Inspection on 10/10/05 for Derriford House

This inspection was carried out on 10th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Derriford House 06/10/08

Derriford House 09/10/06

Derriford House 05/04/05

Derriford House 20/09/04

Derriford House 15/04/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Derriford House Pinewood Hill Fleet Hampshire GU51 3AW Lead Inspector Peter J McNeillie Unannounced Inspection 10th October 2005 09:30 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 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Derriford House Address Pinewood Hill Fleet Hampshire GU51 3AW 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) 01252 627364 01252 629481 Derriford House Limited Mrs Carolyn Denise Lunn Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 05/04/05 Brief Description of the Service: Derriford House is a privately owned and operated care home offering care and support for up to 30 persons accommodated in the OP (older persons ) category. All residents live in single rooms provided with en-suite toilet and washing facilities. The home is located in the North Hampshire town of Fleet, adjacent to public transport local facilities/shops, the nearby towns of Aldershot and Farnborough (within 5 miles) and the towns of Guilford, Basingstoke and Reading within in 30 minutes travelling time by car. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections for 2005/2006. During this inspection which took place between 9:00am and 2:00pm the inspector who was assisted by the registered manager spoke with 16 residents of the residents and all staff on duty. Evidence was also gathered from a tour of the building, reading records, care plans, previous reports comments by management/staff and observations. What the service does well: What has improved since the last inspection? What they could do better: The home need to ensure that it can demonstrate that residents are consulted when assessments and care plans are produced, a system that allows residents Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 6 access to their money at all times be devised and a more robust procedure for checking hot water temperatures be adopted. 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. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 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 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 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): 1,2 and 3. Prospective residents are issued with information they need to make a choice about living in the home which has a well developed system of assessing and identifying residents needs which ensures residents safety and assessed needs can be met. EVIDENCE: Residents confirmed they had all been made aware of the homes statement of purpose which was available in the home and issued with terms and conditions of residence on admission. Residents and records confirmed persons were only admitted on the basis of a full and detailed multi disciplinary assessment of need and risk by the manager or other member of the senior staff and a number of other external health care professionals including GPs, geriatricians, continence advisors, physiotherapists, occupational therapists and care managers. Apart from verbal confirmations, records seen did not include evidence to support and confirm all residents or their representatives were consulted and contributed to the assessment process. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 9 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9 and 10 The arrangements for planning care are clear ensuring that the health, personal care and medication needs of residents are met and their privacy and rights respected. EVIDENCE: Residents in confirming that staff addressed them in a polite manner in the way they wished always knocked before entering their room, expressed in glowing terms total satisfaction with the care they were receiving, the manner in which it was delivered. A sample of the care plans viewed indicated all plans were reviewed monthly and were based on based on multidisciplinary assessments of need(including special needs) and risk. Plans were available for all residents who confirmed they were consulted about the contents of their individual plan, however not all of the written plans viewed confirmed this. The inspector was informed by the manager a new format for care plans was being introduced that required a signature from residents when the plan was completed. Progress will be reviewed at a future visit to the home. A detailed medication policy and procedure covering the storage, handling and disposal of drugs and medicines was available. Records seen confirmed that all drugs and medicines (which were securely stored and administered by Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 11 trained staff) were recorded when administered or disposed of. Since the last inspection the drugs policy and procedure has been reviewed and amended to include the implementation of a new drugs audit trail to ensure that all drugs and medicines entering the home are easier to account for. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The social activities family contacts and the provision of varied and nutritious meals were well managed and reflected service users interests and choices. EVIDENCE: Residents in praising the quality of their day to day lives were very complimentary about the homes staff, management and all other aspects of living in the home. From these comments and observations made by the inspector formed the view that routines were arranged to meet the needs of the residents and not the needs of the home/staff. All residents confirmed they were able to exercise choice in respect of all aspects of their day to day lives including attending in house activities which currently include, quizzes, music and movement, creative crafts, bingo and special entertainers brought into the home. Service users spoken to highlighted the quality, quantity, choice and presentation of food available for special praise. The inspector who joined residents for their mid day meal would confirm the comments made was also informed that special diets and assistance with feeding (if required) are catered for and whilst there are set meal times advertised, these are flexible to meet service users wishes. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 13 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 The home has clear policies and procedures in place which ensures residents are protected from abuse. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon. EVIDENCE: Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 15 A policy/procedure that operates in tandem with the policy and procedure produced by Hampshire County Council designed to protect vulnerable residents from abuse and records to confirmed all staff had received training in the procedures in adult protection were available. Staff spoken with confirmed they were fully aware of the procedure to follow should they witness or suspect the abuse of any resident. The complaints procedure which was also included in the service users guide included information on how to contact The Commission for Social Care Inspection (C.S.C.I) was seen as was record of complaints. Residents spoken to stated they felt comfortable in raising any concerns they had with the homes management and confident any matters raised would be dealt with fairly and promptly but made it clear to the inspector “They did not have concerns”. Since the last inspection C.S.C.I. had received an anonymous complaints about the home covering a number of issues including the availability of activities and the quality of care. Following an investigation at CSCI’S request by the homes joint owner who later reported his findings and written evidence to C.S.C.I the complaint was not upheld in any detail whatsoever and the home totally exonerated. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 16 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 17 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, 24,25 and 26. A safe, well maintained, clean and suitably furnished home is provided for service users which meets their needs. EVIDENCE: A tour of the building indicated that the building was fit for its stated purpose, accessible, safe, well maintained meeting and service users individual and collective needs. Furniture was comfortable and homely and in keeping with the décor. Residents commented how satisfied they were with the accommodation. Since the last inspection three bedrooms had been fitted with ensuite toilet and washing facilities whilst still meeting the national minimum special standards. All of the radiators and hot pipes had been covered. On testing the temperature to the hot water supply to a bath on the first floor it was found to be well in excess of the recommended maximum temperature of 43 degrees C. This error it was felt had probably occurred during the building works previously mentioned above. The bathroom was immediately taken out of Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 18 service and a plumber contacted. C.S.C.I. have since received verbal and written confirmation that the matter has been resolved and a more regular robust checking system introduced. The home which was clean, hygienic and free from adverse odours operated an infection control policy and procedure. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 19 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 and 30. Residents needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all service users. EVIDENCE: Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 20 EVIDENCE: Residents were full of praise for their carers adding, “nothing was too much trouble” ”they always seem to know what to do” ” appear well trained”. At the time of the inspection the four care staff were supported by a number of other personnel including, the manager, a chef plus a kitchen assistant,three housekeepers/ cleaners, a handy man a housekeeper/laundry and an administrator. The care staff confirmed that the availability of good support staff assisted them in providing a prompt, efficient and caring service to residents who also confirmed this view. Records seen confirmed all staff are recruited in accordance with the home’s selection and recruitment procedure which includes the completion of an application form, an interview and satisfactory Criminal Records Bureau( CRB ) Protection of Vulnerable Adults(POVA)and reference checks. On commencement of employment all staff are subject to induction training (records seen),a period of probation and extra supervision before a final permanent position is offered. The inspector noted all staff also receive an operational pack including a copy of the General Social Care Council’s Codes of Practice on commencement of their employment. As part of their terms and conditions of employment all staff agree to participate in NVQ training initiatives to at least level two. Currently 42.7 of staff are trained to at least NVQ level two with a further 15.8 expected to be qualified by Christmas 2005 a total of 63.5 in total which is well in excess of the 50 expectation of the standards. The registered person is a registered accredited trainer in first aid, moving and handling and is a City of Guilds approved 730 trainer (Adults). The manager is an accredited moving and handling trainer. Following their induction. Additional subjects over and above the NVQ training such as dementia, control of medication, and the ageing process the care of the dying and food hygiene are provided in-house. Very comprehensive current training records were available for all staff which also indicated senior staff are encouraged and enabled to assume lead roles for specific areas of training within the home eg care planning, medication, activities etc. Staff interviewed stated how much they enjoyed working in the home and the opportunity to participate in training and gain qualifications. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 21 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 22 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 24 31,33, 35 and 38. The management of the home seeks the views and opinions of residents/ residents representatives and safeguards the health and safety of staff /residents through the implementation of safe working practices. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 25 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 26 EVIDENCE: The registered manager who is due to complete her NVQ 4 registered managers award within four weeks of the inspection is also undertaking additional training to enable her to re register as a qualified general nurse. A Quality assurance and quality monitoring system that seeks the views of residents/residents relatives/advocates and external health professionals is in place. the results of surveys are discussed at residents forums and changes if any agreed. A health and safety policy, control of substances hazardous to health (COSHH) assessments, equipment servicing and accident records were available as were records to confirm all staff have receive training in the techniques of moving and handling first aid health and safety and the procedures to follow in the event of fire (including evacuation. A sample audit was taken of residents monies held for safekeeping .All cash held reconciled with the records that included receipts of all money spent. Following discussions with the manager the inspector noted that due to the current access arrangements resident’s money held for safekeeping may not be immediately available. An alternative source of money has been put in place. The current system appears to be working well however the inspector did comment that should any problems occur in the future the manager will need to review current procedures. Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 27 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 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 4 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 28 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Derriford House DS0000011906.V260609.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!