Inspection on 11/11/08 for Denville Hall

This inspection was carried out on 11th November 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Denville Hall 02/11/09

Denville Hall 25/07/06

Denville Hall 09/02/06

Denville Hall 12/09/05

Denville Hall 01/03/05

Denville Hall 16/08/04

Denville Hall 02/02/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Denville Hall 62 Ducks Hill Road Northwood Middlesex HA6 2SB Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 10:40 11 & 18 November 2008 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Denville Hall DS0000010929.V373011.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denville Hall Address 62 Ducks Hill Road Northwood Middlesex HA6 2SB 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) 01923 825 843 01923 841 855 denvillehall@yahoo.com DENVILLE HALL (REG CHARITY NO. 209480) Julie Gladys Bignell Care Home 40 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (40), Physical disability (40) of places Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE maximum number of places: 15 2. Physical disability - Code PD The maximum number of service users who can be accommodated is: 40 25th July 2006 Date of last inspection Brief Description of the Service: Denville Hall is a large Victorian detached house, set in spacious grounds. The home provides both nursing and personal care for retired actors and people of affiliated professions. The home offers permanent and respite accommodation. 5 years ago the home was completely refurbished and a new dementia care wing built. The bedrooms are spacious and individually designed, each with an en suite comprising of shower, toilet and wash hand basin facilities. There are several communal rooms, providing a variety of usages, to include a library, drawing room, theatre room, green room, games room, relaxation room, art & crafts room, hairdressing salon, two dining rooms, two bar facilities, several sitting rooms of varying sizes plus conservatory and courtyard areas. The extensive external grounds are landscaped and well maintained, with a selection of seating areas. The home is situated within a short drive of Northwood town centre, where there are shops and restaurants, plus public transport links in the form of bus and underground services. The fees range from £590 to £900, dependent on the service users level of care needs. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 24 hours was spent on the inspection process. We carried out a tour of the home, and service user plans, medication management & records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 12 residents, 14 staff and 4 visitors were spoken with as part of the inspection process. The Annual Quality Assurance Assessment (AQAA) documents completed by the home, plus comment cards from residents, healthcare professionals and staff have also been used to inform this report. The Registered Manager was present for the inspection and the Responsible Individual also attended for the feedback session. What the service does well: Prospective residents are assessed prior to admission and on admission to ensure the home is able to meet their needs. Healthcare needs are identified and met, with evidence of input from healthcare professionals. Staff care for residents in a caring and professional manner, respecting their privacy and dignity. Several comments were received from residents who said that they are very well cared for at the home. The home has an open visiting policy and visiting is encouraged. Visitors can attend the home for meals and are made very welcome at the home. Information about advocacy services is on display in the home and each resident in the dementia care unit has an appointed representative. The meal provision in the home is of a very high standard, offering variety and choice and catering to individual needs. Complaints and safeguarding are well managed and staff have received training in safeguarding adults and are clear to report any concerns. The home was built to a high standard, providing the residents with a homely, safe and quality environment to live in. Infection control procedures are in place and adhered to. The home is well staffed to meet the needs of the residents and the home in general. Staff had received training in topics relevant to the diagnoses and needs of the residents, with more dementia training to take place. There are robust systems in place for the vetting and recruitment of staff. The Registered Manager has the qualifications and experience to manage the home and has a good understanding of her role and of the residents in her care. The home does not manage any monies on behalf of residents. Overall the systems in place for the management of health & safety are robust and protect residents, visitors and staff. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, to ascertain that the home is able to meet their needs. EVIDENCE: The home uses a pre-admission assessment document that provides a good picture of the resident and their needs, to include specialist needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed and were comprehensive and clear. The home does not provide intermediate care. It is acknowledged that residents can stay at the home for a period of convalescence, for example, following a holiday admission. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were up to date, however shortfalls in completion could place residents at risk of their needs not being fully met. Medications were being poorly managed and shortfalls identified could place residents at risk. Staff care for the residents in a gentle and courteous manner, thus respecting their privacy and dignity. Information for the wishes of residents and their families in respect of health deterioration and end of life care was incomplete, thus they are at risk of their wishes not being met. EVIDENCE: We viewed 5 service user plans in detail and 2 others for recording on specific topics. Since the last inspection the home has introduced the ‘Standex’ care planning system, and this has been in use for 5 months. A long term needs assessment is completed on admission and from this care plans are developed for specific needs. Some of the information viewed was brief and generalised. We discussed the need to ensure that the care plans reflect each individuals needs and are comprehensively completed, so staff have the information they need to deliver care effectively. Risk assessments for falls were in place and Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 10 there was evidence of falls being recorded and documentation being updated to reflect this. Some of the documentation had been signed by representatives, however it is important to involve the residents, or where they are unable to give input, their representatives, in the formulation and review of the service user plan documentation, so it reflects their wishes. Daily records were brief and needed expanding to provide details of the actual care provided and also to evidence specific instructions from healthcare professionals have been carried out, for example, physiotherapy. The home has separate documentation for respite care, and we discussed ensuring this also reflects each individuals care needs. Documentation had been updated monthly and when there had been a significant change in the residents’ condition. At the time of inspection there were no residents with wounds. Where a resident was prone to skin breakdown this had been clearly recorded. Risk assessments for pressure sores were in place. Pressure relieving equipment in use had been identified in the service user plan. Moving & handling assessments were in place, and overall those viewed reflected accurately the needs of the residents. Nutritional assessments were in place and there was evidence of regular weight monitoring. Care plans for continence needs were in place, and a new document in relation to continence care needs was obtained. The home does also have a continence assessment document and examples of these were seen. Information for the use of bedrails was brief and did not include a full assessment. Improvements in this area had been made by the second day of inspection and signed consents for their use were available. Risk assessments had been carried out for other risks identified. There was evidence of input from the GP, chiropodist, dentist, physiotherapist and fitness instructor. The Registered Manager explained that where they are able, residents are encouraged to attend the GP surgery as part of maintaining their independence. Some comment was received regarding ease of access to GPs and this was fed back to the Registered Manager in general terms. Medication management was viewed and records sampled. A list of specimen signatures and initials was available for registered nurses administering medications. Medications were being securely stored. Incorrect lancing devices for blood glucose monitoring were in use, and by the second day of inspection approved lancing devices had been obtained. On the medication administration record (MAR) charts gaps were noted in some receipts and administration of medications. Liquid medications and eye drops had not been dated when opened. Action had been taken by the second day of inspection to rectify some of these omissions. Where a medication had been omitted for a specific reason, the correct coding had been used. The home had introduced a monitored dosage system (MDS) for medications. In one instance the number of doses signed for did not tally with the stock still available. There was some confusion regarding the disposal of medications, and the home had been instructed to return medications to the dispensing chemist. No records were available of medications that had been returned to the chemist, and therefore it was not possible to audit medication stock control for ‘as required’ medications. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 11 Following the first day of inspection correct procedures for disposal had been put back in place. For residents going on leave medications are supplied for this period, however the quantity of each medication given and returned had not been recorded. Where a medication had been supplied mid-cycle, no balance had been carried forward to the new MAR in use. For medication to be given on some specific days of the week the blister packs had not always been filled to reflect this, although the entries on the MAR identified the correct days. We noted that staff were using medication supplied for one resident for another resident on the same medication as there had been a delay in ordering a new supply. Where a variable dose had been prescribed, the correct amount was being administered however this was not always clearly recorded. Controlled drugs were being correctly administered, recorded and stored. In the dementia care unit the fridge temperatures had been recorded as being above safe range on occasion, plus the room felt quite warm however no room temperatures were being recorded. This needs to be addressed to ensure all medication is stored at safe temperatures. The medication policy had been updated, however further updates were required to reflect the introduction of the MDS. By the second day of inspection the Registered Manager and Deputy Manager had carried out a full audit of medications and identified shortfalls so that action is now being taken to address these. The home must ensure that medication practices are robust and follow the medication policy, which in turn must reflect up to date legislation and guidance. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. Residents are referred to by their preferred term of address. Staff were seen knocking on bedroom doors before entering the room. Residents were smartly dressed to reflect individuality. Many positive comments were received regarding the high standard of care residents receive, and was clear that staff have a great respect for the residents in their care. The home has contact with the palliative care team and input has been provided to effectively care for residents in their final days. Information regarding the wishes of the resident and their families in respect of health deterioration had not been recorded, and there was only brief information available regarding end of life wishes. The need to ensure that the wishes of each resident and their families are ascertained and recorded was discussed and by the second day of inspection some work had been done in this area. Where someone does not wish to discuss this sensitive topic, then this should also be recorded and then it can be revisited at a later date, when they feel more able to discuss it. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the activities provision is good and varied, and each residents’ right to choose to join in is respected, thus meeting their individual needs and wishes. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is of a high standard, offering wide variety and choice, with resident’s choices being clearly ascertained and respected. EVIDENCE: The home provides a variety of activities to try and meet the interests of all the residents living at the home. Outings to include theatre trips and places of interest are arranged and the home has also hosted events by the casts of 2 West End shows, plus various concerts and other entertainments, with more events such as this being planned. Shopping trips take place and some residents are able to travel out of the home independently or with family and friends. Residents with an interest in gardening are encouraged to have an area where they can grow and tend their own plants. Birthdays and festivals are celebrated and visitors are also encouraged to join in events. It is Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 13 acknowledged that there has been increased dependency levels of many of the residents now accommodated at the home, and the need to offer more ‘inhouse’ activities during the day, for example, board games, quizzes and reminiscence groups, to keep residents mentally active and provide a daily activities programme for people to participate in, was discussed. The home does record ‘life history’ information for each resident, and this could be expanded to include hobbies and interests. There are 2 bars in the home and these are open before lunch and supper, and this encourages residents to meet and socialise. The home does have an activities room, however the Registered Manager explained that residents have not expressed interest in taking part in creative activities recently. It is recommended that the views of the residents be ascertained so that the home can then provide such activities that the residents are keen to try out and take part in. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are always made very welcome at the home and can join their loved one for a meal. We spoke with several visitors who expressed their satisfaction with the home and with the high standard of care provided. Residents can receive their visitors in a communal area or in their own rooms, according to their own wishes. Information regarding advocacy services is on display in the home. For the residents living in the dementia care unit a Power of Attorney is appointed prior to admission. The residents also have access to The Actors Charitable Trust Welfare Committee, plus The Actors Benevolent Fund and other likeminded societies. It is clear that the rights of the residents to independent representation is taken seriously and respected. We viewed the kitchen and the area was clean and tidy, with records being up to date. There was a good stock of foodstuffs available with stock rotation in place. The residents spoken with expressed their satisfaction with the food provision at the home and said that alternatives are always offered. Each resident has a menu card to complete each day, so that their choices can be catered for. If they do not like the options available the Chef said that further alternatives are always provided. We took part in the lunchtime meal in the main dining room, and residents were enjoying their food and the company, and there was a very happy and calm atmosphere. The food sampled was of a high quality and well presented and tasty. Each unit has a kitchenette area where residents and relatives can make refreshments and snacks. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There are robust procedures in place for safeguarding adults, thus protecting residents from abuse. EVIDENCE: The home has a clear complaints procedure on display in the reception area. Residents spoken with said that they always felt able to express any concerns, which are listened to and addressed promptly. The home has policies and procedures for safeguarding adults and also follows the Hillingdon Safeguarding Adults procedures. Staff spoken with confirmed that they had received training in this area and were very clear to report any concerns, plus they understood the Whistle Blowing procedures. The Registered Manager is clear to report any medication errors as part of the safeguarding adults procedures. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The environment is of a high standard, providing residents with a homely, clean, safe and pleasant place to live in. Infection control procedures are in place and observed, thus protecting residents. EVIDENCE: Denville Hall has been built to a very high standard, and provides an excellent quality of accommodation for the residents living there. The Registered Manager provided a list of areas that had been refurbished and redecorated, with further work planned, for example a new corridor carpet in the dementia care unit. The grounds are extensive and are also maintained to a high quality, and can be accessed from the ground and first floors. The dementia care unit has an enclosed courtyard area and the gardens are secure. The home has several communal rooms available for residents to sit in and to receive visitors. These include a library, a Green Room, a drawing room, sitting Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 16 rooms and a dining room on each unit. There is a patio area with garden furniture that is easily accessible. All bedrooms have en suite facilities to include shower, wash hand basin and toilet. There are assisted bath facilities available on both units. There are handrails fitted throughout. The home has 2 passenger lifts and one service lift. There are hoists available to meet the moving & handling needs of the residents. All areas of the home accessible to residents have a call bell system in place. There are appropriate storage facilities throughout the building. The bedrooms were designed with individuality in mind, and those viewed were spacious, personalised and had a very homely feel. Where possible residents are encouraged to bring in their own furniture, in line with fire safety, but furnishings can also be provided. All the beds are profiling beds with integrated bedrails, which are only used for residents identified as requiring them. We viewed the laundry and it was clean and tidy. The home has 2 washing machines and 2 tumble dryers, all of industrial standard. Infection control procedures were on display and there is a disinfection system in use in the laundry. Items of personal clothing viewed were well cared for and labelled. Protective clothing to include gloves and aprons was available. The home was bright and fresh throughout. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place and protect residents. The home has an induction and training programme to provide staff with the skills and knowledge to care effectively for the residents. EVIDENCE: The home was being staffed to meet the needs of the residents. The Registered Manager explained that currently the staff work between the general care and the dementia care units, to give all staff have experience of working in both areas. The need to consider a continuity of staffing on both units was discussed. Shortfalls identified in the completion of service user plans and also in the management of medication indicate that the registered nurses need to reflect on their practice and work to ensure the shortfalls are robustly addressed and thereafter standards maintained. The home was clean and fresh, and is being well maintained. Residents said that they are being very well cared for. The possibility of allocating some staff hours to activities co-ordination so that activities appropriate to both units can be encouraged, was discussed. Since the last inspection significant progress has been made with staff training and several staff had completed the NVQ in care level 2 training, and others Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 18 who are in progress with this training. Level 3 training has also been undertaken by 2 of the care staff. We viewed 3 sets of staff records and these included the information required under Schedule 2 of the Care Home Regulations 2001. The home now has a full induction programme that includes the Skills for Care common induction standards. One of these was seen for a member of care staff employed since the last inspection and this had been fully completed. Residents spoken with said that the staff do care for them very well and understand how to care for them. There was evidence that staff had undertaken training in topics relevant to the diagnoses and needs of the residents, with more training planned. The need for further dementia care training courses to be undertaken by staff who can then provide continuity of care in the dementia care unit was discussed. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home and has an open and approachable style. Systems in place for quality assurance must be reviewed as they do not provide a sufficiently robust process of audit and review to identify and address shortfalls. The home does not handle monies on behalf of residents and systems for managing monies are clear. Supervision for staff has been introduced and is to be progressed to provide an effective system of care practice review and development. Overall health & safety is being well managed at the home, however some training shortfalls in health & safety topics could place people at risk. EVIDENCE: Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 20 The Registered Manager is a first level nurse and has completed the Registered Managers Award, NVQ level 4. She has post graduate qualifications in care of the elderly, care of the dying and other associated topics relevant to her role. Residents spoken with said that the Registered Manager is very approachable and helpful, and it was clear that she is always available to speak with residents, visitors and staff. The Registered Manager has a good understanding of the areas in which the home needs to improve. There is a monthly residents meeting chaired by the Responsible Individual and any issues are fed back to the Registered Manager. Residents and representatives can also meet with the Registered Manager at any time. The residents had been involved in the catering audit so that their opinions regarding the food provision were considered and menus adjusted accordingly. There had also been a catering financial and performance review. Residents had completed annual surveys, and there was evidence of a high level of satisfaction with the care provided at the home. Regulation 26 inspections are carried out and the need to ensure that these are unannounced was discussed. The Responsible Individual said that this could be easily addressed. An annual development plan for quality assurance must be drawn up to put systems in place to audit, review and improve the quality of all aspects of the home year on year. Processes currently in place for quality assurance in respect of clinical areas need to be reviewed, particularly in light of the shortfalls identified in the service user plans and the medication management. At the inspection it was identified that the Registered Manager does not attend the meetings held by the Deputy Manager and the registered nurses. The importance of ensuring that the management team is cohesive and effective, so that both the business and clinical aspects of the home are maintained to a good standard, was discussed. The home does not hold any monies on behalf of residents. All items of personal expenditure are itemised and monthly invoices are sent to the resident or their representative for payment. Since the last inspection staff now receive individual supervision. Whilst this process has been commenced, it was clear that the type of supervision taking place is around care practices and does not include one to one meetings between the supervisor and supervisee to discuss current practice issues, career development and any other relevant aspects of their work. More work needs to therefore be done in this area, and this too should help improve clinical practice. Maintenance and servicing records were sampled and those viewed were up to date. Following the last inspection fire drills have been carried out at more frequent intervals and more are due to take place. Information contained in the AQAA indicated that the Registered Manager was in the process of reviewing and updating safe working practice risk assessments. Risk assessments for equipment and safe working practices were seen for the Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 21 kitchen area and these were clear and up to date. The fire risk assessment had last been updated on 22/10/08. The Deputy Manager is responsible for staff training and there was evidence that staff had undertaken training in moving & handling and fire safety. Some staff had undertaken food safety training. There was no evidence of infection control training. All the registered nurses have completed the one-day emergency aid training. Information regarding the training undertaken by each member of staff is recorded on individual staff files. We recommended that a training matrix be developed to give a clear overview of the training required and undertaken for each member of staff. Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 3 X 4 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 17 Requirement Timescale for action 01/02/09 2. OP7 15 3. OP9 13(2) 4. OP9 13(2) Service user plans must be individualised and identify all the needs of the resident, to ensure their needs can be met. Input from the resident and/or 01/02/09 their representative must be sought for the formulation and review of the service user plans, unless it is impracticable to carry out such consultation. This will ensure the needs and wishes of the resident are clear and can be respected. That there are regular robust 01/12/08 audits to provide evidence that medicines are being recorded accurately when received into the home and administered, and that any omissions are identified and the appropriate action taken. This is to ensure the health and welfare of the residents is maintained. The audits must be available for inspection. That records of medication given 01/12/08 to residents/family and returned by residents/family when they go on leave from the home are kept DS0000010929.V373011.R01.S.doc Version 5.2 Denville Hall Page 24 5. OP9 13(2) 6. OP9 13(2) 7. OP11 12 8. OP33 24 9. OP38 18 in the home. This is to maintain the audit trail but also to ensure that medication is being managed safely on behalf of the resident. That the home works with the pharmacist to ensure that medicines do not run out and the monitored dosage system supplied is fit for purpose. That the home ensures that fridge and room temperatures are maintained at the correct temperature and that expiry dates are written on eye drops and liquids. This is to maintain the potency of the medicines and to ensure that they are not used past their expiry date. The wishes of residents and their families in respect of health deterioration and end of life care must be discussed and clearly recorded, to ensure these wishes are met. The home must have an effective system in place for quality assurance so that all areas of the home are audited and reviewed regularly and action taken to address shortfalls and improve standards. This is in order to continually review and improve outcomes for residents. There must be evidence that all staff have undertaken health & safety training at the required intervals so that practices are up to date in line with current legislation and guidance. 01/12/08 01/12/08 01/02/09 01/01/09 01/01/09 Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP12 Good Practice Recommendations That residents be given the opportunity to discuss individually their wishes in respect of access to a GP. It is strongly recommended that information regarding resident hobbies and interests in addition to their career history be obtained. Also that consideration be given to allocating hours for activities co-ordination so that a programme of in-house activities for both units can be introduced. That the staff supervision process be reviewed to ensure that all aspects of practice and development are included. 3. OP36 Denville Hall DS0000010929.V373011.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Denville Hall DS0000010929.V373011.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. 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