Inspection on 12/09/05 for Denville Hall

This inspection was carried out on 12th September 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 but made no statutory requirements on the home.

Other inspections for this house

Denville Hall 02/11/09

Denville Hall 11/11/08

Denville Hall 25/07/06

Denville Hall 09/02/06

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Denville Hall 62 Ducks Hill Road Northwood Middlesex HA6 2SB Lead Inspector Clare Henderson Roe Unannounced 12 September 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Denville Hall Address 62 Ducks Hill Road HA6 2SB Northwood Middlesex Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01923 825843 01923 841855 Denville Hall (Reg Charity No. 209480) Mrs Moira Bridget Miller CRH 40 Care Home Category(ies) of PD(E) Physical dis - over 65 0, PD Physical registration, with number disability 0, OP Old age 0, DE Dementia 15 of places and TI Terminally ill 3 Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users must be over the age of 59 years. 2. Minimum Staffing Notice. Date of last inspection 1st March 2005 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 actors and people of affiliated professions and of pensionable age. The home offers permanent and respite accommodation. In recent years the home has been completely refurbished and a new dementia care wing has been 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. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 12 hours were spent on the inspection process. The Inspector carried out a tour of the home and inspected staffing, administration and medication records, plus 3 service user plans. A total of 8 service users, 3 visitors and 6 staff were spoken with as part of the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls in the formulation and updating of some sections of the service user plans were identified. The management of medications needs work to ensure that there are robust and up to date best practice systems and procedures in place. The ongoing issue with the carrying out of the monthly unannounced visits by or on behalf of the Responsible Individual and the provision of the written report, both to be done in line with Regulation 26 of the Care Homes Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 6 Regulations 2001, is of concern, and the Registered Manager was aware of this. 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. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 & 5. The home does not provide intermediate care. The pre-admission assessments provided are not always comprehensive, and therefore do not provide the home with a clear picture of the prospective service users needs, and information has to be gathered during trial visits. Staff are appropriately trained and experienced to meet the service users needs, to include specialist care needs. Prospective service users are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: The Registered Manager said that where possible the home obtains a copy of the Social Services needs led assessment. Where a prospective service user is already receiving care in another setting, for example, an intermediate care unit, a multi-disciplinary assessment of needs can be obtained. The home does have a pre-admission assessment document, which is usually forwarded to the service users current GP for completion, and it was clear from those viewed that the information provided is often sparse and incomplete. The document needs to be reviewed in line with Standard 3.3 in order to ensure it asks for comprehensive information in respect of any service users. It is acknowledged Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 9 that service users do come for a trial visit to the home for one to two weeks, providing the staff with the opportunity to assess their needs more fully. The home offers general nursing and personal care, palliative care and dementia care. Registered nurses and care staff have received training relevant to the specialist needs of the service users and from observation and speaking with staff and service users it was clear that the service users needs are understood and are being met. In addition to this, the service user group is one of actors and people from affiliated professions, and the Registered Manager is a registered nurse who has also worked within the theatrical profession, providing her with relevant knowledge and experience for this specialist service user group. Prospective service users are encouraged to visit the home for an initial visit, to include a meal, so that they can get a general feel for the home and chat to other service users independently. They then visit for a trial period of one to two weeks after which, unless their medical condition is such that it is not practicable, they return home to reflect on the experience and have the time to decide if they wish to move there permanently. Before their last admission, several of the service users had been to the home for periods of convalescence or respite care. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11 Service user plans are in place and require review and update to ensure that they reflect the service users current condition. Shortfalls in some areas of the management of medications could potentially place service users at risk. Staff are gentle and courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy, dignity and independence. EVIDENCE: Four service user plans were viewed. These gave an overall picture of the service users needs, and the activities of daily living assessment document had been reviewed monthly. The home has a resident admission document, which is completed by the service user or their representative and provides a good picture of the service user to include background information about them. Some of the individual care plans needed reviewing and updating to reflect the service users current condition. Risk assessments for falls had been completed. Information regarding falls had been recorded in the daily record and on the accident form, but the falls risk assessment had not always been updated following a fall. The shortfalls were discussed with the Registered Manager, together with the need to evidence the involvement of the service user and/or their representative when reviewing the service user plan. The Registered Manager said that she was looking at allocating a registered nurse for each Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 11 service user, for the purpose of service user plan review, to ensure updates are carried out consistently. Assessments for moving & handling were in place, one of which needed to be updated. Assessments for pressure sore risk were in place. Documentation for wound care was up to date and there was evidence of input from the Tissue Viability nurse. Appropriate pressure relieving equipment to meet the individual service users needs was seen in use in the home. Where continence or nutritional care needs were identified, assessments for continence or nutrition had not always been carried out. The Registered Manager said that if there are any dementia care or mental health concerns she requests input from the Nursing & Residential Home Support Team, who have provided prompt and effective input. Two care plans for mental health were viewed in the dementia care unit, one of which had been clearly completed, and the other required completion. Assessments for bedrails had been carried out, but these needed expanding to evidence the reason for and appropriateness of their use. At the time of inspection, assessment of a service user who may require other measures to assist with their safety was being progressed, and the need to ensure that written assessment and consent is available for the use of any safety measures of this nature was discussed. Apart from one person, all the service users are registered with the same GP who carries out a weekly visit plus additional visits as necessary. The other service user is registered with a different GP and has been so for several years. There is evidence of input from other healthcare professionals to include physiotherapy, chiropody, aromatherapy, dentist, audiologist and optician. Medication records were viewed. Photographs were available of the service users for identification purposes, and the registered nurse spoken with said that if a service user had an allergy this would be recorded. Registered nurses administer the medications within the home. The monthly receipt of medications had been recorded, but for some medications received midmonth, for example, antibiotics, receipt had not been recorded. A few omissions were noted in signing for administration of medications, and omissions had not always been coded with the reason for omission. In one instance where two strengths of a particular medication were required to make up the prescribed dose, the two tablets for administration had not been individually identified on the medication administration record (MAR) chart. Liquid medications had not been dated when opened. Each of the two units has a medications fridge, and one has a minimum/maximum thermometer. The purchasing of one for the other unit, and also the recording of the minimum, maximum and actual temperatures for both fridges, to ensure they are kept within the 2-8º centigrade safe storage temperature, was discussed. Individual blood glucose monitoring devices are used for each service user with diabetes, and these were labelled individually. Appropriate alternative systems, specifically for use with more than one service user should the need arise, were discussed. Several of the service users are self-medicating. Risk assessments need to be completed for all service users who are selfDenville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 12 medicating, and medications need to be stored securely in their rooms. A lockable facility for medications is provided in each bedroom. Medications are being appropriately stored in the medications rooms and the controlled drugs record was correctly completed. Disposal of medications in line with the new waste disposal regulations was discussed and the Registered Manager said she would put a system in place for this. Policies and procedures for medications were in place, and these needed reviewing and where necessary updating in line with current legislation and guidance. Input from the dispensing pharmacist to include regular auditing of the medications was discussed. The shortfalls identified were discussed with the Registered Manager who said that they would be addressed. Staff were seen to treat service users in a gentle, courteous and caring manner, and the feedback received from service users and visitors confirmed this. A private pay phone is available to service users, and they can also have their own landline or mobile telephones. Each service users preferred term of address is recorded and respected. It was clear that each service users privacy, dignity and individuality is respected at all times. The home has three beds registered for the provision of palliative care. Staff had received appropriate training to enable them to meet the needs of this service user group, and training is ongoing to keep staff up to date. Support is provided by the Hillingdon palliative care team, to include a Consultant, palliative care nurse, and where necessary, psychiatric input. The wishes of the service users are discussed and recorded, and they can spend their final days in their own rooms unless there is a strong medical reason not to do so. Relatives and visitors are able to stay with a service user, and rooms are spacious and comfortable seating plus refreshments are available. Policies and procedures for the care of the dying are in place. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and aspects of 15. Social activities are provided to meet the service users interests, thus improving their quality of life at the home. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. The food provision is of a good standard and meets the requirements and preferences of the service users. EVIDENCE: The home has the facilities for social activities and service users individual interests and wishes are respected. There is a Bridge Club running within the home, and also an Arts & Crafts room where a variety of activities are available. Entertainment is arranged and the home has a grand piano in the Theatre Room, where concerts take place. The home has contact with theatre schools, and entertainments are organised. Theatre trips and outings to Kew Gardens are very popular. The home has two licensed bars on the premises. The Registered Manager said that activities specific to the needs of service users with dementia have been introduced, looking at both one to one and group activities. Information on service users interests is included in the working and playing section of the activities of daily living document and information regarding activities and outings is displayed in the home. Visiting is encouraged, and visitors spoken with said that they are always made welcome at the home. Service users can receive visitors in their rooms, plus Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 14 there are several quiet sitting rooms available for use. The home has a policy regarding maintaining contact between service users and their visitors. The Registered Manager said that if there were any issues regarding unwanted visitors, then this would be recorded and managed. Service users spoken with said that the food provision is good and that they are offered a choice. The dining room tables were well laid out, and fresh flowers had been placed on each table. There had been an improvement in the daily recording of the fridge and freezer temperatures in the kitchen. This standard will be viewed in more depth at the next inspection. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 & 18 The home has a clear complaints procedure and systems in place to ensure service users concerns are listened to and addressed. Service users rights are protected and service users are able to exercise their legal rights directly. There are systems in place for the protection of vulnerable adults. EVIDENCE: The home has a clear complaints procedure, copies of which are in the Service User Guide in each room. There is a monthly meeting with the Responsible Individual, at which any issues can be discussed and arrangements made to address them. Service users spoken with said that any worries or issues are dealt with promptly. The home has contact details for Age Concern advocacy services, plus The Actors Charitable Trust has a Welfare Committee, from which help and advice can be sought. Service users are on the electoral role and arrangements are made for postal votes or for service users to attend the polling station, depending on their wishes and abilities. Staff spoken with were very aware of the Protection of Vulnerable Adults (POVA) procedures and said that they would report any concerns of this nature. The home has POVA procedures in place and the Registered Manager said that she would ensure that the home had a copy of the recently updated Hillingdon documentation. Policies and procedures for the management of aggression and for the management of finances are in place. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 24 & 26 The standard of the environment within this home is high, providing service users with an attractive and homely place to live, and it is to be commended. Infection control procedures are followed thus minimising any risk to service users. EVIDENCE: In recent years the home has been completely refurbished to a high standard, with a new dementia care wing built. The Registered Manager said that when vacant, rooms are reviewed and necessary redecoration carried out. There is a maintenance book where any repairs are recorded, and the maintenance man deals with these. The building compliance with the Fire Safety Department and Environmental Health Officer was addressed as part of the refurbishment process, and there were no obvious issues noted at the time of inspection. There is CCTV in place externally for security purposes. The home has a variety of communal areas available 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 Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 17 sitting rooms of varying sizes plus conservatory areas. The grounds are extensive and have been well landscaped and maintained, with a variety of seating areas. There is also an outside sloped walkway leading from the first floor down to the ground floor, which service users enjoy using to get some fresh air and exercise. There is a large paved courtyard area with wooden furniture and it has been well laid out to include plants and garden features. There is a second courtyard area within the dementia care wing, and again much thought has gone into this, incorporating the courtyard as part of the safe area provided for service users to wander in. The décor throughout is to a high standard and the home is well maintained. The lighting was satisfactory at the time of inspection, and the Registered Manager said that lighting is reviewed when necessary to ensure it is appropriate throughout the home. The furnishings are of good quality and enhance the overall ambience of the home. The bedrooms had been individualised by way of design and also by using different colour ways in the décor and furnishings. The bedrooms viewed were very personalised and reflected the character and interests of each service user. There is a call bell system in place throughout the home and staff responded promptly to any calls. The beds are all electronically adjustable. All the bedrooms have locks and service users are provided with a key. The Registered Manager said that should a service user no longer be able to manage their key, this would be risk assessed. The home was clean and tidy and smelled fresh. The laundry facilities are situated on the second floor, away from service user areas. The laundry was built as part of the refurbishment of the home, and two new industrial washing machines, plus an industrial tumble dryer were installed. The laundry room was clean and tidy and the laundry person understood health and safety procedures. The laundering of bed linen, towels and items for dry cleaning are contracted out. Hand washing facilities are provided in all areas where service users, visitors and staff may require to wash their hands, plus alcohol gel is also used for hand disinfection. There is a separate sluice room on each floor, with a sluice disinfector. Some personal toiletry items were found in the bathroom areas, and the need to ensure that such items are kept in the service users own rooms was discussed. Protective clothing to include gloves and aprons were available. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The home is appropriately staffed to meet the needs of the service users. Overall the systems for the recruitment of staff are robust to safeguard service users. The system for staff induction, foundation and NVQ training needs to be implemented to ensure staff are up to date with best practice. EVIDENCE: The home is appropriately staffed to ensure the needs of the service users can be met. On both units there is a registered nurse in charge of each shift. Service users spoken with said that staff are available to assist them whenever necessary. The Registered Manager said that she reviews the staffing in accordance with any changes in the service users needs. The staffing rosters viewed showed that any duty changes are recorded. The staff employment files viewed contained details of the applicants completed application forms, Criminal Record Bureau check information, health checks, 2 references, evidence of identity and qualification checks. A recent photograph was needed for each member of staff. The Registered Manager said that the home was in the process of updating and renewing all the staff terms & conditions and contracts. This standard will be revisited at the next inspection. The Registered Manager said that she has purchased a training package for staff to include induction, foundation and NVQ training, which is based on the Skills for Care (previously TOPSS) core standards. This is to be implemented in the home and this standard will be re-visited at the next inspection to see what progress has been made. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and aspects of 33 Procedures for the management of finances are in place and the home works to safeguard service users and their finances. The systems for quality assurance need to be documented to evidence service user consultation and ongoing auditing within the home. EVIDENCE: Where service users are unable to manage their own finances, then their representative fulfils this role. The home does not hold any money on behalf of service users, and an invoice is submitted to the service user or their representative for any expenditure. Clear records are maintained. The Registered Manager said that Power of Attorney arrangements are made prior to admission for the service users in the dementia care wing. The home has a safe facility, and receipts are given for any items given in for safe keeping, with a system of signing in place to identify when items are removed from the safe. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 20 There has been an ongoing issue with the lack of Regulation 26 visit reports of the unannounced visits, required to be carried out monthly by the Responsible Individual for this home, or by a person nominated by the Responsible Individual, in accordance with Regulation 26 of the Care Homes Regulations 2001. This was discussed with the Registered Manager, who said that this is an area that is being addressed. It was agreed that a Regulation 26 visit report must be submitted within one month of the inspection and monthly thereafter, or further action would have to be considered. The Registered Manager said that she was formulating a questionnaire for service users, and meetings for staff and service users do take place on a regular basis, plus the Registered Manager carries out a daily round to keep up to date with any issues. The formulation of a simple development plan to identify the ways in which the home is audited for quality assurance purposes was discussed. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 4 x x x 4 x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 2 x 3 x x x Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement The pre-admission assessment documention must be reviewed in line with Standard 3.3 of the National Minimum Standards for Older People. This must include assessments for mental health for prospective service users for the dementia care wing. (previous timescale 18/04/05 not met) Risk assessments for falls must be updated following any falls. The service users plan must be updated monthly and when a service users condition changes. Moving & handling assessments must be kept up to date to reflect any changes in the service users needs. Where a need is identified, assessments for continence and for nutritional needs must be carried out. For service users with dementia care needs, care plans to reflect this need must be in place. Following the completion of the bedrail risk assessment, the appropriateness of and reason for the use of bedrails must be clearly recorded. Timescale for action 01/11/05 2. 3. 4. 7 7 8 13(4) 7(1)(a) 13(5) 01/10/05 21/10/05 21/10/05 5. 8 17(1)(a) 21/10/05 6. 7. 8 8 15 13(7) 21/10/05 21/10/05 Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 23 8. 9. 9 9 13(2) 13(2) 10. 9 13(2) 11. 12. 9 9 13(2) 13(2) 13. 9 13(2) 14. 15. 9 9 13(2) 13(2) 16. 17. 18. 26 29 30 13(3) 19 Schedule 2 18 19. 33 24 All receipts of medications must be recorded. All medications must be signed for at the time of administration. Where an omission is made, the appropriate coding to indicate the reason for omission must be inserted. Where more than one strength of tablet is required to be administered to obtain the prescribed dose, these must be individually entered on the MAR chart for each strength of tablet and each strength must be individually signed for. Dates of opening must be written on all liquid medications. The minimum/maximum/actual drugs fridge temperatures must be recorded daily and these must be maintained between 28º centigrade. Risk assessments must be in place for all service users who are self-medicating, and medications must be stored securely. Arrangements for the disposal of medications in line with current legislation must be put in place. Up to date policies and procedures for medications in line with current guidance and legislation must be available. Personal toiletries must not be left in communal areas. Staff employment files must contain a recent photograph for each employee. The induction, foundation and NVQ in care training must be commenced and evidence to show staff progress be maintained in the home. A development plan to reflect the monitoring processes in 01/10/05 01/10/05 01/10/05 01/10/05 21/10/05 21/10/05 21/10/05 21/10/05 01/10/05 01/11/05 01/11/05 and ongoing 01/11/05 Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 24 20. 33 26 place in the home for quality assurance must be developed. A copy must be forwarded to the CSCI. The Responsible Individual must 14/10/05 ensure that the monthly and unannounced visit to the home is ongoing carried out and a report prepared and distributed, in accordance with Regulation 26 of the Care Homes Regulations 2001. (previous timscale 18/04/05 not met) 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 7 9 Good Practice Recommendations A system for recording and evidencing input from service users and/or their representatives in the formulation and review of the service users plans should be introduced. The dispensing pharmacist should carry out regular medication audits and provide a written report to the home. Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 Denville Hall G61-G10 s10929 Denville Hall v248736 120905 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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