed the inspector window restrictors, which had been replaced since the last inspection. Externally, the drive to the front of the property was muddy as building work behind the home was in progress. At the rear of the home, portable fencing had been erected and two sections of this were very wobbly and could have fallen on residents or staff. A third section was on the ground and may have caused a hazard. A hosepipe led Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 17 from the rear of the home to a new brick wall and was seen off the ground and taught and may have caused a trip hazard. Internally, an intermittent strip was missing from a resident’s fire door. These items were made the subject of immediate requirements and the inspector was pleased to have an immediate response from the acting manager to confirm the matters had been dealt with. It was noted that staff at the home were very busy and that builders called asking for coffee. The senior carer was observed to respond well by saying that he could not oblige. The acting manager said she would talk to the builders. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 18 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, 33, 36 Details of staff training were not available for review. Evidence seen by the inspector indicates there is tension in the home between staff and management, and the acting manager, supported by the responsible individual, will need to work swiftly and positively with staff to ensure residents continue to be protected. EVIDENCE: Staff do not hold their own qualification, training and supervision portfolios and it was understood the information was in the office and not available. This will need to be inspected on the next visit. Staff on duty were clearly confident and concentrating on the needs of residents, who responded well. One member of staff said the staff team, work well together and “residents are 100 safe without doubt.” Staff spoken with did not provide detail about the previous manager leaving but it was clear to the inspector that staff had found the transition difficult so far. This often happens where there has been a change of manager and the acting manager will need every skill as well as support from the proprietor to ensure staff retain the clear commitment and enthusiasm they expressed. Team building may be helpful in an environment of frank and open discussion. During the inspection, staff gave balanced responses to questions and were both positive and honest to ensure points made, put the residents first. It Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 19 appeared to the inspector that the acting manager has a good team of staff to support her work. Staffing levels were insufficient. It was said that it was due to staff on maternity leave, holiday and sickness. During the inspection, staff at the adjacent home had a difficulty with medication, which had not been ordered and support was requested twice. Whilst it may be valuable for the resident from the adjacent home to have social contact with other residents, she/he should not be required to come to the home to ensure sufficient staffing. These points exacerbated the staffing difficulty, as did the need to ensure food was available. The acting manager responded to the staffing issue immediately following the inspection, confirming it would not happen in future. A requirement will be made that adequate staffing is always maintained. The inspector was concerned that the senior carer had been on duty from the afternoon of 03/12/05 until 07:00 on 06/12/05. He said he was happy to undertake the hours and his commitment was commendable to ensure staffing. Staff working long hours may make a mistake and the acting manager must ensure a robust system to check the rota and that good communication enables her to call in other staff or seek external support in good time. The acting manager will need to review the number of senior staff to ensure sufficient experienced staff on duty. The inspector questioned the number of qualified staff able to undertake a senior role and understands there were only two staff. This will need to be considered further. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 20 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, 39,42, 43 The home was moving through the transition of management and difficulties were evident. The sound leadership and management approach will need to be evidenced as the new manager becomes established. Quality assurance review will be needed, taking account of residents, their supporters, others important to them and staff views. Health and safety was mainly adequate. EVIDENCE: Evidence in this report identifies shortfalls in management ensuring a well run home with a management team aware of the issues and demonstrating engagement and ability to actively listen to staff and working together to move the home forward. Evidence for this was not seen and will need to be demonstrated. The standards and requirements within this section will need to be carefully considered so that the next inspection can easily identify good practice. It was recognised that the new acting manager is only just in post and that time is needed for the above points to be developed to provide good evidence. The expectation will be that the next inspection will provide a fully positive appraisal with evidence on these points. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 21 The acting manager responded to environmental issues identified immediately. The Fire log in the dining room cupboard was dated 2004 and it was understood that the up to date record was in the locked office. This must be available for inspection on the next visit. The fire alarm system record of tests was available and the last entry found was for 25/10/05 and needs to be brought up to date. Since it was not possible to review all elements within the requirements and recommendations of the last inspection, they will need to be revisited at the next inspection and it will be helpful if the responsible individual can check the points from that inspection to ensure they have all been responded to. Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 22 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 2 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 2 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 2 X X 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Denmark House Score X 2 3 X Standard No 37 38 39 40 41 42 43 Score 2 2 2 X X 2 2 DS0000016423.V264946.R01.S.doc Version 5.0 Page 23 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 2 3 4 Standard YA43 YA32 YA23 YA8 Regulation 12 (5) (a) 18 (1) (i) 13 (6) 12 (3) Requirement Support the manager and staff through the transition of management. Provided staff with training concerning behaviour, which challenges the service. Provide reinforcement training on adult protection. Conduct quality assurance to gather views on the way the home is run from residents and all others important to them. Ensure adequate staffing is always available to meet the needs of residents. Ensure transport is safe and residents are able to engage in activity in accordance with their care plan. All required records must be available to staff and for inspection Care planning to be developed with regular review. Timescale for action 20/01/06 26/05/06 26/05/06 28/04/06 5 6 YA33 YA13 18 (a) 16 (m) (n) 17 15 22/12/05 24/02/06 7 8 YA41 YA6 24/02/06 31/03/06 Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 24 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 YA14 Good Practice Recommendations Review the use of the sensory room to ensure best use is made of this facility Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Denmark House DS0000016423.V264946.R01.S.doc Version 5.0 Page 26 - 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!