Inspection on 25/07/06 for Denville Hall

This inspection was carried out on 25th July 2006.

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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Denville Hall 62 Ducks Hill Road Northwood Middlesex HA6 2SB Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 25th July 2006 10:00 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.V300242.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.V300242.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 DENVILLE HALL (REG CHARITY NO. 209480) Mrs Moira Bridget Miller Care Home 40 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (0), Physical disability (0), of places Physical disability over 65 years of age (0), Terminally ill (3) Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service Users must be over the age of 59 years. To comply with the Minimum Staffing Notice required by the previous regulator as 31st March 2002. One named service user under the age of 59 years can be accommodated at the home for a two week stay from 22nd November 2005 as agreed by the Commission For Social Care Inspection on 1st December 2005. The home must inform the CSCI when the service user no longer resides at the home. 9th February 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 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. The fees range from £551 to £857, dependent on the service users level of care needs. The Registered Manager is retiring in August 2006 and a Manager Designate has been appointed and is going through the process of registration. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 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 9 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. The CSCI Pharmacist Inspector inspected the management of medications within the home. 10 service users, one visitor and 7 staff were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. What the service does well: What has improved since the last inspection? The homes pre-admission documentation has been reviewed and is now comprehensive. Completion of the service user plans has improved, and additional assessment documentation has been introduced. Overall the service user plans are well completed and the systems are simple and clear. There has been a marked improvement in the management of medications in the home, especially in the management of service users who are self-medicating. With more attention to detail shortfalls identified in this report should be easily addressed. The staff recruitment process documentation viewed was in order, and the application form has been updated. Action has been taken to commence a development plan for quality assurance, and there is evidence of auditing for this, plus Regulation 26 visit reports are forwarded to the CSCI. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 6 The risk assessments for safe working practices are in the process of being updated, and once done these must be reviewed on an annual basis and whenever anything relevant changes. The emergency lighting system has been reviewed and restored to correct working order. 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. Denville Hall DS0000010929.V300242.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.V300242.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4. 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. Service users are assessed prior to admission to the home, to ascertain that the home can meet their needs. Staff have received training in specialist topics to include dementia, and are thus able to meet the care needs of service users, to include those with specialist care needs. EVIDENCE: Several of the service users had previously been admitted for respite visits, prior to living at the home on a permanent basis. Clear records of any changes in care needs between admissions had been recorded on the admission documentation. Where Social Services and/or heath care professionals had assessed service users prior to admission, these assessments were available in the service users records. The home also has a pre-admission assessment document for use, which is comprehensive. The home has a purpose-built dementia care unit. Staff have received training in dementia care and were seen caring for the service users in a professional and caring manner, with a good understanding of their needs. Denville Hall DS0000010929.V300242.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans are well completed and maintained up to date, thus giving a good picture of the service users needs and how these are to be met. Shortfalls in risk assessment documentation could potentially place service users at risk. Medications are being well managed at the home, however some shortfalls need addressing to fully safeguard service users. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. Staff understand end of life care, thus ensuring service users needs and wishes in this area are respected and met. EVIDENCE: The Inspector sampled service user plans on both units. The home uses a twopage care plan that covers all activities of daily living, and where care needs are identified an individual care plan is formulated for each need. Generally the service user plans clearly identify and address the service users’ individual needs. One viewed was somewhat general and needed personalising and the Manager Designate said that this would be addressed. It was noted that correction fluid had been used on some of the service user plans and this practice must cease. Risk assessments for falls had not always been updated Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 10 following a fall, although it is acknowledged that associated documentation had been completed. There was evidence of monthly updates of the service user plans, and where new needs had been identified a care plan had been formulated to meet this. There were no service users with pressure sores or wounds at the time of inspection. Assessments for pressure area risk were seen in the service user plans. Pressure relieving equipment was seen in use in the home, and any skin care issues are promptly addressed. Nutritional assessments are in place and where any nutritional risks are identified, the service user is weighed weekly and referred to the GP. Continence assessments are in place and where continence care needs are identified care plans for this are formulated. Moving & handling assessments and safe environment assessments were seen in the service user plans viewed. On the dementia care unit care plans for mental health needs were in place. Where any behavioural needs identified, care plans had also been formulated to address these. Bedrail assessments had been carried out. In one instance the appropriateness of the use of bedrails needed to be discussed and assessments updated and action taken to address the findings. This was discussed with the Registered Manager and the Manager Designate, who said that this would be addressed promptly. The home has a GP who visits weekly, and one service user is registered with another GP, thus evidencing choice is offered. There was evidence of input from other health care professionals. The CSCI Pharmacist Inspector carried out an inspection on 25/07/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were seen caring for and conversing with service users in a gentle and courteous manner, and service users spoken with said that they are very satisfied with the care they receive at the home. Service users individuality is respected, to include their preferred term of address being used. Health care professionals visit Service users in the privacy of their own rooms. The home is registered to provide palliative care. Policies and procedures are in place, and it was clear that the staff have a good understanding of the needs of service users with palliative care needs. The home receives input from the Macmillan nursing specialists, and documentation is updated following any such visits. The wishes of service users in respect of their final days is ascertained and respected. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 11 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 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. The activity input for the home is specific to the interests of the service users, thus ensuring their individual wishes are respected. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the service users rights and opinions are heard and respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: The home accommodates service users with a wide range of abilities and interests, and it was clear that individual needs are catered for. Theatre trips and outings to places of interest are arranged, plus weekly shopping trips. In house entertainments are also arranged, to include concerts, talks and film shows. Some of the service users are able to go on holiday to stay with relatives and friends, and are able to travel out from the home independently. Card evenings to include Bridge are regular events. Parties to celebrate festivals and special events such as birthdays are arranged in line with service user wishes. There is an activities room for arts & crafts, plus computer and internet facilities available for service users to access. There is also a wellappointed hair dressing room, with the hairdresser visiting the home each Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 12 week. The home has two licensed bar facilities, and these are open prior to the lunchtime and evening meals. There are areas within the home where service users can grow pot plants, for example on some balconies and in some bedroom areas, and these look very attractive. Service users expressed their enjoyment at being able to continue such hobbies as gardening. Service users spoken with said that that they are able to choose what activities they wish to partake in, and that their wishes are respected. The home has an open visiting policy and visiting is encouraged, so that service users maintain contacts with relatives and friends. Arrangements for visitors to attend meals with the service users are in place. The Inspector spoke with one visitor who said that they are made very welcome at the home and are pleased with the care provision. Service users can choose where they wish to receive their guests, either in their own rooms or in one of the communal rooms. On the dementia care unit all service users have an appointed Power of Attorney. Where service users are unable to manage their own finances this is carried out by their representative. Advocacy services are available, to include Age Concern and The Actors Charitable Trust Welfare Committee. In addition, the Actors Benevolent Fund and other like-minded societies can also be accessed for advocacy needs. The food provision in the home is of a good standard. Service users spoken with expressed their satisfaction in this area, and any concerns are promptly addressed. The menu provides choice at all meals, and service users complete their individual choice cards in advance of the meal. Alternatives to the meal choices provided are also available. Food and drink is available to service users throughout the 24 hour period. The lunchtime meal observed was a social occasion, and the atmosphere in both dining rooms was cheerful and lively. Visitors are able to partake of meals with the service users. The kitchen was clean and tidy. Fresh fruit and vegetables were available, and food was being stored and stock rotated correctly. Risk assessments are in place for the equipment in use and for safe working practices. Temperature records to include fridges, freezers, food delivery and food serving were up to date. The kitchen cleaning schedule was in place and up to date. First aid information and equipment relevant to the kitchen was seen. The kitchen is maintained to a high standard. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 13 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 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 service users and their visitors. There is a system in place for the safeguarding of service users from abuse. EVIDENCE: The home has a clear complaints procedure, which is on display in the home. The Registered Manager said that there had been no complaints since the last inspection. Service users spoken with said that they are very happy at the home and had no complaints. Service users are encouraged to voice any concerns so that these can be promptly addressed. The home follows the Hillingdon Safeguarding Adults procedures. There had been one POVA investigation which is ongoing. The reporting of any concerns to the Hillingdon Safeguarding Adults Team and the CSCI as a matter of priority was discussed with the Registered Manager and the Manager Designate and both were clear about this. Staff spoken with said that they would report any concerns of this nature, and had a knowledge of Whistle Blowing procedures. Updates in Safeguarding Adults training were in process. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has been built to a high standard, and is well maintained, thus providing a smart, clean and homely environment for service users to live in. Several communal rooms are available, providing the service users with a choice of venue. Equipment in the home is available to meet the service users needs, thus providing for the service users needs. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: The home has been built, furnished and decorated to provide a high standard of accommodation for service users. The internal and external premises are well maintained, with prompt action being taken to address any repairs identified. Several communal rooms are available, varying in size, for service users and their visitors to access, and each room is well furnished and welcoming. The home also has a library, a Green Room, a drawing room and two licensed bars, Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 15 plus each unit has a dining room. These are furnished to the same high standard throughout. The garden has well tended shrubs and plants plus grassed areas, and is accessible to service users. There is also a large enclosed patio area, called the ‘Rose Garden’ with a water feature, pergolas and good quality outdoor furniture to provide an attractive and peaceful place for service users and their visitors to sit. The dementia care unit has an enclosed outdoor area for service users to sit in, and this again has been well thought out and is an attractive and practical area. All the bedrooms have en suite facilities to include a wash hand basin, a lavatory and a shower. In addition there are assisted shower, bath and toilet facilities suitable to meet the needs of the service users. The home has a passenger lift and wheelchair access. Rails have been provided in the corridor and where required throughout. There is adequate storage provision in the home. Moving & handling equipment to meet the needs of the service users is available. A new call bell system had been recently installed and staff and service users expressed their satisfaction with this system, with calls being answered promptly. All the bedrooms are single with en suite facilities. Much thought has gone into the design of these spacious rooms, with individual features being apparent in each. The bedrooms viewed were personalised and had a very homely feel. Suitable bedroom door locks are in place, to allow staff access in an emergency. All the beds are adjustable. The rooms are decorated and furnished to a good standard throughout. The temperature in the home was comfortable. The home was bright and airy and smelled fresh. Windows can be opened for any additional ventilation, with window restrictors in place. The emergency lighting has been repaired and is being monitored, with any parts being obtained as necessary to maintain the system in good working order. The laundry room was clean and tidy. The laundry person was clear on the use of the equipment and the care of service users personal laundry. Items viewed were appropriately labelled. A cleaning schedule was in place. COSHH safety data sheets for the chemicals in use were available. Infection control procedures are in place. Protective clothing to include gloves and aprons were available in the home. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. 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 was appropriately staffed to meet the needs of the service users. Staff have received training to provide them with the knowledge to meet the needs of the service users, with recognised training programmes being accessed to enhance staff knowledge and provide them with qualifications in care. Systems for vetting and recruitment practices are robust, thus safeguarding service users. EVIDENCE: At the time of inspection the home was being staffed to meet the needs of the service users. Staffing levels are maintained in accordance with the needs of the service users, and it was clear that should the needs of the service users change, staffing levels would be quickly reviewed to ensure their needs were being met at all times. Kitchen, laundry, maintenance, domestic and administration staff are employed in appropriate numbers to meet the needs of the home. The Manager Designate is in the process of accessing NVQ in care training for staff at the home, and suitable training provision has been identified. The need for a clear induction programme for new staff has been identified with the prospective trainers, in order that all aspects of induction, foundation and NVQ training can be incorporated in a training programme. Staff had received training in topics relevant to the needs of the service users, to include dementia care, and further training and updates were being planned. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 17 Staff employment records were sampled. Those viewed contained the information required, and it was clear that the home await any necessary documentation prior to employing new staff. The Registered Manager and Manager Designate were aware of the information to be obtained from any prospective employees. The application form has been updated to request the reason for leaving all previous places of employment. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. 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 Manager Designate has the qualifications and experience to manage the home. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. The home does not handle any monies on behalf of service users, and systems for managing monies are clear. Systems for the management of health and safety throughout the home are generally good, thus safeguarding service users, staff and visitors. Shortfalls should be easily addressed. EVIDENCE: The Registered Manager is retiring during August 2006 and the Manager Designate has been appointed and is working alongside the Registered Manager during the hand-over period. The Manager Designate is a first level registered nurse with post-graduate qualifications in care of the elderly, Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 19 teaching & assessing and palliative care. In addition she has completed several training courses in topics relevant to the needs of the service users. She is also an assessor for NVQ in care training. The Registered Manager and Manager Designate were clear of the areas that require work to bring all areas of the home up to a high standard. Staff spoken with said that they are well supported by the managers of the home, and that they are very approachable. The Registered Manager said that work had been done on a development plan for quality assurance, and confirmation of this has since been forwarded to the CSCI. The new documentation will be viewed at the next visit. Audits take place for health & safety and for medications management, plus the home has staff meetings each morning to discuss any issues. Service user meetings take place each month. Regulation 26 unannounced visits by the Responsible Individual take place, with copies of the report being forwarded to the CSCI. The home does not hold any monies on behalf of service users. All items of expenditure are itemised and monthly invoices are sent to the service user or their representative for payment. Clear records are maintained. The home has not yet introduced individual supervision. Whilst it is noted that group sessions take place each morning with staff, individual supervision sessions to discuss practice, learning & development and any other issues on a one-to-one basis need to be put in place, in line with Standard 36. Staff had undertaken training in health & safety topics to include moving & handling and fire safety. All the registered nurses have undergone a one day training course for appointed persons in First Aid. Fire drills had taken place, but the need to ensure that these are carried out 3 monthly for night staff and 6 monthly for day staff, ensuring a frequency that incorporates all members of staff within those time frames was discussed. Maintenance and servicing records were sampled. Those viewed were up to date with the exception of the Gas Landlords Certificate and confirmation that the system has now been serviced has since been received. Action has been taken to restore the emergency lighting system to working order and where any units have been identified for replacement, the parts have been ordered for installation. There is an ongoing system for the monitoring of the hot water outlets, with evidence of adjustment where necessary to maintain the temperature close to 43° centigrade. The maintenance man stated that the hot water flow and return temperatures are checked and satisfactory, but are not recorded, and the Inspector recommended that this be recorded in future. Monthly maintenance checks of equipment are carried out. Risk assessments for safe working practices for external maintenance had been recently updated and the Manager Designate was in the process of updating all the risk assessments for equipment and safe working practices, to include the laundry. The fire risk assessment had been updated following the last inspection, with additional updates to be completed, and the Manager Designate was aware of the need to carry this out. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 20 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 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 X 4 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES 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 13(4) Requirement Risk assessments for falls must be updated following any falls. (previous timescales of 01/10/05 & 01/03/06 not met) Correction fluid must never be used on legal documents, to include service user plans. Bedrail assessments must identify the appropriateness and safety of their use for the individual, and bedrails must only be used where it is appropriate and safe to do so. That the home continues to update and expand it medicines policy. The errors policy must include a reference to reporting untoward incidents to CSCI. The policy must also contain the homes procedure for managing medicines away from the home, self-administration and refusal of medication. All medicines must be recorded accurately when administered, including variable doses. If not administered then the correct endorsement must be used. DS0000010929.V300242.R01.S.doc Timescale for action 01/09/06 2. 3. OP7 OP8 17 13(7) 01/09/06 01/09/06 4. OP9 13(2) 01/10/06 5. OP9 13(2) 01/08/06 Denville Hall Version 5.2 Page 22 6. 7. OP9 OP30 13(2) 18 8. OP36 18(2) 9. OP38 23(4) 10. OP38 23(4) (Previous timescale of 01/10/05 and 14/02/06 not met) Tippex must not be used. Medicines must be accurately recorded when received into the home The induction, foundation and NVQ in care training must be commenced and evidence to show staff progress be maintained in the home. Evidence that this has been commenced must be forwarded to the CSCI. (previous timescales 01/11/05 & 01/06/06 not met) Staff must receive supervision a minimum of 6 times per year. This must be carried out in line with Standard 36. A system for this must be formulated and implemented. The fire risk assessment must be updated promptly and thereafter reviewed annually and whenever there is a relevant change. (previous timescale 01/03/06 partially met) Fire drills must be carried out at the required intervals of 3 monthly for all night staff and 6 monthly for all day staff. Training records must evidence this. 01/08/06 01/10/06 01/10/06 01/09/06 15/09/06 Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 23 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 OP38 Good Practice Recommendations It is strongly recommended that the designated manager/manager negotiates with service users to use the safe storage provided for medication in rooms. It is strongly recommended that the hot water flow and return temperatures be recorded. Denville Hall DS0000010929.V300242.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 DS0000010929.V300242.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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