Inspection on 08/08/05 for Duchesne House

This inspection was carried out on 8th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Duchesne House 20/02/07

Duchesne House 16/01/06

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 Newnam Unannounced 8th August 2005 10:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Duchesne House Address Aubyn Square Roehampton Lane London SW15 5ND 020 8878 8282 020 8876 2758 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Society of the Sacred Heart Mrs Julie Murrin Care home only (PC) 22 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th August 2004 Brief Description of the Service: Duchesne House is a single storey purpose built care home. It is situated on Roehampton Lane, near Queen Mary’s 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. Service users at Duchesne House belong to the Order of the Sacred Heart and are admitted by referral from the Province. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 10th August 2005 and was conducted by one Regulation Inspector. The deputy manager was present throughout the inspection visit. Documentation examined included care plans, medication records, staff files and health and safety information. A tour was also taken of the premises. Staff were welcoming and open throughout the inspection visit. They demonstrated a conscientious and caring attitude towards residents. The deputy manager was very helpful, informative and gave the impression of being very committed to her work and to the residents. This home has a strong religious ethos as it provides care for residents belonging to the Order of the Sacred Heart. Feedback from residents was very positive, one commented ‘we are so looked after and the carers are wonderful, caring and tactful.’ Staff and residents reported that there is a ‘family’ atmosphere at the home which they like. The home is currently having an extension built comprising of new bedrooms with ensuite facilities and a new kitchen. The deputy manager reported that they are trying to ensure minimal disruption to the running of the home whilst this work is in progress. Residents spoken to reported that they liked to watch the extension being built. Despite the building work in progress the environment was pleasant and clean and the atmosphere was calm, unhurried and relaxed. One resident commented that they ‘can’t praise the home enough.’ What the service does well: Staff have a good rapport with residents and respect their dignity, choice and privacy. Residents are well supported and encouraged to be as independent as possible. Resident’s health and spiritual needs are well met and their psychological needs addressed. There is a good standard of cleanliness at this home, the home is well maintained and has a pleasant relaxed atmosphere. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 6 There is a lovely garden which is accessible to residents and well-maintained. What has improved since the last inspection? 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 G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 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 are looked after in a caring environment. EVIDENCE: 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. A Service Users Guide was available and contained information about the philosophy of care, accommodation, 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 G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 9 The deputy manager reported that some of the residents now have a diagnosis of dementia. She said that the home is currently building a ‘dementia garden’ to help meet the needs of those residents. The home will need to apply for a variation of registration to the CSCI for those residents that this affects. 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.’ Staff were seen to be caring and discreet in the care of the residents. Positive feedback from residents indicates their needs are met at the home. One resident commented ‘I think the care is very good here – it is loving.’ Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 The health and emotional needs of residents are 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 and recorded appropriately, however staff must ensure medication is stored correctly to prevent risk to residents. EVIDENCE: Three residents files were sampled at this inspection and found to be detailed and comprehensive. They contained good information regarding residents’ social history, medical history and personal details. The sections concerning hobbies and interests were informative and allow the reader to build up a good picture of the residents’ likes and dislikes. The inspector discussed with the deputy manager that the care plans would benefit from the format being standardised to ensure information is more easily accessible. The files contained care plans which had been divided into: physical care, psychological care and social care sections. These identified problems specific to the resident and gave clear aims and action plans and were all up-to-date. There is a key worker system in place and one of the residents said they were aware of this and knew who their ‘key person’ was. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 11 Risk assessments were in place for the three residents whose files were sampled these covered areas such as: holding door keys, walking in the garden and the prevention of pressure sores. Evidence was seen in the care plans of input from health care professionals including: GP’s, community nurses and hospital consultants. District Nursing input is provided when required by the residents and the GP visits regularly. One resident reported that ‘the doctor visits weekly.’ Two residents said that if they have any health concerns they approach the staff who will make arrangements for an appointment with the appropriate health care professional. Consultants including psychiatrists visit the home when required. A physiotherapist was noted to be providing support to one of the residents at the time of inspection. Medication was stored securely within a locked cupboard on the day of inspection. One item of medication was found to be stored inappropriately in the medication cabinet instead of in the refrigerator. The deputy manager said she would ensure staff were reminded of the correct procedures for the storage of medication. Medication was observed to be prepared in a monitored dosage system and all medication administration records were fully completed. Residents were observed to be treated with dignity and respect. One commented ‘the staff are very patient and never fuss or hurry us.’ Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 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. EVIDENCE: The deputy manager reported that as this is a religious community daily mass and afternoon prayers take place. She said that residents like to participate in reunion each day where they discuss religious matters. Activities on offer include a weekly quiz organised by the deputy manager which she reported can become very competitive. Another staff member runs a wheelchair exercise class. A minibus can be rented from the local authority community services to enable residents to be taken out on day trips. An outing had taken place to Kew Gardens the week before the inspection visit and the deputy manager said another visit was being arranged to go to Hampton Court Palace. This was confirmed by a resident who informed the inspector about the day trips. They said they however often preferred not to participate and that this choice was respected by staff. Two residents go on holiday independently. Residents were seen taking a walk in the very attractive garden accompanied by visitors. The garden is wheelchair accessible and was seen to be being used by those in wheelchairs. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 13 The deputy manager said that the residents’ choice is very much respected. One resident stated ‘I can choose to get up when I like and go to bed when I like.’ Another reported that ‘I can do what I like to do.’ There is a private area with a telephone for the residents use. The deputy manager said that there are also mobile phones available for the use of the residents. Residents can also have telephones in their rooms. One reported that she uses her phone to ring a relative daily. The deputy manager said that friends and relatives are encouraged to visit. Residents were seen talking with visitors in the dining area and in the garden. There is a range of television and music equipment available for the residents use. The residents also have access to a computer room where they can use the internet or e-mail friends and family. A library is also available for the use of residents. The residents’ diet could not be fully assessed at this visit as the kitchen is currently being extended and many of the meals are being supplied by the local authority Meals on Wheels service. However, two residents spoken to said the food was generally good. One resident said that they could have breakfast in their room if they chose. Another commented that the cook makes ‘lovely soup.’ Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 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 standard(s) 16, 18 There is an appropriate complaints procedure and resident’s rights are protected. Systems are in place to protect service users from abuse. EVIDENCE: A complaints procedure is in place at the home and the deputy manager reported that there have not been any formal complaints to the home since the last inspection. Two residents spoken to said that they did not have any complaints and would feel confident of approaching a member of staff or the Manager if they had a complaint. An organisational abuse policy is in place and the home adheres to the Wandsworth Local Authority Protection of Vulnerable Adults Procedures. A whistle blowing policy was also available at the home and a staff member spoken to demonstrated a good knowledge of this policy and it’s importance. Appropriate individual risk assessments are in place and up-to-date. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 24, 26 The environment at this home is clean, comfortable 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: This home is currently undergoing an improvement programme and an extension is being built which will include a new kitchen and new bedrooms with ensuite facilities. Another small ‘dementia garden’ is also going to be provided. The deputy manager said that the home was trying to minimise any disruption to the residents. Residents commented that they were looking forward to seeing what the extension will look like when it is completed. 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. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 16 Bedrooms were seen to be well personalised to individual residents taste. 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. There is a full-time member of staff responsible for maintenance at the home. The home was clean and hygienic at the time of inspection. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Staff are 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: Feedback about the staff from residents at this inspection visit was very positive. One resident stated that the ‘care is very good’ and that it is ‘very gentle care’ that is provided at the home. The deputy manager reported that there is a full staff compliment at present and if extra staff are needed the home has its’ own bank staff system which helps to ensure continuity of care for the residents. The inspector was informed that one staff member is undertaking the NVQ Level 2 and another is undertaking the NVQ Level 3. The deputy manager said that more staff would be put forward for these qualifications. Three staff files were examined and were found to contain all necessary information. The deputy manager reported that Criminal Record Checks are in place and these are locked away for reasons of confidentiality. Evidence was seen in the staff files of up-to-date training in mandatory areas such as first aid, moving and handling and health and safety. However, one file contained an incomplete training record, full records of staff training must be Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 18 kept to provide evidence that all staff are up-to-date with mandatory training. Also, as some of the residents have a diagnosis of dementia, staff must receive training in this area. Staff reported that regular meetings are held, and some evidence was seen to support this in a log book. However this information was not easily accessible and it is recommended that the regular staff meeting minutes are fully recorded. Staff were helpful throughout the inspection visit and were seen to give care discreetly and sensitively. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, 38 This home is well run and resident’s needs are well met. The home has implemented a quality assurance programme to ensure the views of residents and relatives are sought. EVIDENCE: The registered manager was not on duty on the day of the inspection. Feedback about the registered manager from residents spoken to was very positive. One commented that the home is well run and that the registered manager is approachable. A staff member stated that the manager was ‘brilliant’ and ‘always there to offer advice.’ The deputy manager is experienced and enthusiastic, she reported that she has worked in the care setting for nine years. She has completed the NVQ assessors course and NVQ level 4 in care and assesses staff at the home. She said she encourages them to achieve their qualifications. She commented that the home was a ‘real community’. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 20 A resident reported that the deputy manager was ‘very good’ and another commented that she was ‘absolutely charming and thoughtful.’ A staff member said she was ‘lovely and supportive.’ A member of staff spoken to said they felt well supported at the home and receive regular one-to-one supervision. However it was difficult to judge from staff records if each care staff member was receiving at least six one-to-one supervision sessions a year. It is recommended consideration be given to maintaining a clear log to clearly indicate that each staff member is receiving regular supervision. There is a quality assurance programme in place – questionnaires have been devised about life at the home and these are given to the residents to seek their views. On the day of inspection an up-to-date certificate was not in evidence for the five yearly electrical installation check. This must be obtained. Records of weekly hot water checks were not available and these must be available for inspection. Also first aid boxes were not being checked monthly. They must be checked monthly and this must be fully recorded. The deputy manager said she would address these issues. Records were found to be in good order relating to daily fridge and freezer temperature checks, fire point testing and portable appliance testing. Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 x x 2 x x 3 x 2 Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. The Registered Person must ensure that medication is stored correctly at all times. The Registered Person must ensure: 1. That full records of training are available. This must provide evidence of up-to-date training in mandatory areas. 2. Dementia training is provided for staff. The Registered Person must ensure that an up-to-date certificate is available for the five yearly electrical installation check. The Registered Person must ensure that the weekly hot water temperature checks are Timescale for action 1st October 2005 2. 3. OP9 OP30 13 (2) 18 (1) c 19 (1) (a) 8th August 2005 1st November 2005 4. OP38 13 (4) 1st October 2005 1st September 2005 Page 23 5. OP38 13 (4) Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 available for inspection. 6. OP38 13 (4) The Registered Person must ensure that first aid boxes are checked monthly and that this is fully recorded. 1st September 2005 7. 8. 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 OP7 Good Practice Recommendations It is recommended that service user files have a standardised format and information is archived as required, to ensure that service user files contain current information. It is recommended that staff meeting minutes are fully recorded and easily accessible. It is recommended that a log is kept of all staff receiving supervision to ensure this can be easily audited. 2. 3. OP30 OP36 Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Duchesne House G54-G04 S10188 Duchesne V235988 090805 Stage 4.doc Version 1.40 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. 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