Inspection on 02/11/09 for Denville Hall

This inspection was carried out on 2nd November 2009.

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

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 11/11/08

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 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Denville Hall 62 Ducks Hill Road Northwood Middlesex HA6 2SB Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 2nd November 2009 10:00 DS0000010929.V378231.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Denville Hall DS0000010929.V378231.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.V378231.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 11th November 2008 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. Within the home there is a 15 bedded wing for people living with the experience of dementia. 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 £600 to £920 per week. Denville Hall DS0000010929.V378231.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 one star – adequate service. 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 19 hours was spent on the inspection process, and was carried out by 2 Inspectors. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, administration records and maintenance & servicing records were viewed. 8 residents, 7 staff, the Registered Individual and a member of the visiting House Committee were spoken with as part of the inspection process. The CQC Annual Quality Assurance Assessment (AQAA) document completed by the Manager, plus comment cards from residents, staff and health and social care professionals have also been used to inform this report. Comments and suggestions received via the surveys were fed back to the Manager in general terms and some general comments are included below. It must be noted that it is sometimes difficult to ascertain the views of residents with dementia care needs. What the service does well: Prospective residents are assessed prior to admission to ensure the home is able to meet their needs. The carrying out of an audit on the dementia care wing has led to research based improvements being made in this area, which has in turn enhanced the lives of the residents. The healthcare needs of the residents are identified and met, and there is evidence of input from healthcare professionals. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home has an open visiting policy and visiting is encouraged, with visitors able to join loved ones for refreshments and meals in the home. Information about advocacy services is on display in the home, and residents with dementia care needs have a representative clearly identified prior to admission. The home provides a very high standard of food, offering variety and choice and catering to individual needs. Procedures are in place for the management of complaints and safeguarding adults, and these are followed, thus safeguarding residents. Overall, the environment is of good quality and provides a high standard of accommodation for the residents. Infection control procedures are in place and are kept under review to include any current infection control issues, so that any risks to residents is minimised. The home is being staffed to meet the needs of the residents, with ongoing recruitment of permanent staff taking place. All new staff undertake induction training, and the home continues to promote NVQ in care training for care staff, with the majority now having completed this training. The Manager has Denville Hall DS0000010929.V378231.R01.S.doc Version 5.2 Page 6 the qualifications and experience to manage the home and is approachable and supportive to staff. The home does not manage any monies on behalf of residents. Comments received include: “The freedom of allowing family and friends unlimited visits. This must be the finest retirement home anywhere.” “If you request anything extra from the kitchen they will do anything extra you give them to prepare.” “overall care for people is very good”. “Denville Hall could not be improved”. “Excellent meals. They keep us fully informed.” “communicates well with relatives etc. Resident care is paramount. Everyone’s wishes are considered and if possible implemented.” What has improved since the last inspection? What they could do better: We identified areas where it was clear that work had been done following the last inspection, however shortfalls still identified show that more work is needed to bring these areas up to a good standard. It has been necessary to partially re-state some of the requirements from the last inspection, as they had not been fully met. A robust system for quality assurance needs to be implemented so that there is ongoing monitoring of all aspects of the home and any shortfalls can be identified and addressed without delay, rather than shortfalls being identified at the time of an inspection and then work being done to address them. It is acknowledged that following the inspection the Manager did send through information we asked for in relation to some of the shortfalls identified. Residents and, where appropriate, their representatives are still not being involved in the care planning process, so their views as to their care wishes are not being ascertained and recorded. Some of the information in the service user plans is still quite general and resident involvement would greatly assist with personalising the care plans and ensuring all needs are identified and being met. Monthly reviews and updates of the service user plans had not Denville Hall DS0000010929.V378231.R01.S.doc Version 5.2 Page 7 always been carried out. Some of the medication shortfalls identified at this inspection are the responsibility of individual registered nurses to ensure they follow all the procedures in place for the management of medications. We also identified some shortfalls that need to be addressed by the Manager in conjunction with the GP and pharmacist in respect of maintaining a stock of all prescribed medications. Risk assessments for those who are self-medicating need to be reviewed to ensure they are robust and clear. Action also is needed to ensure medications are always stored at safe temperatures. Some work has been done to find out information regarding the wishes of residents in respect of their care in the event of health deterioration and end of life care needs, however further work is needed in order to ensure all residents are offered the opportunity to express their wishes and to have them discussed, recorded and respected. Some specific environmental issues were identified, and a regular audit of the home would pick up on these issues so they can be addressed promptly, maintaining the high quality throughout. Shortfalls were identified in staff employment records, and this needs to be addressed. Regulation 26 visits are taking place, with further work needed to ensure all aspects of this regulation are being followed. Records of staff attendance at health & safety training and fire drills did not evidence that all staff had undertaken such training and updates within the required timescales. Comments were received expressing concern about the numbers of agency staff being used and also suggesting more maintenance provision in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 8 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.V378231.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are assessed prior to admission to the home, to ascertain if the home is able to meet their needs. Following assessment, the dementia care wing is being updated to incorporate research based care practices, thus enhancing the quality of life for the residents accommodated there. EVIDENCE: We viewed examples of the pre-admission assessments and these had been well completed and provided a good picture of the resident and their needs. Where available, copies of the social services assessments are also obtained, plus copies of hospital discharge information was also available. The Manager commissioned a dementia care assessment of the home and this has been carried out. As a result of the findings there have been several Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 10 changes to the wing, to include environmental changes in the communal and garden areas, plus a designated staffing team with appropriate uniforms for caring for residents with dementia. The changes have been based on up to date research and good practice and it was clear that the staff in this wing have embraced the findings in order to enhance the lives of the residents in their care. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plan documentation does not always provide an up to date picture of each resident and their needs, and therefore the resident is at risk of not having their needs fully identified and met. There is evidence of input from healthcare professionals, ensuring the health needs of residents are being met. Although there has been an improvement in the medication management in the home, shortfalls identified could still place residents at risk. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. There is some information available for end of life care, however more work is still needed in this area so that the wishes of all residents and their representatives are identified and can be respected. EVIDENCE: We viewed 5 residents’ service user plans. Some of the information was quite general and there had been a gap in the monthly reviews between April and August 2009. Although we found some evidence of residents signing the initial Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 12 ‘long term care assessment’ document several months previously, there was no evidence of their input in the care plan documentation or reviews of these documents. This work needs to be progressed so that the residents are given the opportunity to provide valuable information about their care needs and how they would like them to be met. The residents on the general wing would be able to provide this information and be involved in their service user plans. In some instances where a residents needs had changed, this had not been clearly reflected in the relevant care plan. We did find some information in the daily record, but the care plans should be updated whenever there is a change to a residents’ condition. In one instance there had been a new care plan added for a recently identified need, showing that staff can be aware of the importance of doing this. Care plans on the dementia care wing did include information about meeting the dementia care needs of the residents. Risk assessments for falls were in place and falls had been recorded. Risk assessments for other identified risks had been completed. The AQAA for the home stated that resident records were up to date and had been reviewed monthly, which was not found to always be the case. There was no evidence of any auditing of the service user plans having taken place. It was clear that residents were being well cared for, and staff were able to tell us about changes, however the documentation to evidence this was not always available and/or up to date. We viewed wound care documentation. A care plan was in place which evidenced the dressing regime to be followed, with evidence of review, and there was a record of dressing changes and wound progress. There was evidence of input from the GP and the Tissue Viability Nurse. Moving and handling assessments were in place. Continence assessments had been completed where a need had been identified. Nutritional assessments were in place and there was evidence of residents being referred via the GP to the dietician if significant weight loss was noted. Residents observations to include weight are carried out 6 monthly unless a problem is identified. If a resident cannot be weighed then a visual check is done to observe for weight loss. There were records of input from other healthcare professionals to include a dentist, physiotherapist, psychologist, psychiatrist and chiropodist. We viewed medication management on both wings. Since the last inspection the Manager has put in place systems for the management of medications and an improvement was seen. It is noted that the Manager undertakes all the medication ordering, receipting and also monitors the auditing process, all of which is good practice, however also very time consuming. Records of all information sent to the GP and the dispensing chemist are kept, which is comprehensive. We viewed the medication records on each wing. The home uses a monitored dosage system (MDS) and the majority of medications are supplied on a 28 day cycle, in blister packs. Photographs of each resident are prominently displayed on the medication documentation, and allergy information is included on the medication administration record (MAR). There was a list of specimen staff signatures and initials available. Controlled drugs Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 13 records were up to date. Approved lancing devices for blood glucose monitoring were in use. Where a medication stock is ‘brought forward’ from one cycle to the next, this is recorded. On the dementia care wing, with one exception records of administration were up to date and an explanation was given for the shortfall identified. On the general wing we found a discrepancy in the number of tablets signed for as having been administered and the number still in stock for a medication, and asked the Manager to carry out an investigation into this, which she has since done. This had occurred despite a clear daily auditing system being in place, which had not therefore been accurately completed by the registered nurses administering the medication. Where a dose of a medication changes, the medication needs to be re-written on the MAR each time the dose changes, so a clear record is maintained. There were some gaps in signing for the administration of medications noted on this wing, although the medication was no longer in the blister pack, so appeared to have been given. Some medications were found having been placed in a pot for administration and then not given. The reason for this was not clear and the Manager said she would investigate this matter. Where a resident had refused a medication, an explanation had not been recorded on the back of the MAR. A recent medication error had been identified and the Manager confirmed that this had been reported to CQC and the Hillingdon Safeguarding Adults team. An issue with fridge temperatures had been identified by the Manager and action was being taken to address this, to include obtaining a new digital thermometer. Residents are encouraged to self-medicate where possible, and a locked drawer is provided in each bedroom. Risk assessments for selfmedicating were in place, however these did not always clearly identify each residents ability to self-administer. A copy of a risk assessment document specifically for use with residents who self-administer medications has since been forwarded to CQC. There continues to be a problem with obtaining medications when there are not enough tablets to complete one cycle, when a prescription has already been issued for the next cycle. In addition we found that for certain medications, there is an intermittent supply problem from the manufacturer. As a result, there have been occasions when medications have not been available to administer to the resident and this is not acceptable. These issues need to be addressed with the GP and the dispensing chemist, and clear systems put in place to prevent this occurring in the future. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. There was a very good atmosphere throughout the home, and particularly on the dementia care wing, where staff were being very patient and interacting well with the residents. All personal clothing is appropriately labelled, and residents were well groomed and dressed to reflect individuality. There are no equality and diversity issues at the home. Bedrooms are personalised and residents can bring in their own belongings, with rooms looking very homely. Since the last inspection, an ‘advanced care plan’ document has been put in place, and several residents had completed and signed this. For residents on Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 14 the dementia care wing we were informed that these had been sent out to their representatives for completion. It is clear on the documentation that the information provided can be altered at any time in accordance with any changes in the wishes of the residents and their representatives. Although these documents contain some information regarding residents’ wishes for the future, the information needs to be expanded to include health deterioration and emergency situations. This is so that the information is comprehensive and staff have the information they need to react appropriately and respect the wishes of the resident and their representatives. The Manager said that the home does have input from the palliative care team, and 2 members of staff are currently attending a course in care of the dying. The Manager is aware of the need for further improvements in this area. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has been an improvement in the in-house activities provision, and all residents are welcome to join in. Advocacy service information is on display, thus respecting the rights of the residents to independent representation. The home has an open visiting policy and visiting is encouraged, thus ensuring residents maintain contacts with family and friends. The food provision at the home is very good and provides choice and variety to meet the residents needs. EVIDENCE: Since the last inspection there has been an improvement in the in-house activities provision, especially on the dementia care wing, with a weekly activities programme in place that is followed. Activities were taking place at the time of inspection, with poetry and play readings taking place, plus a singa-long, and the residents were seen enjoying themselves. The residents from the general care wing are also made welcome at activity sessions. There are outings to West End shows, and the home has accessed discounted tickets for various theatrical productions. Events are arranged throughout the year to Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 16 celebrate various festivals and significant days in the English calendar, which are relevant to the resident group living at the home. Several residents are interested in gardening, and on the dementia care wing the courtyard area has been redesigned to incorporate raised flowerbeds for residents to access easily. The home has an open visiting policy and visiting is encouraged. Visitors can arrange to have meals with their loved ones and are invited to various events throughout the year. The home has information about advocacy services to include Hillingdon Age Concern, and all residents on the dementia care wing have a power of attorney set up prior to admission. The home has gained 5 stars in the Food Safety Agency ‘Scores on Doors’ scheme, which is the top rating it can gain. Menus are changed weekly and choices are available, to include a vegetarian option. Comment was received regarding some limitations on the vegetarian options, and this was fed back to the Manager. The Sunday supper was in the process of being debated and residents were asked to indicate their preference, a buffet in the dining room or a simpler provision of sandwiches. It is noted that a hot choice is available for each meal apart from Sunday supper, with a 3 course meal being provided every lunchtime. The quality of the food is high and visitors are welcome to partake of meals and a charge for this is made. On the dementia care wing some staff join the residents for meals, in line with research based recommendations. Dietary needs are identified and met. Tables are laid out to a good standard, to include fresh flowers on display. Drinks and snacks are available throughout the 24 hour period. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has clear complaints and safeguarding adults policies and procedures in place, and these are followed, thus protecting residents. EVIDENCE: The home has a clear complaints procedure, which is on display throughout the home, and is included in the Residents Handbook. There is a suggestion box near the dining room for residents to use. Residents can raise any issues at the monthly Committee meetings. There have been no complaints received in the last 12 months and the Manager stated that any issues brought to her attention are addressed promptly. The home has a safeguarding adults procedure in place and also follows the Hillingdon safeguarding adults procedures, and the Manager confirmed that any issues identified to include medication errors are reported to the safeguarding team. Staff spoken with were clear to report any concerns, and overall had a good understanding of whistle blowing procedures. Staff receive training and updates in safeguarding adults, both from in house training sources and also from an external training company. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has been purpose built to a high standard, providing residents with a clean, homely and quality environment to live in, with some minor works needed to maintain this standard on an ongoing basis. Communal and bedroom areas are spacious and there are appropriate adaptations in place to ensure residents can move around the home safely and have any mobility needs met. Bedrooms are individualised both by design and content, providing a personalised, homely environment for each resident to live in. Infection control procedures are in place and are followed, thus protecting residents, staff and visitors. EVIDENCE: Extensive work took place some years ago to upgrade the home to a high level of accommodation provision. We carried out a tour of the home and noted that Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 19 although overall the environment is still of a very good standard, there are some areas of ‘wear and tear’ that need to be addressed. A full environmental audit needs to be carried out so that areas in need of refurbishment or repair, for example, where carpet edges are frayed and where a kitchen cabinet door has come off, can be identified and addressed. There was evidence of redecoration of bedrooms having taken place. Overall the environment is of a very high standard, however it is important that there is ongoing monitoring in place to identify any shortfalls so they can be addressed without delay. Communal space is plentiful throughout the home and residents enjoy using the various lounges and bar facilities, plus the external grounds are well maintained and provide safe, pleasant areas for residents to walk and sit out in. Work has been done to improve the access for residents to the courtyard area in the dementia care wing, plus raised flower beds had been introduced so that residents can access them easily. Each bedroom has an en suite that includes a shower, toilet and wash hand basin. Assisted bath facilities are also available throughout the home. This provides a high level of care provision for residents’ personal needs. There are handrails in place throughout the home and the corridors are wide, allowing for easy access for those in wheelchairs. There are 3 lifts, 2 of which are passenger lifts, one being a service lift. There are 4 hoists for the moving & handling of residents that require this type of assistance. Where identified as useful, equipment is available to assist residents to move themselves when in bed, adding to their independence. There is a call bell system throughout the home and the units are portable, so can be used by the resident wherever they are situated. There are ramps and handrails available in areas of the garden, to assist residents. Residents bedrooms are very personalised and decorated to a high standard. It states in the AQAA: “The design of the rooms allow for choice when arranging furnishings to suit the residents’ needs and comforts” and this was very clear in those viewed on both wings. Where a couple wish to share a bedroom, this can be arranged to provide them with a bedroom and a sitting room. The home has a laundry room with 1 dryer and 2 washing machines. Good practice laundry instructions are on display. There is an Otex ‘ozone’ disinfection system in place, which destroys bacteria such as MRSA at low temperatures, so that personal laundry items can be well cared for and effectively washed. The Manager said that there are plans to have 2 laundry rooms, one for the washing process and one for the drying and ironing process, to enhance infection control. Protective clothing to include gloves and aprons are available for use. The home has a pandemic Flu contingency plan in place and this is also on display in the home. Alcohol gel for disinfection purposes was available in various areas of the home, to help minimise the spread of any infection. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 20 Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is appropriately staffed to meet the needs of the residents, thus ensuring they are being well cared for. Systems are in place for staff vetting and recruitment, however shortfalls could place residents at risk. The training provision in the home is good, thus providing staff with the skills and knowledge to meet the residents’ needs effectively. EVIDENCE: The home was being well staffed to meet the needs of the residents. In recent months there have been many changes to the nursing staff, and agency nursing and care staff are being used for several shifts per week at the present time. We have received comments regarding the wish for a more stable staffing team so that residents can receive continuity of care. The Manager was very aware of this and is actively recruiting nursing and care staff for the home. The domestic and kitchen staff are employed by an external company. There are also estates management and administration staff based at the home. The majority of the care staff are qualified to NVQ level 2 or 3, with more staff currently completing this training. It was clear from speaking with some of the care staff that they have experience in working in care homes without nursing, Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 22 where they had been involved in medication and care planning management, and their experience and skills could be used positively by the home to enhance the work of the registered nurses, especially for residents who do not have nursing care needs. We viewed 4 sets of staff employment records. A photograph was available in one set of records viewed, and in others there were copies of the identification section of the passport. In one instance only one reference could be found, and in another it was not clear if the previous employer had been used as a referee. We viewed the application form and recommended that the wording on the reference section be reviewed to clearly indicate that the current or last employer must be given as a referee, unless a satisfactory reason not to do so is provided. There was evidence that enhanced Criminal Records Bureau checks had been carried out for the 4 members of staff and the Manager confirmed that no staff commence work until this information is received by the home. The home uses the Mulberry House induction programme and this includes the Skills for Care common induction standards. The Manager said that this is given to all new staff to complete as part of the induction process. There was also evidence of other training being undertaken by staff to include sessions in topics relevant to the diagnoses and needs of the residents. The Manager said that they do have some in-house training sessions, plus an external trainer provides regular training sessions for the staff. Specific health and safety training is commented on under Standard 38. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Manager has the qualifications and experience to manage the home. The systems in place for quality assurance require further work, as they do not ensure effective audit and review in all areas. Staff supervision has been improved to ensure all aspects of practice and development are included. Overall health and safety is being well managed at the home, however shortfalls identified could pose a risk to residents. EVIDENCE: The Manager is a first level nurse who has completed the Registered Managers Award. She also has post-graduate qualifications in the care of older people, care of dying people and other training and certificates relevant to her role and Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 24 the diagnoses and needs of the residents. Staff spoken with said that the Manager is approachable and has worked hard to improve the home in several areas. The home has systems in place for quality assurance, however more work is needed in this area to ensure the systems are implemented effectively. Resident surveys have been completed for food provision and also for ‘living in the home’, which covers several aspects of the home. Following a gap of a few months, staff meetings had recommenced in September 2009 and minutes are kept. The Manager has introduced audits for medication, and although there has been an improvement in this area, some shortfalls were still identified. No auditing systems have been introduced for the service user plan documentation and this has been commented upon under standard 7. Environmental audits have not taken place, and the need to carry out a full home audit has been commented on under Standard 19. There is a monthly residents meeting chaired by the Responsible Individual. Residents and representatives can also meet with the Manager at any time. In addition to the Manager and the Responsible Individual, there is a House Committee of people associated with The Actors Charitable Trust who are involved in various areas of overseeing the home and its’ management. They were visiting on the day of inspection and we spoke with one of the members who showed a keen interest in keeping up to date with CQC information, and we provided details of our website. The importance of everyone involved in these processes keeping up to date with the legislation to be met for the effective running of the home has been discussed with the Responsible Individual, who said that she would discuss this at a future House Committee meeting. Regulation 26 visits by the Responsible Individual had been taking place, and work had also been done to ensure there are unannounced visits taking place. Reports were available for some months in 2008 and the Responsible Individual confirmed that she did have records of all the visits carried out since and would formalise these into reports to be kept in the home. The need to ensure the information evidences that these are unannounced visits was also discussed. The home does not handle personal monies on behalf of residents. This is undertaken by the resident themselves or by their representative and the home invoices the individual concerned. Since the last inspection there has been more work done to cover all aspects of development and practice, to include observation of practice during the working day. Staff spoken with confirmed that they do receive formal supervision. We sampled the maintenance and servicing records and those viewed were up to date. The fire risk assessment had been undertaken in October 2008 and a date in November 2009 was identified during the inspection for the review and update of the document. Risk assessments for equipment and safe working practices had been completed and as any new risks are identified, a new Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 25 assessment is done, for example, for the work that took place in the dementia care wing during the summer. We discussed reviewing these annually to ensure the information remains up to date, and for them to be signed, even if the information has not changed, to evidence the fact they have been reviewed. Fire drills had been taking place however it was not clear that all day and night staff had taken part in the drills, and the need to ensure this was discussed. There was evidence of most staff undertaking training in health & safety topics and staff spoken with confirmed this, however there were some staff for whom it was not clear if they had undertaken the training. Action must be taken to ensure all staff undertake training and updates in health & safety training topics at the required intervals, and that the home has evidence of this training having been completed. Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 26 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 3 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 2 3 4 4 X 4 X 3 STAFFING Standard No Score 27 3 28 3 29 2 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.V378231.R01.S.doc Version 5.3 Page 27 Are there any outstanding requirements from the last inspection? Yes, partially. 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 Service user plans must be up to date and accurately reflect the needs of each resident. They must be reviewed monthly and whenever there is a change in the residents needs. This is to ensure that staff have accurate information to follow. There must be evidence that residents are involved in their service user plan, so that their needs can be discussed, recorded and a clear plan formulated to meet these needs. Where a resident is not able to or needs assistance to be involved in this process, involvement of their representative must be sought, unless it is impracticable to do so. This is so the plan of care is an accurate reflection of the needs and wishes of the individual. That all medication administration records are accurate and up to date and that the processes for auditing medications are adhered to, with any discrepancies noted being DS0000010929.V378231.R01.S.doc Timescale for action 01/02/10 2. OP7 15 01/02/10 3. OP9 13(2) 06/11/09 Denville Hall Version 5.3 Page 28 4. OP9 13(2) 5. OP9 13(2) 6. OP9 13 7. OP11 12 8. OP19 23 9. OP29 18 10. OP33 24 reported to the Manager without delay. This is to safeguard residents. That a stock of all prescribed medications is available at all times. This is to ensure all residents receive medication as prescribed. That medication storage temperatures are maintained within safe range at all times, to include refrigerated medications. This is to ensure medications can be stored in accordance with the manufacturers instructions. Risk assessments for residents who are self-medicating must clearly identify the risks and state the protocols in place to minimise such risks. This is to ensure the resident receives the support they need to maintain their independence when selfmedicating. Further work is needed to provide residents and their families with the opportunity to discuss the care they want in the event of health deterioration and during their final days, so that their wishes are clearly identified, recorded and can be respected. That a full environmental audit be carried out, and an action plan drawn up to address any shortfalls identified, with realistic timescales for completion. This it to maintain the home in a good condition throughout at all times. All staff employment records must contain the information required under Schedule 2 of the Care Home Regulations 2001. This is for the protection of residents. The quality assurance system must be fully implemented so DS0000010929.V378231.R01.S.doc 06/11/09 06/11/09 13/11/09 01/02/10 01/01/10 01/12/09 01/02/10 Page 29 Denville Hall Version 5.3 11. OP33 26 12. OP38 23 that all areas are audited, monitored and any shortfalls identified and addressed in a timely manner. This is in order to continually review and improve outcomes for residents. That Regulation 26 visits are carried out in accordance with Regulation 26 of the Care Home Regulations 2001. This is to ensure the home is being monitored effectively. For there to be evidence that health & safety training and fire drills have been completed by all staff at the required intervals. This is to keep their knowledge up to date and protect residents, staff and visitors. 01/12/09 01/01/10 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 OP29 Good Practice Recommendations That the application form be reviewed so that it is clear that one referee must be the applicants’ current employer, or, where they are not working at present, their last employer. If there is a valid reason not to use this person, then this must be clearly recorded. For all those involved in the overseeing of the home and its management to have an up to date knowledge of the legislation to be met for the effective running of the home. That risk assessments for equipment and safe working practices be signed annually to identify that they have been reviewed, even if updates are not required. 2. 3. OP33 OP38 Denville Hall DS0000010929.V378231.R01.S.doc Version 5.3 Page 30 Care Quality Commission Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.london@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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