Inspection on 16/01/06 for Duchesne House

This inspection was carried out on 16th January 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Duchesne House 20/02/07

Duchesne House 08/08/05

Duchesne House 19/08/04

Duchesne House 06/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Duchesne House Aubyn Square, Roehampton Lane London SW15 5ND Lead Inspector Sharon Newman Unannounced Inspection 16th January 2006 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 Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 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. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Duchesne House Address Aubyn Square, Roehampton Lane London SW15 5ND 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) 020 8878 8282 020 8876 2758 Society of the Sacred Heart Mrs Julie Murrin Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 Brief Description of the Service: Duchesne House is a single storey purpose built care home. It is situated on Roehampton Lane, near Queen Marys Hospital and within driving distance of Richmond Park. The home benefits from its own grounds. All accommodation is provided in single rooms, which have a washbasin. Toilet and bathroom facilities are provided within close proximity to all rooms. The home is currently undergoing renovation to improve upon the facilities and will provide ensuite facilities to the new bedrooms. Service users at Duchesne House belong to the Order of the Sacred Heart and are admitted by referral from the Province. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 16th January 2006 and was conducted by one Regulation Inspector. Both the manager and the deputy manager were present during the inspection visit. Documentation examined included care plans, medication records and health and safety information. A tour was also taken of the premises. The manager and deputy manager were very helpful, informative and gave the impression of being very committed to their work and to the residents. Staff were welcoming and open throughout the inspection visit and they continue to demonstrate a conscientious and caring attitude towards residents. The home is still undergoing building and renovation work, which will provide new bedrooms with ensuite facilities and a new kitchen. This home has a strong religious ethos as it provides care for residents belonging to the Order of the Sacred Heart. The deputy manager spoke about the ‘family environment’ at the home and one resident commented that ‘the staff are wonderfully kind and the care is absolutely magnificent.’ Another resident said that the home is ‘heaven on earth.’ What the service does well: What has improved since the last inspection? Medication was stored appropriately at this inspection visit. Up-to-date certificates were seen for legionella testing and gas safety. Improvements to the facilities are taking place and the building work is nearing completion. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 6 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. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 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 Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 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. 3. 4. Residents are given good information to enable them to make an informed decision about the service offered at this home. Full and detailed assessments of need ensure effective care plans can be drawn up. The residents continue to be looked after in a caring environment. EVIDENCE: As reported in the previous inspection report there is a Statement of Purpose in place at the home which emphasises that this is a home for a religious community and is designed to meet their needs. It gives information about the admission procedure, daily life, pastoral care and spiritual support. The Service Users Guide contains information about the philosophy of care, accommodation provided, catering arrangements, social and physical activities and GP and medical services provided. Full assessments of need were in place for three residents whose files were sampled. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 9 As reported in the last inspection report some of the residents have a diagnosis of dementia. The home will need to apply for a variation of registration to the CSCI for those residents that this affects. This requirement remains outstanding from the previous inspection. The Statement of Purpose states that the home does not provide contracts, there is no fee charged because this is a home for a religious community and is considered ‘a family.’ Residents spoken to discussed the importance of having a key worker and how this system helps to ensure that their needs are met. Residents gave positive feedback about the home and one resident commented ‘I am very happy here.’ Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 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. 10. 11 The health and emotional needs of residents continue to be well met and there is evidence of good multi-disciplinary working with community healthcare professionals. Staff have a good knowledge of residents support needs. Medication is administered, stored and recorded appropriately. EVIDENCE: The care plans looked at were detailed and comprehensive in content. They cover areas including: social, psychological and physical care and were closely tailored to individual needs. Documentary evidence in the care plans sampled demonstrated that health needs are well met. Records of hospital, health, social contact and GP visits are kept. Health action sheets are in place and document any issues that arise, the action taken and the outcome. Care plans were observed to address issues such as continence, wound care and medication and each resident has a ‘medical file’ in place. One resident spoken to said that their health needs are ‘wonderfully met’ and that they are assisted to attend medical appointments. Residents reported that a GP visits the home and they have access to chiropody. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 11 One resident said that they are assisted to bathe and wash their hair, which they appreciate. They also reported that a hairdresser visits the home to cut their hair. Staff were seen talking to and supporting residents in a kind manner. The medication administration records were in good order. A medication policy is in place and the home has a copy of the Royal Pharmaceutical guidelines to refer to for information. The medication cabinet was locked securely. Areas such as death and dying are addressed sensitively in the care plans and residents’ wishes in this area are respected. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 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): 12. 14. 15. Residents are able to exercise choice and control over their lives and family and friends are encouraged to visit. Religious and social needs are well met. A wholesome diet is offered in pleasant surroundings. EVIDENCE: Residents care plans address the importance of encouraging socialising and finding out what interests they have, staff then look at ways of encouraging these interests. Daily mass and afternoon prayers take place at the home. Also, residents like to participate in reunion each day where they discuss religious matters. A wheelchair accessible garden is available to all the residents. One resident reported that they like to go out in the garden and listen to the birds. There is a private area with a telephone for the residents use and mobile phones are also available. Residents may also have telephones in their rooms. There is a range of television and music equipment available for the residents. They also have access to a computer room where they can use the internet or e-mail friends and family. A library is also available. A resident said that they enjoyed listening to the radio and going to the community meetings. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 13 A new kitchen has been built at the home and is situated next to the dining area. This area is large, bright and spacious. The lunch served was tomato soup followed by meatballs and broccoli and it looked appetising and well presented. Desserts are offered daily and drinks are served with the meals. Residents were seen helping themselves to water from the jugs on the tables. Residents were seen sitting at tables chatting to each other in a relaxed atmosphere. A resident said ‘I like the food’ and another commented that ‘the food is excellent, you can have a choice, it is like a restaurant – you can ask for the moon and they will give it to you.’ And they went on to say that kitchen staff know about individual residents’ health needs, likes and dislikes and the diet is tailored to these requirements. The manager reported that relatives may stay for lunch if they wish or can stay overnight at the home. She said that dieticians are involved in resident’s care as needed. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 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. 18. There is an appropriate complaints procedure and systems are in place to protect service users from abuse. EVIDENCE: An organisational abuse policy is in place and the home follows the Wandsworth Local Authority Protection of Vulnerable Adults Procedures. A whistle blowing policy is also available at the home and two staff members spoken to demonstrated a good knowledge of this policy and it’s importance. A complaints procedure is in place at the home and the manager reported that there have not been any formal complaints to the home since the last inspection. Two residents spoken to said would feel confident of approaching a member of staff or the manager to raise any issues. They said they were happy at the home and did not have any complaints. . Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. 20. 21. 23. 24. 25. 26. This home is comfortable and homely. The environment at this home continues to be clean, and hygienic. Bedrooms are well decorated and residents have their personal possessions with them. There is a pleasant atmosphere at the home which benefits the residents. EVIDENCE: As reported in the last inspection report the home is undergoing an improvement programme and an extension is being built to include a new kitchen and new bedrooms with ensuite facilities. This home is purpose built and all accommodation is provided on ground level and there is a very attractive and well-maintained garden. The home has a library, computer room and sitting room with a small kitchenette area where residents can make hot drinks. There is also a chapel within the building. Bedrooms were seen to be well personalised to individual residents taste. Residents spoken to commented that they liked their bedrooms. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 16 Bathroom facilities were seen to meet the needs of the current residents and more washing facilities will be available once the ensuite facilities are available. The home was clean and hygienic at the time of inspection. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. 29. 30. Staff continue to be enthusiastic and committed to delivering high standards of care, they have a good knowledge of residents’ needs and a conscientious attitude to their work. They contribute towards a relaxed atmosphere at the home which benefits the residents. EVIDENCE: Staff were observed to be caring and conscientious, one said ‘I love it here – you can feel the peace.’ They commented that there is a ‘good staff team’ at the home. Another staff member said that the manager and deputy manager are supportive and that the home provides ‘excellent care’ to the residents. Residents spoke affectionately about the staff, one said ‘the staff are patient and loving.’ The manager and deputy manager were interviewing for new staff on the day of the inspection. The manager reported that staff turnover was good at the home as many members of staff were long-serving. The manager said that staff supervision is taking place and that all staff are to have an annual review. Staff spoken to said they feel well supported and are having regular supervision. The deputy manager reported that she is one of four staff members who have received training in supervision. Evidence seen in staff files demonstrates that staff receive regular updates in mandatory areas such as moving and handling and first aid. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 18 The manager identified that some residents have a diagnosis of dementia and she is in the process of applying for a variation of registration for this. It was discussed with her that dementia training must be provided for all care staff to ensure they are aware of the needs of residents with this condition. Some staff files did not contain all required documentation such as photographs and identification all files must contain the information required by the Care Homes Regulations 2001. The manager reported that regular meetings are held, however it is recommended that meeting minutes are written to demonstrate that regular meetings are taking place. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31. 32. 33. 38. Both the manager and the deputy manager are experienced, conscientious and caring. This home continues to be run well and resident’s needs are met. This home is run in the best interests of the residents. EVIDENCE: The manager is very experienced and has obtained the Registered Managers Award, NVQ assessors course and the NVQ Level 4. Staff and residents spoke very highly of her and the deputy manager. Staff reported that the manager was supportive and a resident said that ‘she does a tremendous job.’ The deputy manager has completed the NVQ assessor’s course and NVQ level 4 in care. A staff member said ‘she is very good and supportive’ and a resident commented ‘she is grand.’ The home has a full set of policies and procedures in place and the manager said she was in the process of updating some of these. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 20 Appropriate checks are in place for hot water temperatures and first aid boxes and certificates were available for gas safety and legionella testing. However, the home needs to ensure an up-to-date certificate for the five-yearly electrical check is obtained. It is recognised this has been difficult to obtain whilst the building work continues and the manager said she has been advised to obtain this certificate when all this work has been completed. Accident reports were seen to be fully completed with details recorded about action taken. However, the home needs to ensure that all incidents requiring notification under the Care Homes Regulations 2001 are reported to the CSCI. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 N/A 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X X X X 2 Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 22 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 OP4 Regulation 12 (1) Requirement The Registered Person must make an application for variation of the homes registration categories. This application must be supported with full evidence that the home is able to meet the needs of service users suffering from dementia. 2. OP29 Sch.2 17 18(1)c 19 1(a) 37 The Registered Person must ensure that staff files contain all information required by the Care Homes Regulations 2001. The Registered Person must ensure dementia training is provided for all care staff. The Registered Person must ensure that they give notice without delay of any event in the care home which adversely affects the well-being or safety of any service user. The Registered Person must ensure an up-to-date certificate for the five-yearly electrical check is obtained. 01/03/06 Timescale for action 01/03/06 3. 4. OP30 OP38 01/05/06 01/02/06 5. OP38 13(4) 01/04/06 Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 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. Refer to Standard OP32 Good Practice Recommendations It is recommended that regular staff meetings are held and minutes are fully recorded and easily accessible. Duchesne House DS0000010188.V275924.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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